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Walter JK, Hill DL, Schall TE, Szymczak JE, Parikh S, DiDomenico C, Carroll KW, Nye RT, Feudtner C. An Interprofessional Team-Based Intervention to Address Barriers to Initiating Palliative Care in Pediatric Oncology: A Multiple-Method Evaluation of Feasibility, Acceptability, and Impact. J Pain Symptom Manage 2021; 62:1135-1144. [PMID: 34153461 PMCID: PMC8648922 DOI: 10.1016/j.jpainsymman.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Many children with advanced cancer are not referred to palliative care despite both professional recommendations to do so and bereaved parental preference for earlier support from sub-specialty palliative care. OBJECTIVES To assess the feasibility, acceptability, and impact of an adaptive intervention to address individual and team-level barriers to specialty palliative care referrals. METHODS A multiple-method approach assessed feasibility and acceptability among clinicians from pediatric oncology teams at a single institution. Quantitative measures of comfort with palliative care consultations, team cohesion, and team collaboration were conducted before and after the intervention. Number of palliative care consults were examined before, during, and after sessions. Intervention satisfaction surveys and qualitative interviews were conducted after the intervention. RESULTS Twenty-six team members (90% of consented) attended at least one intervention session with 20 (69%) participants completing 75% or more sessions. The intervention was modified in response to participant feedback. After the intervention, participants reported greater team cohesion, comfort discussing palliative care consultation, team collaboration, process satisfaction, and decision satisfaction. Participants agreed that the training was useful, effective, helpful, and worthwhile, that they would use the skills, and that they would recommend the training to other providers. The numbers of palliative care consults increased before intervention sessions were conducted, but did not significantly change during or after the sessions. In the interviews, participants reported overall favorably regarding the intervention with some participants reporting changes in practice. CONCLUSION An adaptive intervention to reduce barriers to initiating palliative care for pediatric oncology teams is feasible and acceptable.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA.
| | - Theodore E Schall
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania (J.E.S.), Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Connie DiDomenico
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Division of Pediatric Oncology (C.D.), Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Russell T Nye
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
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Libert Y, Peternelj L, Canivet D, Farvacques C, Liénard A, Ménard C, Merckaert I, Reynaert C, Slachmuylder JL, Razavi D. How does physicians' decisional conflict influence their ability to address treatment outcomes in a decision-making encounter with an advanced-stage cancer simulated patient? A descriptive study. PATIENT EDUCATION AND COUNSELING 2020; 103:1752-1759. [PMID: 32234266 DOI: 10.1016/j.pec.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 02/21/2020] [Accepted: 03/09/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES This descriptive study assesses how physicians' decisional conflict influences their ability to address treatment outcomes (TOs) in a decision-making encounter with an advanced-stage cancer simulated patient (SP). METHODS Physicians (N = 138) performed a decision-making encounter with the SP trained to ask for TOs information. The physicians' decisional conflict regarding patients' cancer treatments in general was assessed with the General Decisional Conflict Scale (Gen-DCS). The physicians' decisional conflict regarding the SP's cancer treatments was assessed with the Specific Decisional Conflict Scale (Spe-DCS). Physicians' ability to address TOs during the encounter was assessed with an interaction analysis system: the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP). Weekly time spent with cancer patients was assessed with a questionnaire. RESULTS Physicians' Spe-DCS (β = -.21 ; p = .014) and weekly time spent with cancer patients (β = .22 ; p = .008) predicted the number of TOs addressed during the encounter. Spe-DCS scores predicted nearly all MD.POP dimensions (r = -.18 ; p = .040 to r = -.30 to p < .001) whereas Gen-DCS scores predicted nearly none MD.POP dimensions. CONCLUSION Physicians' specific decisional conflict interferes with their ability to address TOs in a decision-making encounter with an advanced-stage cancer SP. PRACTICE IMPLICATIONS Physicians should be trained to address TOs according to patient preferences, despite their own decisional conflict.
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Affiliation(s)
- Yves Libert
- Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels, Belgium; Institut Jules Bordet, Clinique de Psycho-Oncologie, Université Libre de Bruxelles, Brussels, Belgium.
| | - Livia Peternelj
- Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels, Belgium; Institut Jules Bordet, Clinique de Psycho-Oncologie, Université Libre de Bruxelles, Brussels, Belgium.
| | - Delphine Canivet
- Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels, Belgium; Hôpital Universitaire Erasme, Service de Psychologie, Brussels, Belgium.
| | | | - Aurore Liénard
- Institut Jules Bordet, Clinique de Psycho-Oncologie, Université Libre de Bruxelles, Brussels, Belgium.
| | - Catherine Ménard
- Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels, Belgium.
| | - Isabelle Merckaert
- Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels, Belgium; Institut Jules Bordet, Clinique de Psycho-Oncologie, Université Libre de Bruxelles, Brussels, Belgium.
| | - Christine Reynaert
- Université Catholique de Louvain, Faculté de Médecine, Brussels, Belgium.
| | | | - Darius Razavi
- Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l'Éducation, Brussels, Belgium; Institut Jules Bordet, Clinique de Psycho-Oncologie, Université Libre de Bruxelles, Brussels, Belgium.
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Maidment ID, Barton G, Campbell N, Shaw R, Seare N, Fox C, Iliffe S, Randle E, Hilton A, Brown G, Barnes N, Wilcock J, Gillespie S, Damery S. MEDREV (pharmacy-health psychology intervention in people living with dementia with behaviour that challenges): the feasibility of measuring clinical outcomes and costs of the intervention. BMC Health Serv Res 2020; 20:157. [PMID: 32122341 PMCID: PMC7053151 DOI: 10.1186/s12913-020-5014-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 02/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background People living with dementia in care homes frequently exhibit “behaviour that challenges”. Anti-psychotics are used to treat such behaviour, but are associated with significant morbidity. This study researched the feasibility of conducting a trial of a full clinical medication review for care home residents with behaviour that challenges, combined with staff training. This paper focusses on the feasibility of measuring clinical outcomes and intervention costs. Methods People living with moderate to severe dementia, receiving psychotropics for behaviour that challenges, in care homes were recruited for a medication review by a specialist pharmacist. Care home and primary care staff received training on the management of challenging behaviour. Data were collected at 8 weeks, and 3 and 6 months. Measures were Neuropsychiatric Inventory-Nursing Home version (NPI-NH), cognition (sMMSE), quality of life (EQ-5D-5 L/DEMQoL) and costs (Client Services Receipt Inventory). Response rates, for clinical, quality of life and health economic measures, including the levels of resource-use associated with the medication review and other non-intervention costs were calculated. Results Twenty-nine of 34 participants recruited received a medication review. It was feasible to measure the effects of the complex intervention on the management of behaviour that challenges with the NPI-NH. There was valid NPI-NH data at each time point (response rate = 100%). The sMMSE response rate was 18.2%. Levels of resource-use associated with the medication review were estimated for all 29 participants who received a medication review. Good response levels were achieved for other non-intervention costs (100% completion rate), and the EQ-5D-5 L and DEMQoL (≥88% at each of the time points where data was collected). Conclusions It is feasible to measure the clinical and cost effectiveness of a complex intervention for behaviour that challenges using the NPI-NH and quality of life measures. Trial registration ISRCTN58330068. Retrospectively registered, 15 October 2017.
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Affiliation(s)
- Ian D Maidment
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK.
| | - Garry Barton
- Norwich Clinical Trials Unit, University of East Anglia, Earlham Road, Norwich, Norfolk, NR4 7TJ, UK
| | - Niyah Campbell
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Rachel Shaw
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Nichola Seare
- Aston Health Research Innovation Cluster, Aston University, Birmingham, B4 7ET, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Earlham Road, Norwich, Norfolk, NR4 7TJ, UK
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill St, London, NW3 2PF, UK
| | - Emma Randle
- Birmingham and Solihull Mental Health NHS Foundation Trust, Research and Innovation Department, The Barberry, 25 Vincent Drive, Birmingham, B15 2FG, UK
| | - Andrea Hilton
- Faculty of Health Sciences, University of Hull, Hull, HU6 7RX, UK
| | - Graeme Brown
- Birmingham and Solihull Mental Health NHS Foundation Trust, Unit 1, B1, 50 Summer Hill Road, Birmingham, B1 3RB, UK
| | - Nigel Barnes
- Birmingham and Solihull Mental Health NHS Foundation Trust, Unit 1, B1, 50 Summer Hill Road, Birmingham, B1 3RB, UK
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill St, London, NW3 2PF, UK
| | - Sarah Gillespie
- Department of Clinical Healthcare, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0FL, UK
| | - Sarah Damery
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Coates D, Clerke T. Training Interventions to Equip Health Care Professionals With Shared Decision-Making Skills: A Systematic Scoping Review. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2020; 40:100-119. [PMID: 32433322 DOI: 10.1097/ceh.0000000000000289] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION To support the development, implementation, and evaluation of shared decision-making (SDM) training programs, this article maps the relevant evidence in terms of training program design and content as well as evaluation outcomes. METHOD A systematic scoping review methodology was used. To identify studies, the databases PubMed, Medline, and CINAHL were searched from 2009 to 2019, and reference lists of included studies were examined. After removal of duplicates, 1367 articles were screened for inclusion. To be included, studies were to be published in peer-reviewed journals, and should not merely be descriptive but report on evaluation outcomes. Articles were reviewed for inclusion by both authors, and data were extracted using a purposely designed data charting form implemented using REDCap. RESULTS The review identified 49 studies evaluating 36 unique SDM training programs. There was considerable variation in terms of program design and duration. Most programs included an overview of SDM theories and key competencies, as well as SDM skill development through role plays. Few programs provided training in reflective practice, in identifying and working with patients' individually preferred decision-making style, or in relation to SDM in a context of medical uncertainty or ambiguity. Most programs were evaluated descriptively, mostly using mixed methods, and there were 18 randomized controlled trials, showing that training was feasible, well received, and improved participants' knowledge and skills, but was limited in its impact on patients. DISCUSSION Although there is limited capacity to comment on which types of training programs are most effective, overall training was feasible, well received, and improved participants' knowledge and skills.
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Affiliation(s)
- Dominiek Coates
- Dr. Coates: Senior Research Fellow, University of Technology Sydney, Faculty of Health, Sydney, Australia.Clerke: Project Officer, Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE) Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, Australia
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Müller E, Strukava A, Scholl I, Härter M, Diouf NT, Légaré F, Buchholz A. Strategies to evaluate healthcare provider trainings in shared decision-making (SDM): a systematic review of evaluation studies. BMJ Open 2019; 9:e026488. [PMID: 31230005 PMCID: PMC6596948 DOI: 10.1136/bmjopen-2018-026488] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
DESIGN AND OBJECTIVES We performed a systematic review of studies evaluating healthcare provider (HCP) trainings in shared decision-making (SDM) to analyse their evaluation strategies. SETTING AND PARTICIPANTS HCP trainings in SDM from all healthcare settings. METHODS We searched scientific databases (Medline, PsycInfo, CINAHL), performed reference and citation tracking, contacted experts in the field and scanned the Canadian inventory of SDM training programmes for healthcare professionals. We included articles reporting data of summative evaluations of HCP trainings in SDM. Two reviewers screened records, assessed full-text articles, performed data extraction and assessed study quality with the integrated quality criteria for review of multiple study designs (ICROMS) tool. Analysis of evaluation strategies included data source use, use of unpublished or published measures and coverage of Kirkpatrick's evaluation levels. An evaluation framework based on Kirkpatrick's evaluation levels and the Quadruple Aim framework was used to categorise identified evaluation outcomes. RESULTS Out of 7234 records, we included 41 articles reporting on 30 studies: cluster-randomised (n=8) and randomised (n=9) controlled trials, controlled (n=1) and non-controlled (n=7) before-after studies, mixed-methods (n=1), qualitative (n=1) and post-test (n=3) studies. Most studies were conducted in the USA (n=9), Germany (n=8) or Canada (n=7) and evaluated physician trainings (n=25). Eleven articles met ICROMS quality criteria. Almost all studies (n=27) employed HCP-reported outcomes for training evaluation and most (n=19) additionally used patient-reported (n=12), observer-rated (n=10), standardised patient-reported (n=2) outcomes or training process and healthcare data (n=10). Most studies employed a mix of unpublished and published measures (n=17) and covered two (n=12) or three (n=10) Kirkpatrick's levels. Identified evaluation outcomes covered all categories of the proposed framework. CONCLUSIONS Strategies to evaluate HCP trainings in SDM varied largely. The proposed evaluation framework maybe useful to structure future evaluation studies, but international agreement on a core set of outcomes is needed to improve evidence. PROSPERO REGISTRATION NUMBER CRD42016041623.
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Affiliation(s)
- Evamaria Müller
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alena Strukava
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Isabelle Scholl
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ndeye Thiab Diouf
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec, Canada
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec, Canada
| | - Angela Buchholz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Maidment ID, Damery S, Campbell N, Seare N, Fox C, Iliffe S, Hilton A, Brown G, Barnes N, Wilcock J, Randle E, Gillespie S, Barton G, Shaw R. Medication review plus person-centred care: a feasibility study of a pharmacy-health psychology dual intervention to improve care for people living with dementia. BMC Psychiatry 2018; 18:340. [PMID: 30340480 PMCID: PMC6194710 DOI: 10.1186/s12888-018-1907-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 09/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND "Behaviour that Challenges" is common in people living with dementia, resident in care homes and historically has been treated with anti-psychotics. However, such usage is associated with 1800 potentially avoidable deaths annually in the UK. This study investigated the feasibility of a full clinical trial of a specialist dementia care pharmacist medication review combined with a health psychology intervention for care staff to limit the use of psychotropics. This paper focuses on feasibility; including recruitment and retention, implementation of medication change recommendations and the experiences and expectations of care staff. METHODS West Midlands care homes and individuals meeting the inclusion criteria (dementia diagnosis; medication for behaviour that challenges), or their personal consultee, were approached for consent. A specialist pharmacist reviewed medication. Care home staff received an educational behaviour change intervention in a three-hour session promoting person-centred care. Primary healthcare staff received a modified version of the training. The primary outcome measure was the Neuropsychiatric Inventory-Nursing Home version at 3 months. Other outcomes included quality of life, cognition, health economics and prescribed medication. A qualitative evaluation explored expectations and experiences of care staff. RESULTS Five care homes and 34 of 108 eligible residents (31.5%) were recruited, against an original target of 45 residents across 6 care homes. Medication reviews were conducted for 29 study participants (85.3%) and the pharmacist recommended stopping or reviewing medication in 21 cases (72.4%). Of the recommendations made, 57.1% (12 of 21) were implemented, and implementation (discontinuation) took a mean of 98.4 days. In total, 164 care staff received training and 21 were interviewed. Care staff reported a positive experience of the intervention and post intervention adopting a more holistic patient-centred approach. CONCLUSIONS The intervention contained two elements; staff training and medication review. It was feasible to implement the staff training, and the training appeared to increase the ability and confidence of care staff to manage behaviour that challenges without the need for medication. The medication review would require significant modification for full trial partly related to the relatively limited uptake of the recommendations made, and delay in implementation. TRIAL REGISTRATION ISRCTN58330068 . Registered 15 October 2017. Retrospectively registered.
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Affiliation(s)
- Ian D Maidment
- School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK.
| | - Sarah Damery
- 0000 0004 1936 7486grid.6572.6Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Niyah Campbell
- 0000 0004 0376 4727grid.7273.1School of Life and Health Sciences, Aston University, Birmingham, B4 7ET UK
| | - Nichola Seare
- 0000 0004 0376 4727grid.7273.1Aston Health Research Innovation Cluster, Aston University, Birmingham, B4 7ET UK
| | - Chris Fox
- 0000 0001 1092 7967grid.8273.eNorwich Medical School, University of East Anglia, Earlham Road, Norwich, Norfolk NR4 7TJ UK
| | - Steve Iliffe
- 0000000121901201grid.83440.3bResearch Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill St, London, NW3 2PF UK
| | - Andrea Hilton
- 0000 0004 0412 8669grid.9481.4Faculty of Health Science, University of Hull, Hull, HU6 7RX UK
| | - Graeme Brown
- grid.450453.3Birmingham and Solihull Mental Health NHS Foundation Trust, Unit 1, B1, 50 Summer Hill Road, Birmingham, B1 3RB UK
| | - Nigel Barnes
- grid.450453.3Birmingham and Solihull Mental Health NHS Foundation Trust, Unit 1, B1, 50 Summer Hill Road, Birmingham, B1 3RB UK
| | - Jane Wilcock
- 0000000121901201grid.83440.3bResearch Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill St, London, NW3 2PF UK
| | - Emma Randle
- National Centre for Mental Health, Research and Innovation Department, The Barberry, 25 Vincent Drive, Birmingham, B15 2FG UK
| | - Sarah Gillespie
- 0000 0001 0726 8331grid.7628.bDepartment of Clinical Healthcare, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0FL UK
| | - Garry Barton
- 0000 0001 1092 7967grid.8273.eNorwich Clinical Trials Unit, University of East Anglia, Earlham Road, Norwich, Norfolk NR4 7TJ UK
| | - Rachel Shaw
- 0000 0004 0376 4727grid.7273.1School of Life and Health Sciences, Aston University, Birmingham, B4 7ET UK
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Dion M, Diouf NT, Robitaille H, Turcotte S, Adekpedjou R, Labrecque M, Cauchon M, Légaré F. Teaching Shared Decision Making to Family Medicine Residents: A Descriptive Study of a Web-Based Tutorial. JMIR MEDICAL EDUCATION 2016; 2:e17. [PMID: 27993760 PMCID: PMC5206485 DOI: 10.2196/mededu.6442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND DECISION+2, a Web-based tutorial, was designed to train family physicians in shared decision making (SDM) regarding the use of antibiotics for acute respiratory infections (ARIs). It is currently mandatory for second-year family medicine residents at Université Laval, Quebec, Canada. However, little is known about how such tutorials are used, their effect on knowledge scores, or how best to assess resident participation. OBJECTIVE The objective of our study was to describe the usage of this Web-based training platform by family medicine residents over time, evaluate its effect on their knowledge scores, and identify what kinds of data are needed for a more comprehensive analysis of usage and knowledge acquisition. METHODS We identified, collected, and analyzed all available data about participation in and current usage of the tutorial and its before-and-after 10-item knowledge test. Residents were separated into 3 log-in periods (2012-2013, 2013-2014, and 2014-2015) depending on the day of their first connection. We compared residents' participation rates between entry periods (Cochran-Armitage test), assessed the mean rank of the difference in total scores and category scores between pre- and posttest (Wilcoxon signed-rank test), and compared frequencies of each. Subsequent to analyses, we identified types of data that would have provided a more complete picture of the usage of the program and its effect on knowledge scores. RESULTS The tutorial addresses 3 knowledge categories: diagnosing ARIs, treating ARIs, and SDM regarding the use of antibiotics for treating ARIs. From July 2012 to July 2015, all 387 second-year family medicine residents were eligible to take the Web-based tutorial. Out of the 387 eligible residents, 247 (63.8%) logged in at least once. Their participation rates varied between entry periods, most significantly between the 2012-2013 and 2013-2014 cohorts (P=.006). For the 109 out of 387 (28.2%) residents who completed the tutorial and both tests, total and category scores significantly improved between pre- and posttest (all P values <.001). However, the frequencies of those answering correctly on 2 of the 3 SDM questions did not increase significantly (P>.99, P=.25). Distribution of pre- or posttest total and category scores did not increase between entry periods (all P values >.1). Available data were inadequate for evaluating the associations between the tutorial and its impact on the residents' scores and therefore could tell us little about its effect on increasing their knowledge. CONCLUSION Residents' use of this Web-based tutorial appeared to increase between entry periods following the changes to the SDM program, and the tutorial seemed less effective for increasing SDM knowledge scores than for diagnosis or treatment scores. However, our results also highlight the need to improve data availability before participation in Web-based SDM tutorials can be properly evaluated or knowledge scores improved.
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Affiliation(s)
- Maxime Dion
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
- Department of Mathematics and Statistics, Université Laval, Quebec, QC, Canada
| | - Ndeye Thiab Diouf
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
- Department of Community Health, Université Laval, Quebec, QC, Canada
| | - Hubert Robitaille
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
| | - Stéphane Turcotte
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
| | - Rhéda Adekpedjou
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Quebec, QC, Canada
| | - Michel Labrecque
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
| | - Michel Cauchon
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
| | - France Légaré
- Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Saint-François-d'Assise Hospital, Quebec, QC, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada
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Zatorski C, Zocchi M, Cosgrove SE, Rand C, Brooks G, May L. A single center observational study on emergency department clinician non-adherence to clinical practice guidelines for treatment of uncomplicated urinary tract infections. BMC Infect Dis 2016; 16:638. [PMID: 27814677 PMCID: PMC5097367 DOI: 10.1186/s12879-016-1972-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022] Open
Abstract
Background The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidence-based guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG). Methods A single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for non-adherence. Binomial confidence intervals and student’s t-tests were performed to evaluate differences in demographic characteristics and management between patients with pyelonephritis versus cystitis. Regression models were used to analyze the significance of various predictors to non-adherent treatment. Results 103 cases met the inclusion and exclusion criteria, with 63.1 % receiving non-adherent treatment, most commonly use of a fluoroquinolone (FQ) in cases with cystitis (97.6 %). In cases with pyelonephritis, inappropriate antibiotic choice (39.1 %) and no initial IV antibiotic for pyelonephritis (39.1 %) where recommended were the most common characterizations of non-adherence. Overall, cases of cystitis were no more/less likely to receive non-adherent treatment than cases of pyelonephritis (OR 0.9, 95 % confidence interval 0.4–2.2, P = 0.90). In multivariable analysis, patients more likely to receive non-adherent treatment included those without a recent history of a UTI (OR 3.8, 95 % CI 1.3–11.4, P = 0.02) and cystitis cases with back or abdominal pain only (OR 11.4, 95 % CI 2.1–63.0, P = 0.01). Conclusions Patients with cystitis with back or abdominal pain only were most likely to receive non-adherent treatment, potentially suggesting diagnostic inaccuracy. Physician education on evidence-based guidelines regarding the treatment of uncomplicated UTI will decrease broad-spectrum use and drug resistance in uropathogens.
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Affiliation(s)
- Catherine Zatorski
- Department of Emergency Medicine, The George Washington University, 2120 L Street, NW Suite 4-450, Washington, DC, 20037, USA
| | - Mark Zocchi
- Center for Healthcare Innovation & Policy Research, The George Washington University, 2100 Pennsylvania Avenue Suite 300, Washington, DC, 20037, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Medical Institutions, Osler 425, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Cynthia Rand
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins Institutions, 5501 Hopkins Bayview Circle, Baltimore, MD, 21224, USA
| | - Gillian Brooks
- Department of Emergency Medicine, The George Washington University, 2120 L Street, NW Suite 4-450, Washington, DC, 20037, USA
| | - Larissa May
- Department of Emergency Medicine, UC Davis Medical Center, 4150 V Street, Suite 2100, Sacramento, CA, 95817, USA.
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Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, Lancaster GA. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ 2016; 355:i5239. [PMID: 27777223 PMCID: PMC5076380 DOI: 10.1136/bmj.i5239] [Citation(s) in RCA: 1361] [Impact Index Per Article: 170.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Sandra M Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Claire L Chan
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Michael J Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christine M Bond
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lehana Thabane
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Gillian A Lancaster
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
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10
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Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, Lancaster GA. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud 2016; 2:64. [PMID: 27965879 PMCID: PMC5154046 DOI: 10.1186/s40814-016-0105-8] [Citation(s) in RCA: 646] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/10/2016] [Indexed: 01/10/2023] Open
Abstract
The Consolidated Standards of Reporting Trials (CONSORT) statement is a guideline designed to improve the transparency and quality of the reporting of randomised controlled trials (RCTs). In this article we present an extension to that statement for randomised pilot and feasibility trials conducted in advance of a future definitive RCT. The checklist applies to any randomised study in which a future definitive RCT, or part of it, is conducted on a smaller scale, regardless of its design (eg, cluster, factorial, crossover) or the terms used by authors to describe the study (eg, pilot, feasibility, trial, study). The extension does not directly apply to internal pilot studies built into the design of a main trial, non-randomised pilot and feasibility studies, or phase II studies, but these studies all have some similarities to randomised pilot and feasibility studies and so many of the principles might also apply. The development of the extension was motivated by the growing number of studies described as feasibility or pilot studies and by research that has identified weaknesses in their reporting and conduct. We followed recommended good practice to develop the extension, including carrying out a Delphi survey, holding a consensus meeting and research team meetings, and piloting the checklist. The aims and objectives of pilot and feasibility randomised studies differ from those of other randomised trials. Consequently, although much of the information to be reported in these trials is similar to those in randomised controlled trials (RCTs) assessing effectiveness and efficacy, there are some key differences in the type of information and in the appropriate interpretation of standard CONSORT reporting items. We have retained some of the original CONSORT statement items, but most have been adapted, some removed, and new items added. The new items cover how participants were identified and consent obtained; if applicable, the prespecified criteria used to judge whether or how to proceed with a future definitive RCT; if relevant, other important unintended consequences; implications for progression from pilot to future definitive RCT, including any proposed amendments; and ethical approval or approval by a research review committee confirmed with a reference number. This article includes the 26 item checklist, a separate checklist for the abstract, a template for a CONSORT flowchart for these studies, and an explanation of the changes made and supporting examples. We believe that routine use of this proposed extension to the CONSORT statement will result in improvements in the reporting of pilot trials. Editor's note: In order to encourage its wide dissemination this article is freely accessible on the BMJ and Pilot and Feasibility Studies journal websites.
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Affiliation(s)
- Sandra M. Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Claire L. Chan
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Michael J. Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christine M. Bond
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lehana Thabane
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada
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11
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Wyatt KD, List B, Brinkman WB, Prutsky Lopez G, Asi N, Erwin P, Wang Z, Domecq Garces JP, Montori VM, LeBlanc A. Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis. Acad Pediatr 2015; 15:573-83. [PMID: 25983006 DOI: 10.1016/j.acap.2015.03.011] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients. OBJECTIVES To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes. DATA SOURCES We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan. STUDY ELIGIBILITY CRITERIA We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes. STUDY APPRAISAL AND SYNTHESIS METHODS We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction. RESULTS Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD -1.20, 95% CI -2.01 to -0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI -0.04 to 0.78, P = .08). LIMITATIONS Included studies were heterogeneous in nature, including their conceptions of SDM. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).
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Affiliation(s)
- Kirk D Wyatt
- Pediatric and Adolescent Medicine Residency Program, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, Minn; Mayo Medical School, Mayo Clinic, Rochester, Minn; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | - Betsy List
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gabriela Prutsky Lopez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Mich
| | - Noor Asi
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | | | - Zhen Wang
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | - Juan Pablo Domecq Garces
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Internal Medicine, Henry Ford Hospital, Detroit, Mich
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minn; Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| | - Annie LeBlanc
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn.
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12
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Eldridge SM, Costelloe CE, Kahan BC, Lancaster GA, Kerry SM. How big should the pilot study for my cluster randomised trial be? Stat Methods Med Res 2015; 25:1039-56. [PMID: 26071431 DOI: 10.1177/0962280215588242] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There is currently a lot of interest in pilot studies conducted in preparation for randomised controlled trials. This paper focuses on sample size requirements for external pilot studies for cluster randomised trials. We consider how large an external pilot study needs to be to assess key parameters for input to the main trial sample size calculation when the primary outcome is continuous, and to estimate rates, for example recruitment rates, with reasonable precision. We used simulation to provide the distribution of the expected number of clusters for the main trial under different assumptions about the natural cluster size, intra-cluster correlation, eventual cluster size in the main trial, and various decisions made at the piloting stage. We chose intra-cluster correlation values and pilot study size to reflect those commonly reported in the literature. Our results show that estimates of sample size required for the main trial are likely to be biased downwards and very imprecise unless the pilot study includes large numbers of clusters and individual participants. We conclude that pilot studies will usually be too small to estimate parameters required for estimating a sample size for a main cluster randomised trial (e.g. the intra-cluster correlation coefficient) with sufficient precision and too small to provide reliable estimates of rates for process measures such as recruitment or follow-up rates.
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Affiliation(s)
- Sandra M Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Ceire E Costelloe
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Brennan C Kahan
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Gillian A Lancaster
- Postgraduate Statistics Centre, Department of Mathematics and Statistics, University of Lancaster, Lancaster, UK
| | - Sally M Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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13
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Turcotte S, Guerrier M, Labrecque M, Robitaille H, Rivest LP, Hess B, Légaré F. Dyadic validity of the Decisional Conflict Scale: common patient/physician measures of patient uncertainty were identified. J Clin Epidemiol 2015; 68:920-7. [PMID: 25958108 DOI: 10.1016/j.jclinepi.2015.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 01/28/2015] [Accepted: 03/14/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We aimed to assess the dyadic validity of the Decisional Conflict Scale (DCS) for assessing shared decision making in clinical consultations. We applied dyadic criteria, which consider the patient and physician as an interactive dyad instead of as independent individuals, to identify common patient/physician measures of patient uncertainty. STUDY DESIGN AND SETTING Patients and their physicians, participating in a randomized clustered trial, completed separately an adapted version of the DCS with five subscales. We performed factor analysis on the full DCS and each subscale independently. We defined a measure as dyadic when measurement invariance across patients and physicians was supported. RESULTS We analyzed 332 paired responses (physicians with adults or with parents and children) at study entry and 339 at exit. Factor analysis showed that the full DCS is not a valid dyadic measure. However, independent analysis of each subscale showed measurement invariance for values clarity, support, and effective decision (comparative fit index range, 0.93-1; root mean square error of approximation range, 0-0.07; and P-value > 0.05). CONCLUSION Application of our dyadic validation criterion indicated that the full DCS cannot be considered a dyadic measure. However, three of its subscales, values clarity, support and effective decision, are valid dyadic measures.
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Affiliation(s)
- Stéphane Turcotte
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay, Quebec City, Quebec, G1L 3L5, Canada
| | - Mireille Guerrier
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay, Quebec City, Quebec, G1L 3L5, Canada
| | - Michel Labrecque
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay, Quebec City, Quebec, G1L 3L5, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, 1050, avenue Ferdinand-Vandry, Quebec City, Quebec, G1V OA6, Canada
| | - Hubert Robitaille
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay, Quebec City, Quebec, G1L 3L5, Canada
| | - Louis-Paul Rivest
- Department of Mathematics and Statistics, Faculty of Sciences and Engineering, Université Laval, 1045, avenue de la Médecine, Quebec City, Quebec, G1V OA6, Canada
| | - Brian Hess
- Hess Consulting, 272 Rue du Replat, St-Nicolas, Quebec, G7A 5E4, Canada
| | - France Légaré
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 10 rue de l'Espinay, Quebec City, Quebec, G1L 3L5, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, 1050, avenue Ferdinand-Vandry, Quebec City, Quebec, G1V OA6, Canada.
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14
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Giguere AM, Labrecque M, Légaré F, Grad R, Cauchon M, Greenway M, Haynes RB, Pluye P, Syed I, Banerjee D, Carmichael PH, Martin M. Feasibility of a randomized controlled trial to evaluate the impact of decision boxes on shared decision-making processes. BMC Med Inform Decis Mak 2015; 15:13. [PMID: 25880757 PMCID: PMC4350632 DOI: 10.1186/s12911-015-0134-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 01/27/2015] [Indexed: 12/04/2022] Open
Abstract
Background Decision boxes (DBoxes) are two-page evidence summaries to prepare clinicians for shared decision making (SDM). We sought to assess the feasibility of a clustered Randomized Controlled Trial (RCT) to evaluate their impact. Methods A convenience sample of clinicians (nurses, physicians and residents) from six primary healthcare clinics who received eight DBoxes and rated their interest in the topic and satisfaction. After consultations, their patients rated their involvement in decision-making processes (SDM-Q-9 instrument). We measured clinic and clinician recruitment rates, questionnaire completion rates, patient eligibility rates, and estimated the RCT needed sample size. Results Among the 20 family medicine clinics invited to participate in this study, four agreed to participate, giving an overall recruitment rate of 20%. Of 148 clinicians invited to the study, 93 participated (63%). Clinicians rated an interest in the topics ranging 6.4-8.2 out of 10 (with 10 highest) and a satisfaction with DBoxes of 4 or 5 out of 5 (with 5 highest) for 81% DBoxes. For the future RCT, we estimated that a sample size of 320 patients would allow detecting a 9% mean difference in the SDM-Q-9 ratings between our two arms (0.02 ICC; 0.05 significance level; 80% power). Conclusions Clinicians’ recruitment and questionnaire completion rates support the feasibility of the planned RCT. The level of interest of participants for the DBox topics, and their level of satisfaction with the Dboxes demonstrate the acceptability of the intervention. Processes to recruit clinics and patients should be optimized. Electronic supplementary material The online version of this article (doi:10.1186/s12911-015-0134-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anik Mc Giguere
- Research Centre for Excellence in Aging, CHU de Quebec, Saint-Sacrement Hospital, 1050 chemin Ste-Foy, Québec, Québec, G1S 4L8, Canada. .,Department of Family and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, 1050 avenue de la Medecine, Quebec City, Quebec, G1V 0A6, Canada.
| | - Michel Labrecque
- Department of Family and Emergency Medicine, Research Center of the CHU de Quebec, Saint-Francois d'Assise Hospital, Laval University, 10 rue de l'Espinay, D6-730, Quebec City, QC, G1L 3L5, Canada
| | - France Légaré
- Department of Family and Emergency Medicine, Research Center of the CHU de Quebec, Saint-Francois d'Assise Hospital, Laval University, 10 rue de l'Espinay, D6-730, Quebec City, QC, G1L 3L5, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Herzl Family Practice Centre, 3755 Cote Sainte Catherine, Montreal, QC H3T 1E2, Canada
| | - Michel Cauchon
- Department of Family and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, 1050 avenue de la Medecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Matthew Greenway
- Department of Family Medicine, McMaster University, 118 Lake Street, St. Catharines, ON, Canada
| | - R Brian Haynes
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, L8S 4K1, Canada.,Department of Medicine, DeGroote School of Medicine, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, L8S 4K1, Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, 5858 Côte-des-neiges, 3rd Floor, Suite 300, Montreal, QC, H3S 1Z1, Canada
| | - Iqra Syed
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, L8S 4K1, Canada
| | - Debi Banerjee
- The University of Toronto, Faculty of Medicine, 1 King's College Circle, Medical Sciences Building (Rm. 2109), Toronto, ON, M5S-1A8, Canada
| | - Pierre-Hugues Carmichael
- Research Centre for Excellence in Aging, CHU de Quebec, Saint-Sacrement Hospital, 1050 chemin Ste-Foy, Québec, Québec, G1S 4L8, Canada
| | - Mélanie Martin
- Research Centre for Excellence in Aging, CHU de Quebec, Saint-Sacrement Hospital, 1050 chemin Ste-Foy, Québec, Québec, G1S 4L8, Canada.,Department of Family and Emergency Medicine, Laval University, Pavillon Ferdinand-Vandry, 1050 avenue de la Medecine, Quebec City, Quebec, G1V 0A6, Canada
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15
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Vaillancourt H, Légaré F, Gagnon MP, Lapointe A, Deschênes SM, Desroches S. Exploration of shared decision-making processes among dieticians and patients during a consultation for the nutritional treatment of dyslipidaemia. Health Expect 2014; 18:2764-75. [PMID: 25135143 DOI: 10.1111/hex.12250] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) holds great potential for improving the therapeutic efficiency and quality of nutritional treatment of dyslipidaemia by promoting patient involvement in decision making. Adoption of specific behaviours fostering SDM during consultations has yet to be studied in routine dietetic practice. OBJECTIVE Using a cross-sectional study design, we aimed to explore both dieticians' and patients' adoption of SDM behaviours in dietetic consultations regarding the nutritional treatment of dyslipidaemia. METHODS Twenty-six dieticians working in local health clinics in the Quebec City metropolitan area were each asked to identify one dyslipidaemic patient they would see in an upcoming consultation. Based on the Theory of Planned Behaviour (TPB), questionnaires were designed to study two targeted SDM behaviours: 'to discuss nutritional treatment options for dyslipidaemia' and 'to discuss patients' values and preferences about nutritional treatment options for dyslipidaemia'. These questionnaires were administered to the dietician-patient dyad individually before the consultation. Associations between TPB constructs (attitude, subjective norm and perceived behavioural control) towards behavioural intentions were analysed using Spearman's partial correlations. RESULTS Thirteen unique patient-dietician dyads completed the study. Perceived behavioural control was the only TPB construct significantly associated with both dieticians' and patients' intentions to adopt the targeted SDM behaviours (P < 0.05). CONCLUSIONS As perceived behavioural control seems to determine dieticians' and patients' adoption of SDM behaviours, interventions addressing barriers and reinforcing enablers of these behaviours are indicated. This exploratory study highlights issues that could be addressed in future research endeavours to expand the knowledge base relating to SDM adoption in dietetic practice.
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Affiliation(s)
- Hugues Vaillancourt
- Institute on Nutrition and Functional Foods (INAF), Laval University, Quebec City, QC, Canada.,Department of Food and Nutrition Sciences, Faculty of Agriculture and Food Sciences, Laval University, Quebec City, QC, Canada
| | - France Légaré
- CHUQ Research Center (Centre Hospitalier Universitaire de Québec - Hôpital St-François-d'Assise), Quebec City, QC, Canada.,Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, QC, Canada
| | - Marie-Pierre Gagnon
- CHUQ Research Center (Centre Hospitalier Universitaire de Québec - Hôpital St-François-d'Assise), Quebec City, QC, Canada.,Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | - Annie Lapointe
- Institute on Nutrition and Functional Foods (INAF), Laval University, Quebec City, QC, Canada
| | - Sarah-Maude Deschênes
- Institute on Nutrition and Functional Foods (INAF), Laval University, Quebec City, QC, Canada
| | - Sophie Desroches
- Institute on Nutrition and Functional Foods (INAF), Laval University, Quebec City, QC, Canada.,Department of Food and Nutrition Sciences, Faculty of Agriculture and Food Sciences, Laval University, Quebec City, QC, Canada.,CHUQ Research Center (Centre Hospitalier Universitaire de Québec - Hôpital St-François-d'Assise), Quebec City, QC, Canada
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16
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May L, Gudger G, Armstrong P, Brooks G, Hinds P, Bhat R, Moran GJ, Schwartz L, Cosgrove SE, Klein EY, Rothman RE, Rand C. Multisite exploration of clinical decision making for antibiotic use by emergency medicine providers using quantitative and qualitative methods. Infect Control Hosp Epidemiol 2014; 35:1114-25. [PMID: 25111919 DOI: 10.1086/677637] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To explore current practices and decision making regarding antimicrobial prescribing among emergency department (ED) clinical providers. METHODS We conducted a survey of ED providers recruited from 8 sites in 3 cities. Using purposeful sampling, we then recruited 21 providers for in-depth interviews. Additionally, we observed 10 patient-provider interactions at one of the ED sites. SAS 9.3 was used for descriptive and predictive statistics. Interviews were audio recorded, transcribed, and analyzed using a thematic, constructivist approach with consensus coding using NVivo 10.0. Field and interview notes collected during the observational study were aligned with themes identified through individual interviews. RESULTS Of 150 survey respondents, 76% agreed or strongly agreed that antibiotics are overused in the ED, while half believed they personally did not overprescribe. Eighty-nine percent used a smartphone or tablet in the ED for antibiotic prescribing decisions. Several significant differences were found between attending and resident physicians. Interview analysis identified 42 codes aggregated into the following themes: (1) resource and environmental factors that affect care; (2) access to and quality of care received outside of the ED consult; (3) patient-provider relationships; (4) clinical inertia; and (5) local knowledge generation. The observational study revealed limited patient understanding of antibiotic use. Providers relied heavily upon diagnostics and provided limited education to patients. Most patients denied a priori expectations of being prescribed antibiotics. CONCLUSIONS Patient, provider, and healthcare system factors should be considered when designing interventions to improve antimicrobial stewardship in the ED setting.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, George Washington University, Washington, DC
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Guerrier M, Légaré F, Turcotte S, Labrecque M, Rivest LP. Shared decision making does not influence physicians against clinical practice guidelines. PLoS One 2013; 8:e62537. [PMID: 23638111 PMCID: PMC3634782 DOI: 10.1371/journal.pone.0062537] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 03/20/2013] [Indexed: 11/30/2022] Open
Abstract
Background While shared decision making (SDM) and adherence to clinical practice guidelines (CPGs) are important, some believe they are incompatible. This study explored the mutual influence between physicians’ intention to engage in SDM and their intention to follow CPGs. Methods Embedded within a clustered randomized trial to assess the impact of training physicians in SDM about using antibiotics to treat acute respiratory tract infections, this study evaluated physicians’ intentions to both engage in SDM and follow CPGs. A self-administered questionnaire based on the theory of planned behavior evaluated both behavioral intentions and their respective determinants (attitude, subjective norm and perceived behavioral control) at study entry and exit. We used path analysis to explore the relationships between the intentions. We conducted statistical analyses using the maximum likelihood method and the variance-covariance matrix. Goodness of fit indices encompassed the chi-square statistic, the comparative fit index and the root mean square error of approximation. Results We analyzed 244 responses at entry and 236 at exit. In the control group, at entry we observed that physicians’ intention to engage in SDM (r = 0, t = 0.03) did not affect their intention to follow CPGs; however, their intention to follow CPGs (r = −0.31 t = −2.82) did negatively influence their intention to engage in SDM. At exit, neither behavioral intention influenced the other. In the experimental group, at entry neither behavioral intention influenced the other; at exit, the intention to engage in SDM still did not influence the intention to use CPGs, although the intention to follow CPGs (r = −0.15 t = −2.02) slightly negatively influenced the intention to engage in SDM, but this was not clinically significant. Conclusion Physicians’ intention to engage in SDM does not affect their intention to adopt CPGs even after SDM training. Physicians’ intention to adopt CPGs had no clinically significant influence on intention to engage in SDM. Trial Registration ClinicalTrials.gov NCT01116076
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Affiliation(s)
- Mireille Guerrier
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Québec, Canada
| | - France Légaré
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Québec, Canada
- Faculty of Medicine, Department of Family Medicine and Emergency Medicine, Université Laval, Québec, Québec, Canada
- * E-mail:
| | - Stéphane Turcotte
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Québec, Canada
| | - Michel Labrecque
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Québec, Canada
| | - Louis-Paul Rivest
- Faculty of Sciences and Engineering, Department of Mathematics and Statistics, Université Laval, Québec, Québec, Canada
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Benzer JK, Beehler S, Cramer IE, Mohr DC, Charns MP, Burgess JF. Between and within-site variation in qualitative implementation research. Implement Sci 2013; 8:4. [PMID: 23286552 PMCID: PMC3598511 DOI: 10.1186/1748-5908-8-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 12/11/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Multisite qualitative studies are challenging in part because decisions regarding within-site and between-site sampling must be made to reduce the complexity of data collection, but these decisions may have serious implications for analyses. There is not yet consensus on how to account for within-site and between-site variations in qualitative perceptions of the organizational context of interventions. The purpose of this study was to analyze variation in perceptions among key informants in order to demonstrate the importance of broad sampling for identifying both within-site and between-site implementation themes. METHODS Case studies of four sites were compared to identify differences in how Department of Veterans Affairs (VA) medical centers implemented a Primary Care/Mental Health Integration (PC/MHI) intervention. Qualitative analyses focused on between-profession variation in reported referral and implementation processes within and between sites. RESULTS Key informants identified co-location, the consultation-liaison service, space, access, and referral processes as important topics. Within-site themes revealed the importance of coordination, communication, and collaboration for implementing PC/MHI. The between-site theme indicated that the preexisting structure of mental healthcare influenced how PC/MHI was implemented at each site and that collaboration among both leaders and providers was critical to overcoming structural barriers. CONCLUSIONS Within- and between-site variation in perceptions among key informants within different professions revealed barriers and facilitators to the implementation not available from a single source. Examples provide insight into implementation barriers for PC/MHI. Multisite implementation studies may benefit from intentionally eliciting and analyzing variation within and between sites. Suggestions for implementation research design are presented.
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Affiliation(s)
- Justin K Benzer
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - Sarah Beehler
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
| | - Irene E Cramer
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - David C Mohr
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - Martin P Charns
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
| | - James F Burgess
- Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA
- Department of Health Policy and Management, Boston University, Boston, MA, USA
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Decision-making in oncology: a selected literature review and some recommendations for the future. Curr Opin Oncol 2012; 24:381-90. [PMID: 22572724 DOI: 10.1097/cco.0b013e328354b2f6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Decision-making in oncology is associated with uncertainty and potential decisional conflict. The purpose of this paper is to review strategies suggested to improve treatment decision-making, discuss their limits and describe recommendations that have been made to improve the decision-making process. RECENT FINDINGS To improve the decision-making process, uncertainty reduction, shared decision-making and multidisciplinary teamwork have been initially proposed. Due to their limits, alternative approaches such as uncertainty management, collaborative decision-making and collaborative multidisciplinary teamwork have been recommended. Uncertainty management considers uncertainty as a multilevel concept. It may be achieved through collaborative decision-making and collaborative multidisciplinary teamwork. Collaborative decision-making is an in-depth personalized iterative assessment of patient medical, psychological and social status. It promotes the patient's proactive role as a key stakeholder of decision-making and the physician's proactive role as a key support to patient decision-making. Collaborative multidisciplinary teamwork promotes an optimal environment for collaborative decision-making in which patients are key stakeholders and all relevant healthcare professionals are actively involved. These approaches require developing interventions for patients, and trainings for physicians and multidisciplinary teams. SUMMARY On the basis of these recent approaches, we propose a 'three-step model of multidisciplinary collaborative treatment decision-making' in oncology. This model should be tested for its validity.
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Giguere A, Labrecque M, Grad R, Cauchon M, Greenway M, Légaré F, Pluye P, Turcotte S, Dolovich L, Haynes RB. Barriers and facilitators to implementing Decision Boxes in primary healthcare teams to facilitate shared decisionmaking: a study protocol. BMC Med Inform Decis Mak 2012; 12:85. [PMID: 22867107 PMCID: PMC3472191 DOI: 10.1186/1472-6947-12-85] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 07/23/2012] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Decision Boxes are summaries of the most important benefits and harms of health interventions provided to clinicians before they meet the patient, to prepare them to help patients make informed and value-based decisions. Our objective is to explore the barriers and facilitators to using Decision Boxes in clinical practice, more precisely factors stemming from (1) the Decision Boxes themselves, (2) the primary healthcare team (PHT), and (3) the primary care practice environment. METHODS/DESIGN A two-phase mixed methods study will be conducted. Eight Decision Boxes relevant to primary care, and written in both English and in French, will be hosted on a website together with a tutorial to introduce the Decision Box. The Decision Boxes will be delivered as weekly emails over a span of eight weeks to clinicians of PHTs (family physicians, residents and nurses) in five primary care clinics located across two Canadian provinces. Using a web-questionnaire, clinicians will rate each Decision Box with the Information Assessment Method (cognitive impacts, relevance, usefulness, expected benefits) and with a questionnaire based on the Theory of Planned Behavior to study the determinants of clinicians' intention to use what they learned from that Decision Box in their patient encounter (attitude, social norm, perceived behavioral control). Web-log data will be used to monitor clinicians' access to the website. Following the 8-week intervention, we will conduct semi-structured group interviews with clinicians and individual interviews with clinic administrators to explore contextual factors influencing the use of the Decision Boxes. Data collected from questionnaires, focus groups and individual interviews will be combined to identify factors potentially influencing implementation of Decision Boxes in clinical practice by clinicians of PHTs. CONCLUSIONS This project will allow tailoring of Decision Boxes and their delivery to overcome the specific barriers identified by clinicians of PHTs to improve the implementation of shared decision making in this setting.
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Affiliation(s)
- Anik Giguere
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, McMaster University, CRL-139, 1280 Main Street West, Hamilton, ON, L8S 4 K1, Canada
| | - Michel Labrecque
- Research Center of the CHUQ, Saint-Francois d'Assise Hospital, 10 rue de l'Espinay, D6-730, Quebec City (QC), G1L 3 L5, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, 515-517 Pine Avenue West, Montreal (QC), H2W 1 S4, Canada
| | - Michel Cauchon
- Dept. of Family and Emergency Medicine, Laval University Laval, Pavillon Ferdinand-Vandry, 1050 avenue de la Médecine, Local 4617, Québec (QC), G1V 0A6, Canada
| | - Matthew Greenway
- Department of Family Medicine, McMaster University, 118 Lake Street, Saint-Catharines, ON, Canada
| | - France Légaré
- Research Center of the CHUQ, Saint-Francois d'Assise Hospital, 10 rue de l'Espinay, D6-730, Quebec City (QC), G1L 3 L5, Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, 515-517 Pine Avenue West, Montreal (QC), H2W 1 S4, Canada
| | - Stephane Turcotte
- Research Center of the CHUQ, Saint-Francois d'Assise Hospital, 10 rue de l'Espinay, D6-730, Quebec City (QC), G1L 3 L5, Canada
| | - Lisa Dolovich
- Department of Family Medicine, McMaster University, McMaster Innovation Park, 175 Longwood Road South, Hamilton, ON, L8P 0A1, Canada
| | - R Brian Haynes
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, DeGroote School of Medicine, McMaster University, 1280 Main Street West, CRL-125, Hamilton, ON, Canada
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Giguère A, Labrecque M, Njoya M, Thivierge R, Légaré F. Development of PRIDe: a tool to assess physicians' preference of role in clinical decision making. PATIENT EDUCATION AND COUNSELING 2012; 88:277-283. [PMID: 22543001 DOI: 10.1016/j.pec.2012.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 02/11/2012] [Accepted: 03/02/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM). METHODS This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up. RESULTS Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02). CONCLUSION This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis. PRACTICE IMPLICATIONS The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.
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Affiliation(s)
- Anik Giguère
- Health Information Research Unit, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ 2012; 184:E726-34. [PMID: 22847969 DOI: 10.1503/cmaj.120568] [Citation(s) in RCA: 154] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. We evaluated the effect of DECISION+2, a shared decision-making training program, on the percentage of patients who decided to take antibiotics after consultation with a physician or resident. METHODS We performed a randomized trial, clustered at the level of family practice teaching unit, with 2 study arms: DECISION+2 and control. The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making. The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation. We also recorded patients' perception that shared decision-making had occurred. Two weeks after the initial consultation, we assessed patients' adherence to the decision, repeat consultation, decisional regret and quality of life. RESULTS We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group, and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group. The percentage of patients who decided to use antibiotics after consultation was 52.2% in the control group and 27.2% in the DECISION+2 group (absolute difference 25.0%, adjusted relative risk 0.48, 95% confidence interval 0.34-0.68). DECISION+2 was associated with patients taking a more active role in decision-making (Z = 3.9, p < 0.001). Patient outcomes 2 weeks after consultation were similar in both groups. INTERPRETATION The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections. This reduction did not have a negative effect on patient outcomes 2 weeks after consultation. ClinicalTrials.gov trial register no. NCT01116076.
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Affiliation(s)
- France Légaré
- Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada.
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Allaire AS, Labrecque M, Giguere A, Gagnon MP, Légaré F. What motivates family physicians to participate in training programs in shared decision making? THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2012; 32:98-107. [PMID: 22733637 DOI: 10.1002/chp.21132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Little is known about the factors that influence family physician (FP) participation in continuing professional development (CPD) programs in shared decision making (SDM). We sought to identify the factors that motivate FPs to participate in DECISION+, a CPD program in SDM. METHODS In 2007-2008, we collected data from 39 FPs who participated in a pilot randomized trial of DECISION+. In 2010, we collected data again from 11 of those participants and from 12 new subjects. Based on the theory of planned behavior, our questionnaire assessed FPs' intentions to participate in a CPD program in SDM and evaluated FPs' attitudes, subjective norms and perceived behavioral control. We also conducted 4 focus groups to explore FPs' salient beliefs. RESULTS In 2010, FPs' mean intention to participate in a CPD program in SDM was relatively strong (2.6 ± 0.5 on a scale from -3 = "strongly disagree" to +3 = "strongly agree"). Affective attitude was the only factor significantly associated with intention (r = .51, p = .04). FPs identified the attractions of participating in a CPD program in SDM as (1) its interest, (2) the pleasure of learning, and (3) professional stimulation. Facilitators of their participation were (1) a relevant clinical topic, (2) an interactive program, (3) an accessible program, and (4) decision support tools. DISCUSSION To attract FPs to a CPD program in SDM, CPD developers should make the program interesting, enjoyable, and professionally stimulating. They should choose a clinically relevant topic, ensure that the program is interactive and accessible, and include decision support tools.
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Affiliation(s)
- Anne-Sophie Allaire
- Research Centre of the Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, G1L 3L5, Canada
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Légaré F, Labrecque M, Godin G, LeBlanc A, Laurier C, Grimshaw J, Castel J, Tremblay I, Frémont P, Cauchon M, Lemieux K, Rhéaume C. Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial. BMC FAMILY PRACTICE 2011; 12:3. [PMID: 21269509 PMCID: PMC3041682 DOI: 10.1186/1471-2296-12-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 01/26/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND To explore ways to reduce the overuse of antibiotics for acute respiratory infections (ARIs), we conducted a pilot clustered randomized controlled trial (RCT) to evaluate DECISION+, a training program in shared decision making (SDM) for family physicians (FPs). This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician. Consequently, the objective of this study is to evaluate, in patients consulting for ARIs, if exposure of physicians to a modified version of DECISION+, DECISION+2, would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician. METHODS/DESIGN The study is a multi-center, two-arm, parallel clustered RCT. The 12 family practice teaching units (FPTUs) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be randomized to a DECISION+2 intervention group (experimental group) or to a no-intervention control group. These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study. There will be two data collection periods: pre-intervention (baseline) including 175 patients with ARIs in each study arm, and post-intervention including 175 patients with ARIs in each study arm (total n = 700). The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician. Secondary outcome measures include: 1) physicians and patients' decisional conflict; 2) the agreement between the parties' decisional conflict scores; and 3) perception of patients and physicians that SDM occurred. Also in patients, at 2 weeks follow-up, adherence to the decision, consultation for the same reason, decisional regret, and quality of life will be assessed. Finally, in both patients and physicians, intention to engage in SDM in future clinical encounters will be assessed. Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration. DISCUSSION DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed, value-based decisions.
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Affiliation(s)
- France Légaré
- Research Center of Centre Hospitalier Universitaire de Québec, Hospital St-François D'Assise, Knowledge Transfer and Health Technology Assessment Research Group, 10 Espinay, Québec, QC, G1L 3L5, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Michel Labrecque
- Research Center of Centre Hospitalier Universitaire de Québec, Hospital St-François D'Assise, Knowledge Transfer and Health Technology Assessment Research Group, 10 Espinay, Québec, QC, G1L 3L5, Canada
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Gaston Godin
- Faculty of Nursing, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Annie LeBlanc
- Knowledge and Encounter Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Claudine Laurier
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, Montréal, QC, H3T 1J4, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, Ottawa, ON, K1Y 4E9, Canada
| | - Josette Castel
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Isabelle Tremblay
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Pierre Frémont
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Michel Cauchon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Kathleen Lemieux
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
| | - Caroline Rhéaume
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, PavillonVandry, Cité Universitaire, Québec, QC, G1K 7P4, Canada
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Allaire AS, Labrecque M, Giguère A, Gagnon MP, Grimshaw J, Légaré F. Barriers and facilitators to the dissemination of DECISION+, a continuing medical education program for optimizing decisions about antibiotics for acute respiratory infections in primary care: a study protocol. Implement Sci 2011; 6:3. [PMID: 21214919 PMCID: PMC3023690 DOI: 10.1186/1748-5908-6-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/07/2011] [Indexed: 11/28/2022] Open
Abstract
Background In North America, acute respiratory infections are the main reason for doctors' visits in primary care. Family physicians and their patients overuse antibiotics for treating acute respiratory infections. In a pilot clustered randomized trial, we showed that DECISION+, a continuing medical education program in shared decision making, has the potential to reduce the overuse of antibiotics for treating acute respiratory infections. DECISION+ learning activities consisted of three interactive sessions of three hours each, reminders at the point of care, and feedback to doctors on their agreement with patients about comfort with the decision whether to use antibiotics. The objective of this study is to identify the barriers and facilitators to physicians' participation in DECISION+ with the goal of disseminating DECISION+ on a larger scale. Methods/design This descriptive study will use mixed methods and retrospective and prospective components. All analyses will be based on an adapted version of the Ottawa Model of Research Use. First, we will use qualitative methods to analyze the following retrospective data from the pilot study: the logbooks of eight research assistants, the transcriptions of 15 training sessions, and 27 participant evaluations of the DECISION+ training sessions. Second, we will collect prospective data in semi-structured focus groups composed of family physicians to identify barriers and facilitators to the dissemination of a future training program similar to DECISION+. All 39 family physicians exposed to DECISION+ during the pilot project will be eligible to participate. We will use a self-administered questionnaire based on Azjen's Theory of Planned Behaviour to assess participants' intention to take part in future training programs similar to DECISION+. Discussion Barriers and facilitators identified in this project will guide modifications to DECISION+, a continuing medical education program in shared decision making regarding the use of antibiotics in acute respiratory infections, to facilitate its dissemination in primary care on a large scale. Our results should help continuing medical educators develop a continuing medical education program in shared decision making for other clinically relevant topics. This will help optimize clinical decisions in primary care.
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Affiliation(s)
- Anne-Sophie Allaire
- Research Center of Centre Hospitalier Universitaire de Québec, Hospital St-François D'Assise, Knowledge Transfer an Health Technology Assessment Research Group, 10 rue de l'Espinay, Québec, QC, G1L 3L5, Canada.
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