1
|
Koebel J, Kazemi M, Kennedy VL, Medeiros P, Bertozzi B, Bevan L, Tharao W, Logie CH, Underhill A, Pick N, King E, Kestler M, Yudin MH, Rana J, Carvalhal A, Webster K, Lee M, Islam S, Nicholson V, Ndung’u M, Narasimhan M, Gagnier B, Habanyama M, de Pokomandy A, Kaida A, Loutfy M. Dissemination of the Women-Centred HIV Care Model: A Multimodal Process and Evaluation. J Int Assoc Provid AIDS Care 2024; 23:23259582231226036. [PMID: 38389331 PMCID: PMC10894538 DOI: 10.1177/23259582231226036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Using data from a national cohort study and focus groups, the Women-Centred HIV Care (WCHC) Model was developed to inform care delivery for women living with HIV. METHODS Through an evidence-based, integrated knowledge translation approach, we developed 2 toolkits based on the WCHC Model for service providers and women living with HIV in English and French (Canada's national languages). To disseminate, we distributed printed advertising materials, hosted 3 national webinars and conducted 2 virtual capacity-building training series. RESULTS A total of 315 individuals attended the webinars, and the average WCHC knowledge increased by 29% (SD 4.3%). In total, 131 service providers engaged in 22 virtual capacity-building training sessions with 21 clinical cases discussed. Learners self-reported increased confidence in 15/15 abilities, including the ability to provide WCHC. As of December 2023, the toolkits were downloaded 7766 times. CONCLUSIONS We successfully developed WCHC toolkits and shared them with diverse clinical and community audiences through various dissemination methods.
Collapse
Affiliation(s)
- Jill Koebel
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Mina Kazemi
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- School of Nursing, Johns Hopkins University, Baltimore, USA
| | - V Logan Kennedy
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Priscilla Medeiros
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Canada
| | - Breklyn Bertozzi
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | | | - Wangari Tharao
- Women's Health in Women's Hands Community Health Centre, Toronto, Canada
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Angela Underhill
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Neora Pick
- Oak Tree Clinic, BC Women's Hospital, Vancouver, Canada
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Elizabeth King
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Mary Kestler
- Oak Tree Clinic, BC Women's Hospital, Vancouver, Canada
| | - Mark H Yudin
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jesleen Rana
- Women's Health in Women's Hands Community Health Centre, Toronto, Canada
| | - Adriana Carvalhal
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Scarborough Health Network Research Institute, Toronto, Canada
| | - Kath Webster
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Melanie Lee
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Shaz Islam
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Alliance for South Asian AIDS Prevention, Toronto, Canada
| | - Valerie Nicholson
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Mary Ndung’u
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Women's Health in Women's Hands Community Health Centre, Toronto, Canada
| | - Manjulaa Narasimhan
- Department of Sexual and Reproductive Health and Research/Human Reproduction Programme, World Health Organization, Geneva, Switzerland
| | - Brenda Gagnier
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Muluba Habanyama
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- The Ontario HIV Treatment Network, Toronto, Canada
| | - Alexandra de Pokomandy
- Department of Family Medicine, McGill University, Montreal, Canada
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
- The CHIWOS Research Team is detailed in the Acknowledgments
| | | |
Collapse
|
2
|
Kithulegoda N, Chu C, Tadrous M, Bean T, Salach L, Regier L, Bevan L, Burton V, Price D, Ivers N, Desveaux L. Academic detailing to improve appropriate opioid prescribing: a mixed-methods process evaluation. CMAJ Open 2023; 11:E932-E941. [PMID: 37848255 PMCID: PMC10586496 DOI: 10.9778/cmajo.20210050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing. METHODS In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing. RESULTS Physicians receiving academic detailing (n = 238) achieved a greater reduction in opioid prescribing than matched controls (n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change. INTERPRETATION The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing.
Collapse
Affiliation(s)
- Natasha Kithulegoda
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.
| | - Cherry Chu
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Tupper Bean
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Lena Salach
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Loren Regier
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Lindsay Bevan
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Victoria Burton
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - David Price
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Laura Desveaux
- Women's College Institute for Health Systems Solutions and Virtual Care (Kithulegoda, Chu, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Institute of Health Policy, Management, and Evaluation (Kithulegoda, Desveaux), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Institute for Better Health (Desveaux), Trillium Health Partners, Mississauga, Ont.; Centre for Effective Practice (Bean, Salach, Regier, Bevan, Burton, Price), Toronto, Ont.; Department of Family Medicine (Price), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| |
Collapse
|
3
|
Lacroix M, Abdelmalek F, Everett K, Salach L, Bevan L, Burton V, Ivers NM, Tadrous M. Effects of an academic detailing service on benzodiazepine prescribing patterns in primary care. PLoS One 2023; 18:e0289147. [PMID: 37498812 PMCID: PMC10374092 DOI: 10.1371/journal.pone.0289147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Benzodiazepines are commonly used to treat anxiety and/or insomnia but are associated with substantial safety risks. Changes to prescribing patterns in primary care may be facilitated through tailored quality improvement strategies. Academic detailing (AD) may be an effective method of promoting safe benzodiazepine prescribing. The objective of this study was to evaluate the effectiveness of AD on benzodiazepine prescribing among family physicians. METHODS AND FINDINGS We used an interrupted time series matched cohort design using population-based administrative claims databases. Participants were family physicians practicing in Ontario, Canada. The intervention was a voluntary AD service which involves brief service-oriented educational outreach visits by a trained pharmacist. The focus was on key messages for safer benzodiazepine prescribing in primary care with an emphasis on judicious prescribing to older adults aged 65 and older. Physicians in the intervention group were those who received at least one AD visit on benzodiazepine use between June 2019 and February 2020. Physicians in the control group were included if they did not receive an AD visit during the study period. Intervention physicians were matched to control physicians 1:4, on a variety of characteristics. Physicians were excluded if they had inactive billing or billing of less than 100 unique patient visits in the calendar year prior to the index date. The primary outcome was mean total benzodiazepine prescriptions at the level of the physician. Secondary outcomes were rate (per 100) of patients with long-term prescriptions, high-risk prescriptions, newly started prescriptions, and benzodiazepine-related patient harms. Data were analyzed using a repeated measures pre-post comparison with an intention-to-treat. Analyses were then stratified to focus on effects within higher-prescribing physicians. There were 1337 physicians were included in the study; 237 who received AD and 1064 who did not. There was no significant change in benzodiazepine prescribing when considering all physicians in the intervention and matched control groups. Although not significant, a greater reduction in total benzodiazepine prescriptions was observed amongst the highest-volume prescribing physicians who received the intervention (% change in slope = -0.53, 95%CI = -2.34 to 1.30, p > .05). The main limitation of our study was the voluntary nature of the AD intervention, which may have introduced a self-selection bias of physicians most open to changing their prescribing. CONCLUSION This study suggests that future AD interventions should focus on physicians with the greatest room for improvement to their prescribing.
Collapse
Affiliation(s)
- Meagan Lacroix
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Fred Abdelmalek
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Lena Salach
- Centre for Effective Practice, Toronto, Ontario, Canada
| | - Lindsay Bevan
- Centre for Effective Practice, Toronto, Ontario, Canada
| | | | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Leslie Dan faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
McCleary N, Laur C, Presseau J, Dobell G, Lam JM, Gushue S, Hagel K, Bevan L, Salach L, Desveaux L, M. Ivers N. Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing. Implement Res Pract 2023; 4:26334895231206569. [PMID: 37936967 PMCID: PMC10624081 DOI: 10.1177/26334895231206569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work. Method We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized. Results Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]). Conclusions The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.
Collapse
Affiliation(s)
- Nicola McCleary
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Justin Presseau
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Gail Dobell
- Health System Performance & Support, Ontario Health, Toronto, Canada
| | - Jonathan M.C. Lam
- Health System Performance & Support, Ontario Health, Toronto, Canada
| | - Sharon Gushue
- Population Health & Prevention, Ontario Health, Toronto, Canada
| | - Katie Hagel
- Centre for Effective Practice, Toronto, Canada
| | | | - Lena Salach
- Centre for Effective Practice, Toronto, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Noah M. Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| |
Collapse
|
5
|
Kucia-Tran J, Bevan L, Chessari G, Fazal L, Ferrari N, Lyons J, Saini H, Wallis N, Ward G, Ahn M. Low SKP2 expression is predictive of sensitivity to an MDM2 antagonist in p53 wild-type AML. Eur J Cancer 2022. [DOI: 10.1016/s0959-8049(22)01020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
6
|
Mukerji G, Halperin I, Hunter K, Segal P, Wolfs M, Bevan L, Jeffs L, Goguen J. Developing a set of indicators to monitor quality in ambulatory diabetes care using a modified Delphi panel process. Int J Qual Health Care 2018; 30:65-74. [PMID: 29340632 DOI: 10.1093/intqhc/mzx167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 11/24/2017] [Indexed: 12/31/2022] Open
Abstract
Objective There is a large evidence to practice gap in diabetes care with limited performance assessments that capture the full spectrum of care delivery. Our study aimed to develop a set of ambulatory diabetes quality indicators across six domains (effectiveness, safety, patient-centered, timely, equitable and efficient) to provide a broad view of quality. Design A modified Delphi panel process was conducted. Phase I involved compiling a list of indicators through literature review and generation of patient and healthcare provider-derived indicators through interviews and surveys, respectively. Phase II involved panelists rating indicators using the Agency for Healthcare Research and Quality measure attributes on 9-point Likert scale, attending a face-to-face meeting followed by re-rating, and final ranking. Setting This study was conducted across five adult academic medical centers affiliated with the University of Toronto. Participants A multi-disciplinary Delphi panel (n = 16) including patients was assembled. Main Outcome measure For indicator advancement for ranking, ≥75% of panelists' responses in the top tertile (between 7 and 9) with a median composite score of ≥7 was required. Results There were 202 indicators included in the Delphi panel process including 171 from a comprehensive literature review, 14 from patient interviews, and 17 from healthcare provider surveys. Following the first round, 40 indicators proceeded directly to ranking, while 162 indicators were re-rated and distilled down to 12 for ranking. In the final ranking round, the 52 indicators were reduced to 35 including 13 effective, 10 safe, 6 patient-centered, 1 equitable, 3 efficient and 2 timely indicators. Conclusion Thirty-five selected indicators developed with broad stakeholder engagement can be used to monitor quality in diabetes care.
Collapse
Affiliation(s)
- Geetha Mukerji
- Women's College Hospital, 76 Grenville St, Toronto, Ontario M5S 1B2, Canada.,Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Ilana Halperin
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Katie Hunter
- Centre for Effective Practice, 400 University Ave Suite 2100, Toronto, Ontario M5G 1S5, Canada
| | - Phillip Segal
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,University Health Network, 101 College St, Toronto, Ontario M5G 1L7, Canada
| | - Maria Wolfs
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| | - Lindsay Bevan
- Centre for Effective Practice, 400 University Ave Suite 2100, Toronto, Ontario M5G 1S5, Canada
| | - Lianne Jeffs
- St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| | - Jeannette Goguen
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| |
Collapse
|
7
|
Tu K, Bevan L, Hunter K, Rogers J, Young J, Nesrallah G. Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach. CMAJ Open 2017; 5:E74-E81. [PMID: 28401122 PMCID: PMC5378542 DOI: 10.9778/cmajo.20160113] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The detection and management of chronic kidney disease lies within primary care; however, performance measures applicable in the Canadian context are lacking. We sought to develop a set of primary care quality indicators for chronic kidney disease in the Canadian setting and to assess the current state of the disease's detection and management in primary care. METHODS We used a modified Delphi panel approach, involving 20 panel members from across Canada (10 family physicians, 7 nephrologists, 1 patient, 1 primary care nurse and 1 pharmacist). Indicators identified from peer-reviewed and grey literature sources were subjected to 3 rounds of voting to develop a set of quality indicators for the detection and management of chronic kidney disease in the primary care setting. The final indicators were applied to primary care electronic medical records in the Electronic Medical Record Administrative data Linked Database (EMRALD) to assess the current state of primary care detection and management of chronic kidney disease in Ontario. RESULTS Seventeen indicators made up the final list, with 1 under the category Prevalence, Incidence and Mortality; 4 under Screening, Diagnosis and Risk Factors; 11 under Management; and 1 under Referral to a Specialist. In a sample of 139 993 adult patients not on dialysis, 6848 (4.9%) had stage 3 or higher chronic kidney disease, with the average age of patients being 76.1 years (standard deviation [SD] 11.0); 62.9% of patients were female. Diagnosis and screening for chronic kidney disease were poorly performed. Only 27.1% of patients with stage 3 or higher disease had their diagnosis documented in their cumulative patient profile. Albumin-creatinine ratio testing was only performed for 16.3% of patients with a low estimated glomerular filtration rate (eGFR) and for 28.5% of patients with risk factors for chronic kidney disease. Family physicians performed relatively better with the management of chronic kidney disease, with 90.4% of patients with stage 3 or higher disease having an eGFR performed in the previous 18 months and 83.1% having a blood pressure recorded in the previous 9 months. INTERPRETATION We propose a set of measurable indicators to evaluate the quality of the management of chronic kidney disease in primary care. These indicators may be used to identify opportunities to improve current practice in Canada.
Collapse
Affiliation(s)
- Karen Tu
- Institute for Clinical Evaluative Sciences (Tu, Young), Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation (Tu), University of Toronto; Centre for Effective Practice (Bevan); Faculty of Medicine (Hunter, Rogers), University of Toronto; Nephrology Program (Nesrallah), Humber River Hospital; Keenan Research Centre (Nesrallah), The Li Ka Shing Knowledge Institute, Toronto, Ont
| | - Lindsay Bevan
- Institute for Clinical Evaluative Sciences (Tu, Young), Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation (Tu), University of Toronto; Centre for Effective Practice (Bevan); Faculty of Medicine (Hunter, Rogers), University of Toronto; Nephrology Program (Nesrallah), Humber River Hospital; Keenan Research Centre (Nesrallah), The Li Ka Shing Knowledge Institute, Toronto, Ont
| | - Katie Hunter
- Institute for Clinical Evaluative Sciences (Tu, Young), Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation (Tu), University of Toronto; Centre for Effective Practice (Bevan); Faculty of Medicine (Hunter, Rogers), University of Toronto; Nephrology Program (Nesrallah), Humber River Hospital; Keenan Research Centre (Nesrallah), The Li Ka Shing Knowledge Institute, Toronto, Ont
| | - Jess Rogers
- Institute for Clinical Evaluative Sciences (Tu, Young), Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation (Tu), University of Toronto; Centre for Effective Practice (Bevan); Faculty of Medicine (Hunter, Rogers), University of Toronto; Nephrology Program (Nesrallah), Humber River Hospital; Keenan Research Centre (Nesrallah), The Li Ka Shing Knowledge Institute, Toronto, Ont
| | - Jacqueline Young
- Institute for Clinical Evaluative Sciences (Tu, Young), Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation (Tu), University of Toronto; Centre for Effective Practice (Bevan); Faculty of Medicine (Hunter, Rogers), University of Toronto; Nephrology Program (Nesrallah), Humber River Hospital; Keenan Research Centre (Nesrallah), The Li Ka Shing Knowledge Institute, Toronto, Ont
| | - Gihad Nesrallah
- Institute for Clinical Evaluative Sciences (Tu, Young), Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation (Tu), University of Toronto; Centre for Effective Practice (Bevan); Faculty of Medicine (Hunter, Rogers), University of Toronto; Nephrology Program (Nesrallah), Humber River Hospital; Keenan Research Centre (Nesrallah), The Li Ka Shing Knowledge Institute, Toronto, Ont
| |
Collapse
|
8
|
Le Clerc SP, Bateman W, Bevan L, Lockey DJ. Entrapment in an unstable structure. Emerg Med J 2012. [PMID: 23180295 DOI: 10.1136/emermed-2012-201932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- S P Le Clerc
- London's Air Ambulance, The Royal London Hospital, London E1 1BB, UK
| | | | | | | |
Collapse
|
9
|
Laouris Y, Bevan L, Reinking RM, Stuart DG. Associations between force and fatigue in fast-twitch motor units of a cat hindlimb muscle. Can J Physiol Pharmacol 2004; 82:577-88. [PMID: 15523515 DOI: 10.1139/y04-062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Associations were quantified between the control force and fatigue-induced force decline in 22 single fast-twitch-fatigable motor units of 5 deeply anesthetized adult cats. The units were subjected to intermittent stimulation at 1 train/s for 360 s. Two stimulation patterns were delivered in a pseudo-random manner. The first was a 500-ms train with constant interpulse intervals. The second pattern had the same number of stimuli, mean stimulus rate, and stimulus duration, but the stimulus pulses were rearranged to increase the force produced by the units in the control (prefatigue) state. The associations among the control peak tetanic force of these units, 3 indices of fatigue, and total cumulative force during fatiguing contractions were dependent, in part, on the stimulation pattern used to produce fatigue. The associations were also dependent, albeit to a lesser extent, on the force measure (peak vs. integrated) and the fatigue index used to quantify fatigue. It is proposed that during high-force fatiguing contractions, neural mechanisms are potentially available to delay and reduce the fatigue of fast-twitch-fatigable units for brief, but functionally relevant, periods. In contrast, the fatigue of slow-twitch fatigue-resistant units seems more likely to be controlled largely, if not exclusively, by metabolic processes within their muscle cells.Key words: cat, catch-like property, fatigue, force, motor units, size principle.
Collapse
Affiliation(s)
- Y Laouris
- Department of Physiology, University of Arizona College of Medicine, Tucson, AZ 85724, USA
| | | | | | | |
Collapse
|
10
|
Abstract
AIM To prospectively audit stomas and to determine the nature and rate of complications and their relationship with various risk factors and their management. MATERIALS AND METHODS The study was performed prospectively on 97 consecutive patients who had stomas formed between January 2000 to August 2000. Patients were followed up for one year. Risk factors including age, body mass index (BMI), preoperative siting, contour of the abdominal wall, smoking, grade of operating surgeon, emergency or elective procedure, diabetes, type of stoma and suture material used were noted. The type of surgery, and indications for surgery were also recorded. The complications were documented by two qualified stoma nurses and a photographic record taken. Statistical analysis comprising both univariate and multivariate methods, was performed by SPSS 10. RESULTS The mean age was 65 years (standard deviation 16.01, range 16-99) and mean body mass index was 24.5 (standard deviation 4.66, range 15-37). Forty-nine of 97 (50.5%) stomas developed one or more complications. Twenty-three patients experienced retraction, 18 had stomas sited in a skin crease, 16 had early and 12 had late skin excoriation, 12 had detachments and a further 12 had parastomal hernia. Eleven further stoma complications were noted including prolapse, necrosis, ischaemia and sloughing. None of the risk factors achieved statistical significance when analysed against the overall complication rate. However, when the risk factors were analysed against individual complications using univariate logistic regression, a high body mass index was associated with more retractions (P = 0.003), early skin excoriation (P = 0.036) and poor siting (stoma in crease) occurred more commonly in emergencies (P = 0.022). Diabetes was associated with late skin excoriation (P = 0.02). Multivariate logistic regressions confirmed an independent association of body mass index, diabetes and emergency surgery with complications. Forty-five of 49 patients who had complications needed some conservative management such as a convexity appliance. Four patients needed refashioning. CONCLUSION Body mass index, diabetes and emergency surgery were the significant risk factors identified in our study. Overall complications compare favourably with other series. We found that preoperative siting by stoma nurses and the grade of operating surgeon did not affect the outcome.
Collapse
Affiliation(s)
- P J Arumugam
- Colorectal Unit, Singleton Hospital, Sketty, Swansea SA2 8QA, UK.
| | | | | | | | | | | | | |
Collapse
|
11
|
Affiliation(s)
- G T Chiodo
- Department of Public Health Dentistry, Oregon Health Sciences University, Portland 97201-3097, USA.
| | | | | |
Collapse
|
12
|
Abstract
Although osteoporosis in men is increasingly recognized as an important health issue and bone mass appears to be a major determinant of fracture, there remain few data concerning the determinants of bone mass in men. To determine the correlates of bone density in men, we studied a large group of older subjects recruited from three rural communities in the northwestern United States. Three hundred and fifty-five men over the age of 60 years (mean 71.5 +/- 7.4 years) without known disorders of mineral metabolism were recruited by community advertising. Bone mineral density was measured at the lumbar spine, proximal femur and radius by dual-energy X-ray absorptiometry, and factors potentially related to skeletal status were assessed by direct measurements or questionnaire. In univariate analyses weight (positively) and age (negatively) were associated with bone density. After adjustment for these two factors, alcohol intake, osteoarthritis and thiazide use were associated with higher bone density, while previous fractures, gastrectomy, peptic ulcer disease, rheumatoid arthritis, glucocorticoid use, hypertension, previous hyperthyroidism, height loss since age 20 years, chronic lung disease and smoking were related to lower density. In multivariate models, only weight and a history of cancer were related to higher bone mass, and age, previous fracture, rheumatoid arthritis, gastrectomy and hypertension were associated with lower density. These data contribute to the emerging field of osteoporosis in men, and may help in the clinical identification of men at higher risk of osteopenia.
Collapse
Affiliation(s)
- E S Orwoll
- Bone and Mineral Unit, School of Medicine, Oregon Health Sciences University and Portland VA Medical Center (111P), 3181 SW Sam Jackson Park Road, Portland, OR 97201, USA
| | | | | |
Collapse
|
13
|
Chiodo GT, Tolle SW, Bevan L. Experimental therapy research in general dental practice. Gen Dent 2000; 48:22-7. [PMID: 11199548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Affiliation(s)
- G T Chiodo
- Center for Ethics in Health Care, Oregon Health Sciences University, 611 SW Campus Drive, Portland, OR 97201, USA
| | | | | |
Collapse
|
14
|
Abstract
While the benefit of fluoridation in the prevention of dental caries has been overwhelmingly substantiated, the effect of fluoride on bone mineral density is less clear. This cross-sectional study was designed to compare the bone mineral densities of older adults exposed to various levels of fluoride from community water systems. Participants were recruited from 3 rural communities with naturally occurring fluoride in their water systems at 0.03, 0.7, and 2.5 mg/L. All adults, age 60 and over, were eligible if they were ambulatory and had a long-term history (> or = 20 yrs) of ingesting city water. Bone mineral density (BMD) was measured by means of dual-energy x-ray absorptiometry at 3 anatomical sites: lumbar spine, proximal femur, and forearm. A total of 353 white non-Hispanic women and 317 white non-Hispanic men took part in the study. When the data were stratified by city of residence and gender, men and women living in the community with high levels of fluoride in their community water system had significantly higher lumbar spine BMD than their counterparts from the communities with low and moderate fluoride levels. The women in the high-fluoride community had significantly higher proximal femur BMD, but there were no statistically significant differences among men in either proximal femur or forearm BMD. Long-term exposure (> or = 20 yrs) to higher levels of fluoride appears to have a positive impact on lumbar spine and proximal femur BMD. Based on the results of this study, exposure to fluoride at levels considered "optimal" for the prevention of dental caries (from 0.7 to 1.2 mg/L) appears to have no significant impact on bone mineral density. The relationship between higher levels of fluoride exposure and bone mineral density requires further investigation.
Collapse
Affiliation(s)
- K R Phipps
- Oregon Health Sciences University, School of Dentistry, Portland 97201, USA
| | | | | |
Collapse
|
15
|
Thomas SH, Horner JE, Chew K, Connolly J, Dorani B, Bevan L, Bhattacharyya S, Bramble MG, Han KH, Rodgers A, Sen B, Tesfayohannes B, Wynne H, Bateman DN. Paracetamol poisoning in the north east of England: presentation, early management and outcome. Hum Exp Toxicol 1997; 16:495-500. [PMID: 9306135 DOI: 10.1177/096032719701600903] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
1. Paracetamol is increasingly involved in self-poisoning in the United Kingdom and remains a common cause of fatal poisoning. 2. To document the epidemiology and early management of paracetamol poisoning data were collected on consecutive patients with suspected paracetamol poisoning presenting to 6 hospitals in the North East of England over 12 weeks in 1994. 3. There were 400 presentations (attendance rate 1.14/10(3) population/yr) involving 343 persons (45% male). Paracetamol concentrations at 4 h correlated weakly with reported paracetamol dose (R = 0.49, P < 0.0001) and were similar comparing those treated and not treated by gastric decontamination. 4. In 38 (9%) cases paracetamol concentrations were above the appropriate nomogram treatment line, including 3% and 20% of patients who reported ingesting less than and more than 12 g respectively. In 21 patients acetylcysteine treatment was deferred until admission to the ward, the mean delay involved was 2.8 h. 5. One patient died, from arrhythmias caused by co-ingested dothiepin. 6. Paracetamol poisoning is common. Most cases do not have potentially toxic plasma paracetamol concentrations, but those who do often present late and antidotal treatment may be delayed inappropriately.
Collapse
Affiliation(s)
- S H Thomas
- Wolfson Unit of Clinical Pharmacology, University of Newcastle upon Tyne, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Thomas SH, Lewis S, Bevan L, Bhattacharyya S, Bramble MG, Chew K, Connolly J, Dorani B, Han KH, Horner JE, Rodgers A, Sen B, Tesfayohannes B, Wynne H, Bateman DN. Factors affecting hospital admission and length of stay of poisoned patients in the north east of England. Hum Exp Toxicol 1996; 15:915-9. [PMID: 8938488 DOI: 10.1177/096032719601501109] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
1. Poisoning is a common reason for presentation to hospital and hospital admission but there is no agreed policy for managing these patients. This study examined the management of patients presenting with poisoning and the factors affecting the probability of hospital admission and prolonged stay. 2. Data on all cases of poisoning presenting to six Accident and Emergency departments in the North East of England over 12 weeks in 1994 was collected prospectively from A&E notes. Length of stay and outcome were recorded from hospital computer records. 3. Overall, 73% of patients were admitted to a medical ward. Probability of admission was not independently affected by age or gender but was increased in those with intentional poisoning (Odds Ratio (OR) 3.3 [95% CI 1.8, 6.1]), a history of self harm (OR 1.7, [1.0, 2.9]) or potentially hazardous poisoning (OR 3.7 [2.1, 6.6]). There were significant variations between hospitals (50-80%) which could not be attributed to case mix. 4. Prolonged stay (> 2 nights) was more common in patients over 65 years (OR 6.8 [2.9, 16.1]), those with intentional poisoning (OR 2.7 [1.1, 6.6]) and those with potentially hazardous poisoning (OR 2.6 [1.4, 4.9]). Mean hospital stay was 1.5 days and varied significantly between hospitals from 0.8 to 2.1 days and this was independent of case mix. 5. There are appreciable variations in the management of poisoning between hospitals which are not explained by patient characteristics. Savings would occur if rates of admission and duration of stay were reduced by those hospitals where admission is more frequent or hospital stay is longer. However, the impact of this on long term morbidity is unknown.
Collapse
Affiliation(s)
- S H Thomas
- Wolfson Unit of Clinical Pharmacology, University of Newcastle upon Tyne, Newcastle
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Thomas SH, Bevan L, Bhattacharyya S, Bramble MG, Chew K, Connolly J, Dorani B, Han KH, Horner JE, Rodgers A, Sen B, Tesfayohannes B, Wynne H, Bateman DN. Presentation of poisoned patients to accident and emergency departments in the north of England. Hum Exp Toxicol 1996; 15:466-70. [PMID: 8793528 DOI: 10.1177/096032719601500602] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
1. A 12 week prospective survey of all patients of any age with confirmed or suspected poisoning presenting to six accident and emergency departments in the North East of England was performed to establish the local incidence and patterns of presentation of poisoning. 2. 945 episodes of poisoning involving 852 patients were recorded representing approximately 1.2% of all A&E presentations and suggesting an annual attendance rate of 2.7 per 1000 persons per year. 3. Attendance rates varied threefold between hospitals and were similar in males and females overall; between the ages of five and 14 attendances were more common in females (1.9 vs 0.6/10(3)/y) while between 0 and 4 y (3.1 vs 2.4) and 25 and 34 y (3.9 vs 2.9/10(3)/y) they were more common in males. 4. The median interval between poisoning and presentation was 2 h (mean 4.1 h) and only 19% of cases presented within 1 h. Presentation was most common between Friday evening and Tuesday morning and in the late afternoon and evening. 5. 6% of the patients presented more than once with poisoning during the study period and 37% had a past history of deliberate self-harm. The most common poisons involved were paracetamol (43%), opioids (15%) and benzodiazepines (15%). 6. The study illustrates the frequency of presentations of poisoning to A&E departments. The high rate of poisoning in young men and the increasing use of paracetamol are particular causes for concern.
Collapse
Affiliation(s)
- S H Thomas
- Wolfson Unit of Clinical Pharmacology, University of Newcastle upon Tyne
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
1. Previous studies have used tendon vibration to investigate kinesthetic illusions in the isometric limb and end point control in the moving limb. These previous studies have shown that vibration distorts the perceptions of static joint angle and movement and causes systematic errors in the end point of movement. In this paper we describe the effects of tendon vibration during movement while human subjects performed a proprioceptively coordinated motor task. In an earlier study we showed that the CNS coordinates this motor task-a movement sequence-with proprioceptive information related to the dynamic position and velocity of the limb. 2. When performing this movement sequence, each subject sat at a table and opened the right hand as the right elbow was passively rotated in the extension direction through a prescribed target angle. Vision of the arm was prevented, and the movement velocity was changed randomly from trial to trial, leaving proprioception as the only useful source of kinematic information with which to perform the task. 3. In randomly occurring trials, vibration was applied to the tendon of the biceps brachii, a muscle that lengthens during elbow extension. In some experiments the timing of tendon vibration was varied with respect to the onset of elbow rotation, and in other experiments the frequency of vibration was varied. In each experiment we compared the accuracy of the subject's response (i.e., the elbow angle at which the subject opened the hand) in trials with tendon vibration with the accuracy in trials without tendon vibration. 4. The effect of tendon vibration depended on the frequency of vibration. When the biceps tendon was vibrated at 20 Hz, subjects opened the hand after the elbow passed through the target angle ("overshooting"). Overshooting is consistent with an underestimate of the actual displacement or velocity of the elbow. Vibration at 30 Hz had little or no effect on the elbow angle at hand opening. Vibration at 40 Hz caused subjects to open the hand before the elbow reached the target angle ("undershooting"). Undershooting is consistent with an overestimate of the actual displacement or velocity of the elbow. The size of the error depended on the velocity of the passively imposed elbow rotation. 5. The effect of tendon vibration also depended on the timing of vibration. If 40-Hz vibration began at the onset of movement, the subject undershot the target. If 40-Hz vibration started 5 s before movement onset and continued throughout the movement, the undershoot error increased in magnitude. However, if 40-Hz vibration started 5 s before movement onset and then stopped at movement onset, the subject overshot the target. When vibration was shut off during movement, a transition occurred from an over-shooting error to an undershooting error at a time that depended on the velocity of elbow rotation. 6. In a separate experiment, subjects were instructed to match either the perceived dynamic position or the perceived velocity of rotation imposed on the right elbow by actively rotating the left elbow. In both matching tasks, tendon vibration produced oppositely directed errors depending on the frequency of vibration. Vibration at 20 Hz produced a perception of decreased elbow velocity and a bias in dynamic position in the flexion direction, and vibration at 40 Hz produced the opposite perceptions. 7. We conclude that muscle spindle afferents, which are activated by tendon vibration, are an important source of the dynamic position and velocity information that the CNS uses to coordinate this movement sequence task. The observed effects of vibration timing and frequency suggest that perceptual changes evoked by vibration cannot be explained by the simple summation of sensory input evoked by movement and by vibration. Rather, the bias in perception produced by vibration appears to be related to the difference between vibration- and movement-evoked activity in muscle spindle afferents.
Collapse
Affiliation(s)
- P Cordo
- Robert S. Dow Neurological Sciences Institute, Legacy Good Samaritan Hospital and Medical Center, Portland, Oregon 97209, USA
| | | | | | | |
Collapse
|
19
|
Cordo P, Bevan L, Gurfinkel V, Carlton L, Carlton M, Kerr G. Proprioceptive coordination of discrete movement sequences: mechanism and generality. Can J Physiol Pharmacol 1995; 73:305-15. [PMID: 7621369 DOI: 10.1139/y95-041] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A "discrete" movement sequence is defined as a movement with a single goal that involves a series of overlapping joint rotations. Reaching-and-grasping and throwing are examples of discrete movement sequences. The central nervous system (CNS) can use reafferent proprioceptive information from one joint rotation in a sequence to coordinate subsequent rotations at other joints. The experiments reported in this paper demonstrate how the human CNS uses proprioceptive information to coordinate discrete movement sequences. We examined the mechanism (at an information processing level) underlying proprioceptive coordination and the generality (i.e., the boundary conditions) of these mechanisms as they apply to everyday movement sequences. Adult human subjects performed a discrete movement sequence that resembles backhand throwing: elbow extension followed by hand opening. The task was to open the hand as the elbow passed through a prescribed "target" angle. We eliminated visual information and made the arrival time at the target angle unpredictable so that the available kinematic information was provided exclusively by proprioception. The subjects were capable of performing this motor task with a high degree of precision, thereby demonstrating that the nervous system can use proprioceptive input to coordinate discrete movement sequences. Our data indicate that precise coordination is achieved by extracting kinematic information related to both the velocity of elbow rotation as well as the elbow position during movement (i.e., "dynamic position"). Dynamic position information appears to be encoded as both absolute joint angle and angular distance, although more precisely as angular distance. Although our experiments were conducted under rather restrictive laboratory conditions, this mechanism of motor coordination might also apply to everyday movement. Our results suggest that this mechanism could be employed for passive as well as active movement sequences, with and without opposing loads; it could exert its influence in discrete movement sequences as brief as 210 ms or as long as 1.5 s; and it does not involve any significant degree of learning (this proprioceptive mechanism appears to be readily available for use on the first attempt of a novel motor task).
Collapse
Affiliation(s)
- P Cordo
- Robert S. Dow Neurological Sciences Institute, Legacy Good Samaritan Hospital and Medical Center, Portland, OR 97209, USA
| | | | | | | | | | | |
Collapse
|
20
|
Bevan L, Cordo P, Carlton L, Carlton M. Proprioceptive coordination of movement sequences: discrimination of joint angle versus angular distance. J Neurophysiol 1994; 71:1862-72. [PMID: 8064353 DOI: 10.1152/jn.1994.71.5.1862] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
1. The purpose of these experiments was to determine the accuracy with which human subjects could discriminate proprioceptive (nonretinotopic) targets during movement. The targets were located at either a specified angle in joint space, or a specified angular distance from an initial joint angle. 2. In these experiments the right elbows of normal human subjects were passively extended from either predictable or unpredictable starting angles. The subjects were instructed to open the right hand to indicate that the elbow was passing through a target joint angle or a target angular distance. The subjects were not given visual information about the location of the elbow, so they had to rely on proprioceptive input to perform this task. The target (criterion joint angle or angular distance) was learned by the use of proprioception during 8-15 practice trials. 3. Four experiments were conducted. In three experiments the target was located at a constant joint angle, and in the fourth experiment the target was located at a constant angular distance from the starting angle. The starting angle in all four experiments was pseudorandomly varied from trial to trial. 4. On the basis of an analysis of constant errors, subjects were more accurate at discriminating angular distance than joint angle. The slope of the relationship between the starting position and the constant errors was dictated by the task requirement. 5. In the distance discrimination experiment, when the starting angle was more flexed than the intermediate (i.e., central) position, the subjects slightly overshot the target distance. Conversely, when the starting angle was more extended than the intermediate position, the subjects slightly undershot the target distance. 6. In the joint angle discrimination experiments, the opposite results were obtained. Subjects overshot the target when the starting position of the elbow was more extended than the intermediate starting position, and they undershot the target when the starting position was more flexed than the intermediate starting position. The amplitude of these systematic errors increased when the subjects were unaware that the initial angle of their elbow was variable. 7. It is concluded that, in kinesthetic tasks of this type, the discrimination of angular distance is more accurate than the discrimination of joint angle. We hypothesize that the nervous system extracts kinematic information related to both joint angle and angular distance from proprioceptors, and that the encoding and or decoding of angular distance is more accurate than that of absolute joint angle.(ABSTRACT TRUNCATED AT 400 WORDS)
Collapse
Affiliation(s)
- L Bevan
- Robert S. Dow Neurological Sciences Institute, Good Samaritan Hospital and Medical Center, Portland, Oregon 97209
| | | | | | | |
Collapse
|
21
|
Abstract
1. Recent studies have shown that the CNS uses proprioceptive information to coordinate multijoint movement sequences; proprioceptive input related to the kinematics of one joint rotation in a movement sequence can be used to trigger a subsequent joint rotation. In this paper we adopt a broad definition of "proprioception," which includes all somatosensory information related to joint posture and kinematics. This paper addresses how the CNS uses proprioceptive information related to the velocity and position of joints to coordinate multijoint movement sequences. 2. Normal human subjects sat at an experimental apparatus and performed a movement sequence with the right arm without visual feedback. The apparatus passively rotated the right elbow horizontally in the extension direction with either a constant velocity trajectory or an unpredictable velocity trajectory. The subjects' task was to open briskly the right hand when the elbow passed through a prescribed target position, similar to backhand throwing in the horizontal plane. The randomization of elbow velocities and the absence of visual information was used to discourage subjects from using any information other than proprioceptive input to perform the task. 3. Our results indicate that the CNS is able to extract the necessary kinematic information from proprioceptive input to trigger the hand opening at the correct elbow position. We estimated the minimal sensory conduction and processing delay to be 150 ms, and on the basis of this estimate, we predicted the expected performance with different degrees of reduced proprioceptive information. These predictions were compared with the subjects' actual performances, revealing that the CNS was using proprioceptive input related to joint velocity in this motor task. To determine whether position information was also being used, we examined the subjects' performances with unpredictable velocity trajectories. The results from experiments with unpredictable velocity trajectories indicate that the CNS extracts proprioceptive information related to both the velocity and the angular position of the joint to trigger the hand movement in this movement sequence. 4. To determine the generality of proprioceptive triggering in movement sequences, we estimated the minimal movement duration with which proprioceptive information can be used as well as the amount of learning required to use proprioceptive input to perform the task. The temporal limits for proprioceptive processing in this movement task were established by determining the minimal movement time during which the task could be performed.(ABSTRACT TRUNCATED AT 400 WORDS)
Collapse
Affiliation(s)
- P Cordo
- Robert S. Dow Neurological Sciences Institute, Good Samaritan Hospital and Medical Center, Portland, Oregon 97209
| | | | | | | | | |
Collapse
|
22
|
Abstract
Motor coordination has been too poorly defined to be a useful construct in studying the control of movement. In general, motor coordination involves controlling both the timing and the kinematics of movement. Yet the motor behaviors typically used for the study of coordination have required controlling only the timing or the spatial aspects of a movement. To understand better the basis of motor behavior, this study examined movement sequences, a class of movement in which both the timing and the kinematics must be controlled. In one experiment we studied a reaching and grasping movement sequence to characterize the central coordination of movement sequences. In another experiment we studied a throwing movement sequence to characterize the peripheral (kinesthetic) coordination of movement sequences. An heuristic model is presented to explain how central and peripheral mechanisms of coordination might interact to produce accurate movement.
Collapse
Affiliation(s)
- P Cordo
- Robert S. Dow Neurological Sciences Institute of the Good Samaritan Hospital and Medical Center, Portland, OR 97209
| | | | | | | | | |
Collapse
|
23
|
Bevan L, Laouris Y, Garland SJ, Reinking RM, Stuart DG. Prolonged depression of force developed by single motor units after their intermittent activation in adult cats. Brain Res Bull 1993; 30:127-31. [PMID: 8420622 DOI: 10.1016/0361-9230(93)90048-g] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The fatigue of fast-twitch, glycolytic mammalian motor units [i.e., type FF; nomenclature of (3)] is dependent, in part, on the stimulation regimen (total number of stimuli, frequency, duty cycle, temporal patterning of stimuli, etc.) used to induce fatigue. To study the effect of the temporal pattern of the stimulus train on the rate and extend of fatigue in single FF units, one theoretically acceptable approach would be to use each motor unit as its own control: i.e., a sequential testing with two fatigue tests that differ only in the temporal organization of their stimuli. The purpose of this communication is to provide evidence that such an approach is not feasible when studying FF units, due to the delayed recovery of force following their repetitive activation. It was shown that 1/s activation of single FF units for only 15 or 45 s with intermittent 40-Hz, 300-ms duration trains significantly reduced their force response to a double-pulse shock for several hours. This finding suggests that in studies designed to test for the effects of different stimulation patterns on the fatigue of single motor units, deeply anaesthetized, reduced animal preparations are not appropriate models for the sequential application of different stimulation regimens to fast-twitch, glycolytic, mammalian motor units.
Collapse
Affiliation(s)
- L Bevan
- Department of Physiology, College of Medicine, University of Arizona, Tucson 85724
| | | | | | | | | |
Collapse
|
24
|
|
25
|
|
26
|
Abstract
1. The main purpose of this study was to examine the effects of two subtly different stimulus patterns on the force developed by fast-twitch, fatiguable motor units in a cat hindlimb muscle during control (pre-fatigue) and fatiguing contractions. 2. The peak force and the force-time integral responses of nineteen high fatigue (FF) and three intermediate fatigue (FI) motor units of the tibialis posterior muscle in five deeply anaesthetized adult cats were measured at selected times during the course of a 360-s fatigue test. 3. The fatigue test involved a pseudo-random alternation of two patterns of stimulation. One pattern (regular) was composed of a train of stimuli with constant interpulse intervals, set at 1.8 x the twitch contraction time of each unit (interval range, 27-51 ms), and delivered for 500 (or 400) ms. For the total (FF + FI) motor-unit sample, the mean (+/- S.D.) stimulation frequency was 26 +/- 4 Hz (range, 19-37 Hz). The other stimulus pattern (optimized) consisted of three initial stimuli with short (10 ms) interpulse intervals, followed by a constant interpulse-interval train that was adjusted (interval range, 29-62 ms; frequency, 23 +/- 5 Hz; frequency range, 16-36 Hz) such that the total train had the same number of pulses, and the same average frequency and duration as the regular train. 4. The stimulus trains were delivered at 1 s-1 for 360 s, using three-train sequences of each pattern, randomly alternating with one another. The response of the third train in each sequence was selected for the force measurements. The force profile obtained from the fatigue test was subsequently decomposed into two profiles: one attributable to regular and one to optimized stimulation. 5. During the initial responses to the fatigue test, the optimized stimulus pattern produced significantly more force than the regular stimulus pattern. For FF units, the mean increase in peak force (141%) was significantly greater than the increase in the force-time integral (59%). 6. All motor units exhibited an initial potentiation of peak force with the regular stimulation pattern, whereas peak force declined monotonically with the optimized pattern. In contrast, the force-time integral potentiated in the first 30 s for both regular and optimized stimulus patterns. 7. Each motor unit maintained an increased force response to optimized stimulation during the fatigue test, with the greatest relative increase occurring about 120 s into the test, well after the potentiation effect had subsided.(ABSTRACT TRUNCATED AT 400 WORDS)
Collapse
Affiliation(s)
- L Bevan
- Department of Physiology, University of Arizona, Tucson 85724
| | | | | | | |
Collapse
|
27
|
Abstract
The purpose of this study was to quantify the changes in motor-unit action potentials (MUAP) and force during a standard motor-unit fatigue test. MUAP waveforms were characterized by the measurement of amplitude, duration, area, and shape (as reflected in a coefficient of proportionality). Fatigue-resistant motor units exhibited small, but statistically significant, changes in MUAP amplitude and area during the fatigue test, whereas fatigable motor units displayed variable changes in MUAP amplitude, duration, and area. For all motor-unit types, the coefficient of proportionality did not change, and hence the change in MUAP area was proportional to the combined changes in amplitude and duration. The between- and within-train changes in MUAP were also distinct for the fatigue-resistant and fatigable motor units. Although several mechanisms could be responsible for the changes in the MUAP as the fatigue test proceeded, the dissociation of the time courses for MUAP and force indicated that these MUAP changes were not the principal reason for the decline in force under these conditions.
Collapse
Affiliation(s)
- R M Enoka
- Department of Physiology, University of Arizona, Tucson 85721
| | | | | | | | | | | |
Collapse
|
28
|
Abstract
The purpose of this study was to determine the effect of a reduced ventilatory frequency (Vf) on blood gases and acid-base changes during three intensities of cycling exercise. VO2max and lactate threshold workload (LaT) of six subjects were assessed on a Monark ergometer. Experimental rides were performed 1) with no restriction on Vf (NB) and 2) with a prescribed Vf of 10/min (CFB). Each exercise period consisted of 8 min at 10% of VO2max below the LaT (WI), followed immediately by 8 min at LaT (WII), followed immediately by 8 min at 10% of VO2max above LaT (WIII). Blood was taken from a heated fingertip at the end of each load and analyzed for lactate concentration, pH, PO2, and PCO2. Respiratory exchange was monitored continuously using open circuit indirect calorimetry. Minute ventilation (VE) was significantly reduced by CFB at all three workloads. The reduced VE resulted in lower (p less than 0.05) blood PO2 at each workload (p less than 0.05), however, neither blood lactate nor VO2 were significantly different between CFB and NB for the three loads. Blood [H+] was significantly higher in CFB than NB at all three loads with the greatest difference between trials at WIII (NB: 37.93 +/- 0.68 nM: CFB: 44.77 +/- 1.02 nM). This was accounted for by a significantly higher PCO2 during CFB in WII and WIII (WII, NB: 33.0 +/- 1.4 mmHg, CFB: 35.7 +/- 2.7 mmHg; WIII, NB: 31.2 +/- 1.7 mmHg, CFB: 38.9 +/- 2.4 mmHg).(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- R L Sharp
- Department of Physical Education, Iowa State University
| | | | | |
Collapse
|
29
|
Enoka R, Laouris Y, Reinking R, Trayanova N, Bevan L, Stuart D. Quantification of neuromuscular-propagation failure in single motor units of cats during a fatigue test. J Biomech 1989. [DOI: 10.1016/0021-9290(89)90197-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
30
|
Abstract
Corpora lutea were surgically collected from superovulated ewes 36 h post-injection of human chorionic gonadotropin (hCG) (Day 2), dissociated (0.2% collagenase), plated, and maintained in culture Days 2-10 in Medium 199 supplemented with 5% calf serum. Accumulation of progesterone in the cultures did not decrease (p greater than 0.05) from Day 3 (17.5 +/- 5.1 nmol/10(6) cells) to Day 10 (4.8 +/- 1.7 nmol/10(6) cells). Calf serum (5%) in the medium supported greater (p less than 0.05) progesterone production than fetal calf serum (5%) or medium without added serum. Steroidogenic cells did not increase (Days 2-10) in numbers, but increased (p less than 0.01) in mean cell diameter (Day 2, 11.7 +/- 0.4 micron; Day 10, 24.5 +/- 1.6 micron). Steroidogenic capacity on Day 10 of cells cultured Days 2-10 (in vitro) was not different (p greater than 0.05) from that of cells collected from the ovary on Day 10 (in vivo); however, steroidogenic cells recovered from plates had greater (p less than 0.01) mean cell diameters (24.5 +/- 1.6 micron, in vitro, compared to 15.2 +/- 1.0 micron, in vivo). Transmission electron microscopy revealed that cultured cells (Days 5, 10) possessed less smooth endoplasmic reticulum but more lipid droplet inclusions, ribosomes, and rough endoplasmic reticulum than cells obtained in situ (Day 10). Electron-dense secretory granules were rarely seen. Although subcellular morphology of ovine luteal cells in culture was altered, these changes did not appear to significantly affect the ability of these cells to produce progesterone.
Collapse
Affiliation(s)
- P B Hoyer
- Department of Physiology, University of Arizona, Tucson 85724
| | | | | | | | | |
Collapse
|
31
|
Sharp RL, Perkins DR, Bevan L. EFFECT OF METABOLIC ALKALOSIS ON MUSCLE AND BLOOD ACID-BASE STATUS F0LL0WING INTERMITTENT, INCREMENTAL EXERCISE TO EXHAUSTION. Med Sci Sports Exerc 1985. [DOI: 10.1249/00005768-198504000-00340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
32
|
Stanford PD, Williams DJ, Sharp RL, Bevan L. EFFECT OF REDUCED BREATHING FREQUENCY DURING EXERCISE ON BLOOD GASES AND ACID-BASE STATUS. Med Sci Sports Exerc 1985. [DOI: 10.1249/00005768-198504000-00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
33
|
Bevan L, Sharp RL, Stanford PD. THE EFFECTS OF EIGHT WEEKS OF SPRINT TRAINING ON THE CONCENTRATION OF CARNOSINE IN HUMAN SKELELTAL MUSCLE. Med Sci Sports Exerc 1985. [DOI: 10.1249/00005768-198504000-00053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
34
|
Bevan L, Sharp RL, Hutchison WW, Runyan WS. THE INTERACTIVE EFFECTS OF DIET AND PROLONGED EXERCISE ON ACID-BASE BALANCE. Med Sci Sports Exerc 1984. [DOI: 10.1249/00005768-198404000-00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
35
|
|
36
|
|
37
|
|
38
|
|
39
|
|