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1.  Adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers 
Objective:
Evidence-based practice (EBP) provides nurses with a method to use critically appraised and scientifically proven evidence for delivering quality health care to a specific population. The objective of this study was to explore nurses' awareness of, knowledge of, and attitude toward EBP and factors likely to encourage or create barriers to adoption. In addition, information sources used by nurses and their literature searching skills were also investigated.
Method:
A total of 2,100 copies of the questionnaire were distributed to registered nurses in 2 public hospitals in Singapore, and 1,486 completed forms were returned, resulting in a response rate of 70.8%.
Results:
More than 64% of the nurses expressed a positive attitude toward EBP. However, they pointed out that due to heavy workload, they cannot keep up to date with new evidence. Regarding self-efficacy of EBP-related abilities, the nurses perceived themselves to possess moderate levels of skills. The nurses also felt that EBP training, time availability, and mentoring by nurses with EBP experience would encourage them to implement EBP. The top three barriers to adopting EBP were lack of time, inability to understand statistical terms, and inadequate understanding of the jargon used in research articles. For literature searching, nurses were using basic search features and less than one-quarter of them were familiar with Boolean and proximity operators.
Conclusion:
Although nurses showed a positive attitude toward EBP, certain barriers were hindering their smooth adoption. It is, therefore, desirable that hospital management in Southeast Asia, particularly in Singapore, develop a comprehensive strategy for building EBP competencies through proper training. Moreover, hospital libraries should also play an active role in developing adequate information literacy skills among the nurses.
doi:10.3163/1536-5050.99.3.010
PMCID: PMC3133901  PMID: 21753915
2.  Robotic-Assisted Minimally Invasive Surgery for Gynecologic and Urologic Oncology 
Executive Summary
Objective
An application was received to review the evidence on the ‘The Da Vinci Surgical System’ for the treatment of gynecologic malignancies (e.g. endometrial and cervical cancers). Limitations to the current standard of care include the lack of trained physicians on minimally invasive surgery and limited access to minimally invasive surgery for patients. The potential benefits of ‘The Da Vinci Surgical System’ include improved technical manipulation and physician uptake leading to increased surgeries, and treatment and management of these cancers.
The demand for robotic surgery for the treatment and management of prostate cancer has been increasing due to its alleged benefits of recovery of erectile function and urinary continence, two important factors of men’s health. The potential technical benefits of robotic surgery leading to improved patient functional outcomes are surgical precision and vision.
Clinical Need
Uterine and cervical cancers represent 5.4% (4,400 of 81,700) and 1.6% (1,300 of 81,700), respectively, of incident cases of cancer among female cancers in Canada. Uterine cancer, otherwise referred to as endometrial cancer is cancer of the lining of the uterus. The most common treatment option for endometrial cancer is removing the cancer through surgery. A surgical option is the removal of the uterus and cervix through a small incision in the abdomen using a laparoscope which is referred to as total laparoscopic hysterectomy. Risk factors that increase the risk of endometrial cancer include taking estrogen replacement therapy after menopause, being obese, early age at menarche, late age at menopause, being nulliparous, having had high-dose radiation to the pelvis, and use of tamoxifen.
Cervical cancer occurs at the lower narrow end of the uterus. There are more treatment options for cervical cancer compared to endometrial cancer, however total laparoscopic hysterectomy is also a treatment option. Risk factors that increase the risk for cervical cancer are multiple sexual partners, early sexual activity, infection with the human papillomavirus, and cigarette smoking, whereas barrier-type of contraception as a risk factor decreases the risk of cervical cancer.
Prostate cancer is ranked first in men in Canada in terms of the number of new cases among all male cancers (25,500 of 89,300 or 28.6%). The impact on men who develop prostate cancer is substantial given the potential for erectile dysfunction and urinary incontinence. Prostate cancer arises within the prostate gland, which resides in the male reproductive system and near the bladder. Radical retropubic prostatectomy is the gold standard treatment for localized prostate cancer. Prostate cancer affects men above 60 years of age. Other risk factors include a family history of prostate cancer, being of African descent, being obese, consuming a diet high in fat, physical inactivity, and working with cadium.
The Da Vinci Surgical System
The Da Vinci Surgical System is a robotic device. There are four main components to the system: 1) the surgeon’s console, where the surgeon sits and views a magnified three-dimensional image of the surgical field; 2) patient side-cart, which sits beside the patient and consists of three instrument arms and one endoscope arm; 3) detachable instruments (endowrist instruments and intuitive masters), which simulate fine motor human movements. The hand movements of the surgeon’s hands at the surgeon’s console are translated into smaller ones by the robotic device and are acted out by the attached instruments; 4) three-dimensional vision system: the camera unit or endoscope arm. The main advantages of use of the robotic device are: 1) the precision of the instrument and improved dexterity due to the use of “wristed” instruments; 2) three-dimensional imaging, with improved ability to locate blood vessels, nerves and tissues; 3) the surgeon’s console, which reduces fatigue accompanied with conventional laparoscopy surgery and allows for tremor-free manipulation. The main disadvantages of use of the robotic device are the costs including instrument costs ($2.6 million in US dollars), cost per use ($200 per use), the costs associated with training surgeons and operating room personnel, and the lack of tactile feedback, with the trade-off being increased visual feedback.
Research Questions
For endometrial and cervical cancers,
1. What is the effectiveness of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
2. What are the incremental costs of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
For prostate cancer,
3. What is the effectiveness of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
4. What are the incremental costs of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
Research Methods
Literature Search
Search Strategy
A literature search was performed on May 12, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, Wiley Cochrane, CINAHL, Centre for Reviews and Dissemination/International Agency for Health Technology Assessment for studies published from January 1, 2000 until May 12, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low or very low according to GRADE methodology.
Inclusion Criteria
English language articles (January 1, 2000-May 12, 2010)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a primary data source (e.g. obtained in a clinical setting)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a secondary data source (e.g. hospital- or population-based registries)
Study design and methods must be clearly described
Health technology assessments, systematic reviews, randomized controlled trials, non-randomized controlled trials and/or cohort studies, case-case studies, regardless of sample size, cost-effectiveness studies
Exclusion Criteria
Duplicate publications (with the more recent publication on the same study population included)
Non-English papers
Animal or in-vitro studies
Case reports or case series without a referent or comparison group
Studies on long-term survival which may be affected by treatment
Studies that do not examine the cancers (e.g. advanced disease) or outcomes of interest
Outcomes of Interest
For endometrial and cervical cancers,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Number of complications*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of conversions to laparotomy*
Number of lymph nodes recovered
For prostate cancer,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Amount of morphine use/pain*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of transfusions*
- Duration of catheterization
- Number of complications*
- Number of anastomotic strictures*
Number of lymph nodes recovered
Oncologic factors
- Proportion of positive surgical margins
Long-term outcomes
- Urinary continence
- Erectile function
Summary of Findings
Robotic use for gynecologic oncology compared to:
Laparotomy: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations.
The beneficial effect of robotic surgery was shown in pooled analysis for complications, owing to increased sample size.
More work is needed to clarify the role of complications in terms of safety, including improved study designs, analysis and measurement.
Laparoscopy: benefits of robotic surgery in terms of shorter length of hospitalization, less blood loss and fewer conversions to laparotomy likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for length of hospitalizations and blood loss is low.
Fewer conversions to laparotomy indicate clinical effectiveness in terms of reduced morbidity.
Robotic use for urologic oncology, specifically prostate cancer, compared to:
Retropubic surgery: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss/fewer individuals requiring transfusions. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations. There was a beneficial effect in terms of decreased positive surgical margins and erectile dysfunction. These results indicate clinical effectiveness in terms of improved cancer control and functional outcomes, respectively, in the context of study design limitations.
Surgeon skill had an impact on cancer control and functional outcomes.
The results for complications were inconsistent when measured as either total number of complications, pain management or anastomosis. There is some suggestion that robotic surgery is safe with respect to less post-operative pain management required compared to retropubic surgery, however improved study design and measurement of complications need to be further addressed.
Clinical significance of significant findings for length of hospitalizations is low.
Laparoscopy: benefits of robotic surgery in terms of less blood loss and fewer individuals requiring transfusions likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for blood loss is low.
The potential link between less blood loss, improved visualization and improved functional outcomes is an important consideration for use of robotics.
All studies included were observational in nature and therefore the results must be interpreted cautiously.
Economic Analysis
The objective of this project was to assess the economic impact of robotic-assisted laparoscopy (RAL) for endometrial, cervical, and prostate cancers in the province of Ontario.
A budget impact analysis was undertaken to report direct costs associated with open surgery (OS), endoscopic laparoscopy (EL) and robotic-assisted laparoscopy (RAL) based on clinical literature review outcomes, to report a budget impact in the province based on volumes and costs from administrative data sets, and to project a future impact of RAL in Ontario. A cost-effectiveness analysis was not conducted because of the low quality evidence from the clinical literature review.
Hospital costs were obtained from the Ontario Case Costing Initiative (OCCI) for the appropriate Canadian Classification of Health Intervention (CCI) codes restricted to selective ICD-10 diagnostic codes after consultation with experts in the field. Physician fees were obtained from the Ontario Schedule of Benefits (OSB) after consultation with experts in the field. Fees were costed based on operation times reported in the clinical literature for the procedures being investigated. Volumes of procedures were obtained from the Ministry of Health and Long-Term Care (MOHLTC) administrative databases.
Direct costs associated with RAL, EL and OS included professional fees, hospital costs (including disposable instruments), radiotherapy costs associated with positive surgical margins in prostate cancer and conversion to OS in gynecological cancer. The total cost per case was higher for RAL than EL and OS for both gynecological and prostate cancers. There is also an acquisition cost associated with RAL. After conversation with the only supplier in Canada, hospitals are looking to spend an initial 3.6M to acquire the robotic surgical system
Previous volumes of OS and EL procedures were used to project volumes into Years 1-3 using a linear mathematical expression. Burden of OS and EL hysterectomies and prostatectomies was calculated by multiplying the number of cases for that year by the cost/case of the procedure.
The number of procedures is expected to increase in the next three years based on historical data. RAL is expected to capture this market by 65% after consultation with experts. If it’s assumed that RAL will capture the current market in Ontario by 65%, the net impact is expected to be by Year 3, 3.1M for hysterectomy and 6.7M for prostatectomy procedures respectively in the province.
RAL has diffused in the province with four surgical systems in place in Ontario, two in Toronto and two in London. RAL is a more expensive technology on a per case basis due to more expensive robot specific instrumentation and physician labour reflected by increased OR time reported in the clinical literature. There is also an upfront cost to acquire the machine and maintenance contract. RAL is expected to capture the market at 65% with project net impacts by Year 3 of 3.1M and 6.7M for hysterectomy and prostatectomy respectively.
PMCID: PMC3382308  PMID: 23074405
3.  Evidence-Based Practice 
Objectives:
The aim of this study was to describe nurses’ practices, attitudes, knowledge/skills and perceived barriers in relation to evidence-based practice (EBP) in Oman.
Methods:
This descriptive cross-sectional study was conducted between February and November 2012. A self-reported 24-item questionnaire was used to measure EBP practices, attitudes and knowledge/skills among a convenience sample of 600 nurses working in four governmental hospitals in Muscat, Oman. Responses were scored on a one to seven rating scale. Barriers to EBP were measured on a five-point Likert scale using two subscales. Descriptive statistics and general linear regression were used to analyse the data.
Results:
A total of 414 nurses were included in the study. The greatest barriers to developing EBP among nurses were insufficient time for research (3.51 ± 0.97) and insufficient resources to change practices (3.64 ± 0.99). Nurses with more years of experience reported increased use of EBP (P <0.01), more positive attitudes towards EBP (P <0.001) and fewer barriers to research (P <0.01). Significant positive correlations were found between years of experience and practice (r = 0.16) and attitudes (r = 0.20). Nurses with a baccalaureate degree reported fewer barriers to research than those qualified at a diploma level (P <0.001). Nurses who perceived more barriers to research reported less use of EBP (P <0.001), less positive attitudes towards EBP (P <0.001) and limited EBP knowledge/skills (P <0.001).
Conclusion:
These findings provide a basis for enhancing nursing practices, knowledge and skills. Continuing education for nurses and minimising barriers is crucial to increasing the use of EBP in Oman.
PMCID: PMC4205067  PMID: 25364558
Evidence-Based Practice; Nurses; Attitudes; Knowledge; Oman
4.  Surgical checklists: the human factor 
Background
Surgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist.
Methods
Using the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital.
Results
Responses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process.
Conclusion
In order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.
doi:10.1186/1754-9493-7-14
PMCID: PMC3669630  PMID: 23672665
Surgical checklist; Surgery; Patient safety
5.  SURGEON-REPORTED CONFLICT WITH INTENSIVISTS ABOUT POSTOPERATIVE GOALS OF CARE 
JAMA surgery  2013;148(1):29-35.
Objective
To examine surgeons’ experiences of conflict with intensivists and nurses about goals of care for their postoperative patients.
Design
Cross-sectional incentivized U.S. mail-based survey.
Setting
Private and academic surgical practices.
Participants
2,100 vascular, neurological, and cardiothoracic surgeons.
Main Outcome Measures
Surgeon-reported rates of conflict with intensivists and nurses about goals of care in patients with poor post-surgical outcomes.
Results
The adjusted response rate was 55.6%. Forty-three percent of surgeons report sometimes or always experiencing conflict about postoperative goals of care with intensivists, and 43% report conflict with nurses. Younger surgeons report higher rates of conflict than older surgeons with both intensivists (57 vs. 32%, p=0.001) and nurses (48 vs. 33%, p=0.001). Surgeons practicing in closed ICUs report more frequent conflict than those practicing in open ICUs (60 vs. 41% p=0.005). On multivariate analysis, the odds of reporting conflict with intensivists were 2.5 times higher for surgeons with fewer years of experience as compared to their older colleagues (OR: 2.5, 95% CI: 1.6-3.8) and 70% higher for reporting conflict with nurses (OR: 1.7, 95% CI: 1.1-2.6). The odds of reporting conflict with intensivists about goals of postoperative care were 40% lower for surgeons who primarily manage their ICU patients than for those who work in a closed unit (OR: 0.6, 95% CI: 0.4-0.96).
Conclusions
Surgeons regularly experience conflict with critical care clinicians about goals of care for patients with poor postoperative outcomes. Higher rates of conflict are associated with less experience and working in a closed ICU.
doi:10.1001/jamasurgery.2013.403
PMCID: PMC3624604  PMID: 23324837
6.  Interactions between Non-Physician Clinicians and Industry: A Systematic Review 
PLoS Medicine  2013;10(11):e1001561.
In a systematic review of studies of interactions between non-physician clinicians and industry, Quinn Grundy and colleagues found that many of the issues identified for physicians' industry interactions exist for non-physician clinicians.
Please see later in the article for the Editors' Summary
Background
With increasing restrictions placed on physician–industry interactions, industry marketing may target other health professionals. Recent health policy developments confer even greater importance on the decision making of non-physician clinicians. The purpose of this systematic review is to examine the types and implications of non-physician clinician–industry interactions in clinical practice.
Methods and Findings
We searched MEDLINE and Web of Science from January 1, 1946, through June 24, 2013, according to PRISMA guidelines. Non-physician clinicians eligible for inclusion were: Registered Nurses, nurse prescribers, Physician Assistants, pharmacists, dieticians, and physical or occupational therapists; trainee samples were excluded. Fifteen studies met inclusion criteria. Data were synthesized qualitatively into eight outcome domains: nature and frequency of industry interactions; attitudes toward industry; perceived ethical acceptability of interactions; perceived marketing influence; perceived reliability of industry information; preparation for industry interactions; reactions to industry relations policy; and management of industry interactions. Non-physician clinicians reported interacting with the pharmaceutical and infant formula industries. Clinicians across disciplines met with pharmaceutical representatives regularly and relied on them for practice information. Clinicians frequently received industry “information,” attended sponsored “education,” and acted as distributors for similar materials targeted at patients. Clinicians generally regarded this as an ethical use of industry resources, and felt they could detect “promotion” while benefiting from industry “information.” Free samples were among the most approved and common ways that clinicians interacted with industry. Included studies were observational and of varying methodological rigor; thus, these findings may not be generalizable. This review is, however, the first to our knowledge to provide a descriptive analysis of this literature.
Conclusions
Non-physician clinicians' generally positive attitudes toward industry interactions, despite their recognition of issues related to bias, suggest that industry interactions are normalized in clinical practice across non-physician disciplines. Industry relations policy should address all disciplines and be implemented consistently in order to mitigate conflicts of interest and address such interactions' potential to affect patient care.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Making and selling health care goods (including drugs and devices) and services is big business. To maximize the profits they make for their shareholders, companies involved in health care build relationships with physicians by providing information on new drugs, organizing educational meetings, providing samples of their products, giving gifts, and holding sponsored events. These relationships help to keep physicians informed about new developments in health care but also create the potential for causing harm to patients and health care systems. These relationships may, for example, result in increased prescription rates of new, heavily marketed medications, which are often more expensive than their generic counterparts (similar unbranded drugs) and that are more likely to be recalled for safety reasons than long-established drugs. They may also affect the provision of health care services. Industry is providing an increasingly large proportion of routine health care services in many countries, so relationships built up with physicians have the potential to influence the commissioning of the services that are central to the treatment and well-being of patients.
Why Was This Study Done?
As a result of concerns about the tension between industry's need to make profits and the ethics underlying professional practice, restrictions are increasingly being placed on physician–industry interactions. In the US, for example, the Physician Payments Sunshine Act now requires US manufacturers of drugs, devices, and medical supplies that participate in federal health care programs to disclose all payments and gifts made to physicians and teaching hospitals. However, other health professionals, including those with authority to prescribe drugs such as pharmacists, Physician Assistants, and nurse practitioners are not covered by this legislation or by similar legislation in other settings, even though the restructuring of health care to prioritize primary care and multidisciplinary care models means that “non-physician clinicians” are becoming more numerous and more involved in decision-making and medication management. In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers examine the nature and implications of the interactions between non-physician clinicians and industry.
What Did the Researchers Do and Find?
The researchers identified 15 published studies that examined interactions between non-physician clinicians (Registered Nurses, nurse prescribers, midwives, pharmacists, Physician Assistants, and dieticians) and industry (corporations that produce health care goods and services). They extracted the data from 16 publications (representing 15 different studies) and synthesized them qualitatively (combined the data and reached word-based, rather than numerical, conclusions) into eight outcome domains, including the nature and frequency of interactions, non-physician clinicians' attitudes toward industry, and the perceived ethical acceptability of interactions. In the research the authors identified, non-physician clinicians reported frequent interactions with the pharmaceutical and infant formula industries. Most non-physician clinicians met industry representatives regularly, received gifts and samples, and attended educational events or received educational materials (some of which they distributed to patients). In these studies, non-physician clinicians generally regarded these interactions positively and felt they were an ethical and appropriate use of industry resources. Only a minority of non-physician clinicians felt that marketing influenced their own practice, although a larger percentage felt that their colleagues would be influenced. A sizeable proportion of non-physician clinicians questioned the reliability of industry information, but most were confident that they could detect biased information and therefore rated this information as reliable, valuable, or useful.
What Do These Findings Mean?
These and other findings suggest that non-physician clinicians generally have positive attitudes toward industry interactions but recognize issues related to bias and conflict of interest. Because these findings are based on a small number of studies, most of which were undertaken in the US, they may not be generalizable to other countries. Moreover, they provide no quantitative assessment of the interaction between non-physician clinicians and industry and no information about whether industry interactions affect patient care outcomes. Nevertheless, these findings suggest that industry interactions are normalized (seen as standard) in clinical practice across non-physician disciplines. This normalization creates the potential for serious risks to patients and health care systems. The researchers suggest that it may be unrealistic to expect that non-physician clinicians can be taught individually how to interact with industry ethically or how to detect and avert bias, particularly given the ubiquitous nature of marketing and promotional materials. Instead, they suggest, the environment in which non-physician clinicians practice should be structured to mitigate the potentially harmful effects of interactions with industry.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001561.
This study is further discussed in a PLOS Medicine Perspective by James S. Yeh and Aaron S. Kesselheim
The American Medical Association provides guidance for physicians on interactions with pharmaceutical industry representatives, information about the Physician Payments Sunshine Act, and a toolkit for preparing Physician Payments Sunshine Act reports
The International Council of Nurses provides some guidance on industry interactions in its position statement on nurse-industry relations
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice website, which describes what is required of all registered doctors in the UK
Understanding and Responding to Pharmaceutical Promotion: A Practical Guide is a manual prepared by Health Action International and the World Health Organization that schools of medicine and pharmacy can use to train students how to recognize and respond to pharmaceutical promotion.
The Institute of Medicine's Report on Conflict of Interest in Medical Research, Education, and Practice recommends steps to identify, limit, and manage conflicts of interest
The University of California, San Francisco, Office of Continuing Medical Education offers a course called Marketing of Medicines
doi:10.1371/journal.pmed.1001561
PMCID: PMC3841103  PMID: 24302892
7.  Surgeon’s experiences of receiving peer benchmarked feedback using patient-reported outcome measures: a qualitative study 
Background
The use of patient-reported outcome measures (PROMs) to provide healthcare professionals with peer benchmarked feedback is growing. However, there is little evidence on the opinions of professionals on the value of this information in practice. The purpose of this research is to explore surgeon’s experiences of receiving peer benchmarked PROMs feedback and to examine whether this information led to changes in their practice.
Methods
This qualitative research employed a Framework approach. Semi-structured interviews were undertaken with surgeons who received peer benchmarked PROMs feedback. The participants included eleven consultant orthopaedic surgeons in the Republic of Ireland.
Results
Five themes were identified: conceptual, methodological, practical, attitudinal, and impact. A typology was developed based on the attitudinal and impact themes from which three distinct groups emerged. ‘Advocates’ had positive attitudes towards PROMs and confirmed that the information promoted a self-reflective process. ‘Converts’ were uncertain about the value of PROMs, which reduced their inclination to use the data. ‘Sceptics’ had negative attitudes towards PROMs and claimed that the information had no impact on their behaviour. The conceptual, methodological and practical factors were linked to the typology.
Conclusion
Surgeons had mixed opinions on the value of peer benchmarked PROMs data. Many appreciated the feedback as it reassured them that their practice was similar to their peers. However, PROMs information alone was considered insufficient to help identify opportunities for quality improvements. The reasons for the observed reluctance of participants to embrace PROMs can be categorised into conceptual, methodological, and practical factors. Policy makers and researchers need to increase professionals’ awareness of the numerous purposes and benefits of using PROMs, challenge the current methods to measure performance using PROMs, and reduce the burden of data collection and information dissemination on routine practice.
doi:10.1186/1748-5908-9-84
PMCID: PMC4227108  PMID: 24972784
Health status; Outcome assessment (health care); Patient reported outcome measures; Quality of life; Qualitative research; Quality improvements
8.  Current practice of abdominal fascial closure: a survey of Ontario general surgeons 
Canadian Journal of Surgery  2001;44(5):366-370.
Objectives
To determine the current practice of abdominal fascial closure among provincial general surgeons. The primary objective was to determine the proportion of surgeons choosing absorbable versus nonabsorbable sutures. Secondary objectives included determining knowledge and attitudes of surgeons to evidence-based medicine and concordance of current practice with level I evidence.
Design
A survey.
Setting
The province of Ontario.
Participants
One hundred general surgeons.
Methods
A stratified random sample of community and academic surgeons was assembled and a questionnaire was mailed to them. Common clinical scenarios and questions pertaining to attitudes and knowledge of evidence-based medicine were included.
Main outcome measures
Use of absorbable versus nonabsorbable suture material. Willingness to change current practice on evidence-based level I reports.
Results
Most surgeons (86%) chose an absorbable suture for abdominal fascial closure. Nonabsorbable suture was chosen by 58% of surgeons in the highly contaminated surgical scenario. Eighty-one percent of surgeons indicated they would be willing to change their current practice of fascial closure if there was evidence that the incidence of wound complications was reduced. Polyglactin (Vicryl) was the most commonly chosen suture.
Conclusions
The current practice of abdominal fascial closure among Ontario general surgeons is in disagreement with the findings from a recent meta-analysis, recommending a nonabsorbable suture for a 32% relative risk reduction in the incisional hernia rate. The majority of surgeons employ a continuous absorbable closure in common surgical scenarios. A definitive randomized controlled trial comparing continuous nonabsorbable closure versus continuous absorbable closure is warranted.
PMCID: PMC3692644  PMID: 11603750
9.  Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey 
PLoS Medicine  2010;7(3):e1000242.
In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.
Background
There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.
Methods and Findings
We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.
Conclusion
African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Infectious diseases remain the major killers in developing countries, but traumatic injuries, complications of childbirth, and other conditions that need surgery are important contributors to the overall burden of disease in these countries. Unfortunately, the provision of surgical services in low- and middle-income countries is often insufficient. There are many fewer operations per a head of population in developing countries than in developed countries, essential operations such as cesarean sections for complicated deliveries are not always available, and elective operations such as male and female sterilization can be difficult to obtain. Lack of funding for surgical procedures and shortages of trained health workers have often been blamed for the low rates of surgery in developing countries. For example, anesthesiologists (doctors who are trained to give anesthetics and other pain-relieving agents) and trained anesthetists (usually nurses and technicians) are rare in many African countries, as are surgeons and obstetricians (doctors who look after women during pregnancy and childbirth). To make matters worse, these specialists often work in tertiary referral hospitals in large cities. In district hospitals, which provide most of the primary health care needs of rural populations, basic surgical care is usually provided by “mid-level health care providers” (MLPs)—individuals with a level of training between that of nurses and physicians.
Why Was This Study Done?
Various organizations are currently working to improve emergency and essential surgical care in developing countries. For example, the Bellagio Essential Surgery Group (BESG) seeks to define, quantify, and address the problem of unmet surgical needs in sub-Saharan Africa. Importantly, however, before any programs can be introduced to improve access to surgical services in developing countries, better baseline data on existing surgical services needs to be collected—most of the available information on these services is anecdotal. In this study, the researchers (most of whom are members of the BESG) investigate the provision of surgical procedures and anesthesia in district hospitals in three sub-Saharan African countries and estimate the costs of surgery performed in the same hospitals.
What Did the Researchers Do and Find?
The researchers collected recent data on the number of doctors, MLPs, and nurses in two district hospitals in Tanzania and in Mozambique, and from four district hospitals in Uganda and information on each hospital's expenditure. Most of the health workers in these hospitals (which care for 3 million people between them) were nurses (77.5%), followed by MLPs not trained to provide surgical care (7.8%), and MLPs trained to provide surgical care (3.8%). The hospitals had between one and six medical doctors each (28 across all the hospitals), but there were no trained surgeons or anesthesiologists posted at any of the hospitals. About half of the major surgical procedures undertaken at these hospitals were performed by doctors but more than a third were done by MLPs although the exact pattern of personnel involved in surgery varied among the three countries. Anesthesia was mostly provided by nurses and doctors; again the pattern of anesthesia provision varied among countries and hospitals. Only 7%–14% of overall hospital expenditure was allocated to surgical care and most of this allocation was used for obstetric services. Finally, the researchers estimate that, on the basis of district populations, the district hospitals spent between US$0.05 and US$0.14 per head on surgical services.
What Do These Findings Mean?
These findings indicate that, in the district hospitals investigated in this study, physicians, MLPs, and nurses provide most of the surgical care. Furthermore, although all the hospitals in the study provide some surgical care, it accounts for a small part of the hospitals' overall operating costs. These findings may not be generalizable to other district hospitals in sub-Saharan Africa and provide no information about the unmet needs for surgical care. Nevertheless, these findings and those of a separate paper that investigates the range and volume of surgical procedures undertaken in the same district hospitals provide a valuable baseline for planning the expansion of health care services in Africa. They also suggest that increasing the funds allocated to surgery and formalizing the training of MLPs might be a cost-effective way of increasing access to surgical care in sub-Saharan Africa and other developing regions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000242.
The range and volume of surgery in the same hospitals is investigated in a PLoS Medicine Research Article by Moses Galukande et al.
Information on the Bellagio Essential Surgery Group is available
WHO's Global initiative for Emergency and Essential Surgical Care plans to take essential emergency, basic surgery and anesthesia skills to health care staff in low- and middle-income countries around the world; WHO also has a page describing the importance of emergency and essential surgery in primary health care
doi:10.1371/journal.pmed.1000242
PMCID: PMC2834706  PMID: 20231869
10.  Nurses’ Perceived Barriers to and Facilitators of Research Utilization in Mainland China: A Cross-Sectional Survey 
The Open Nursing Journal  2013;7:96-106.
Despite the drive towards evidence-based practice, the extent to which research evidence is being implemented in nursing practice is unclear, particularly in developing countries. This study was to assess the levels of perceived barriers to and facilitators of research utilization in practice among Chinese nurses and inter-relationships between these barriers and facilitators and their socio-demographic characteristics. A cross-sectional, descriptive survey was conducted in 2011 with 743 registered nurses randomly selected from four general hospitals in China. They completed the Barriers to Research Utilization and Facilitators of Research Utilization scales. Correlation tests were used to test the relationships between the nurses’ perceived barriers and facilitators, their demographic characteristics and research training and involvement. The Chinese nurses’ level of perceived barriers was moderate on average and lower than that in previous research. Among the 10 top-ranked items, six were from the subscale ‘Organizational Characteristics’. Their perceived barriers were correlated positively with age and post-registration experience and negatively with research training undertaken. Junior diplomatic nurses reported a significantly higher degree of barriers than those senior ones with postgraduate education. Higher and more diverse barriers to research utilization in practice are perceived by Chinese nurses than those in Western countries and they are associated with a few socio-demographic factors. Future research on these barriers/facilitators and their relationships with occupational and socio-cultural factors in Chinese and other Asian nurses is recommended.
doi:10.2174/1874434601307010096
PMCID: PMC3731799  PMID: 23919099
Cross-sectional survey; perceived barriers; perceived facilitators; research utilization; registered nurses; Chinese.
11.  Management of single brain metastasis: a practice guideline 
Current Oncology  2007;14(4):131-143.
Questions
Should patients with confirmed single brain metastasis undergo surgical resection?
Should patients with single brain metastasis undergoing surgical resection receive adjuvant whole-brain radiation therapy (wbrt)?
What is the role of stereotactic radiosurgery (srs) in the management of patients with single brain metastasis?
Perspectives
Approximately 15%–30% of patients with cancer will develop cerebral metastases over the course of their disease. Patients identified as having single brain metastasis generally undergo more aggressive treatment than do those with multiple metastases; however, in the province of Ontario, management of patients with single brain metastasis varies. Given that conflicting evidence has been reported, the Neuro-oncology Disease Site Group (dsg) of the Cancer Care Ontario Program in Evidence-based Care felt that a systematic review of the evidence and a practice guideline were warranted.
Outcomes
Outcomes of interest were survival, local control of disease, quality of life, and adverse effects.
Methodology
The medline, cancerlit, embase, and Cochrane Library databases and abstracts published in the proceedings of the annual meetings of the American Society of Clinical Oncology (1997–2005) and American Society for Therapeutic Radiology and Oncology (1998–2004) were systematically searched for relevant evidence. The review included fully published reports or abstracts of randomized controlled trials (rcts), nonrandomized prospective studies, and retrospective studies.
The present systematic review and practice guideline has been reviewed and approved by the Neuro-oncology dsg, which comprises medical and radiation oncologists, surgeons, neurologists, a nurse, and a patient representative. External review by Ontario practitioners was obtained through an electronic survey. Final approval of the guideline report was obtained from the Report Approval Panel and the Neuro-oncology dsg.
Results
Quality of Evidence
The literature search found three rcts that compared surgical resection plus wbrt with wbrt alone. In addition, a Cochrane review, including a meta-analysis of published data from those three rcts, was obtained.
One rct compared surgical resection plus wbrt with surgical resection alone. One rct compared wbrt plus srs with wbrt alone. Evidence comparing srs with surgical resection or examining srs with or without wbrt was limited to prospective case series and retrospective studies.
Benefits
Two of three rcts reported a significant survival benefit for patients who underwent surgical resection as compared with those who received wbrt alone. Pooled results of the three rcts indicated no significant difference in survival or likelihood of dying from neurologic causes; however, significant heterogeneity was detected between the trials. The rct that compared surgical resection plus wbrt with surgical resection alone reported no significant difference in overall survival or length of functional independence; however, tumour recurrence at the site of the metastasis and anywhere in the brain was less frequent in patients who received wbrt as compared with patients in the observation group. In addition, patients who received wbrt were less likely to die from neurologic causes.
Results of the rct that compared wbrt plus srs with wbrt alone indicated a significant improvement in median survival in patients who received srs. No quality evidence compares the efficacy of srs with surgical resection or examines the question of whether patients who receive srs should also receive wbrt.
Harms
Pooled results of the three rcts that examined surgical resection indicated no significant difference in adverse effects between groups. Postoperative complications included respiratory problems, intracerebral hemorrhage, and infection. One rct reported no significant difference in adverse effects between patients who received wbrt plus srs and those who received wbrt alone.
Practice Guideline
Target Population
The recommendations that follow apply to adults with confirmed cancer and a single brain metastasis. This practice guideline does not apply to patients with metastatic lymphoma, small-cell lung cancer, germ-cell tumour, leukemia, or sarcoma.
Recommendations
Surgical excision should be considered for patients with good performance status, minimal or no evidence of extracranial disease, and a surgically accessible single brain metastasis amenable to complete excision. Because treatment in cases of single brain metastasis is considered palliative, invasive local treatments must be individualized. Patients with lesions requiring emergency decompression because of intracranial hypertension were excluded from the rcts, but should be considered candidates for surgery.
To reduce the risk of tumour recurrence for patients who have undergone resection of a single brain metastasis, postoperative wbrt should be considered. The optimal dose and fractionation schedule for wbrt is 3000 cGy in 10 fractions or 2000 cGy in 5 fractions.
As an alternative to surgical resection, wbrt followed by srs boost should be considered for patients with single brain metastasis. The evidence is insufficient to recommend srs alone as a single-modality therapy.
Qualifying Statements
No high-quality data are available regarding the choice of surgery versus radiosurgery for single brain metastasis. In general, the size and location of the metastasis determine the optimal approach.
The standard wbrt regimen for management of patients with single brain metastasis in the United States is 3000 cGy in 10 fractions, and this treatment is usually the standard arm in randomized studies of radiation in patients with brain metastases. Based solely on evidence, the understanding that no reason exists to choose 3000 cGy in 10 fractions over 2000 cGy in 5 fractions is correct; however, fraction size is believed to be important, and therefore 300 cGy daily (3000/10) is believed to be associated with fewer long-term neurocognitive effects than 400 cGy daily (2000/5) in the occasional long-term survivor. For that reason, many radiation oncologists in Ontario prefer 3000 cGy in 10 fractions. No data exist to either support or refute that preference; therefore, finding a resolution to this issue is not currently possible. The Neuro-oncology dsg will update the recommendations as new evidence becomes available.
PMCID: PMC1948870  PMID: 17710205
Brain metastasis; surgery; radiotherapy; radiosurgery; systematic review; practice guideline
12.  A Survey of Knowledge, Attitude and Practice of Nurses towards Pharamacovigilance in Taleqani Hospital 
Detection of probable harmful consequences arised from the usage of pharmaceutical products requires decisive, continuous and close monitoring by medical staff whom should have knowledge of adverse drug reactions and they should also have to report any suspected instances, when any kind of adverse drug reactions have been observed. This study has been carried out on the knowledge, attitude and practice of nurses towards pharmacovigilance in the Taleqani medical, teaching and treatment center in Tehran, before and after an ADR educational program. This study was commenced in March 2005 and ended in October 2005, using a questionnaire through two steps. In every step, 150 questionnaires were distributed in various wards of the Taleqani Hospital. Collected data were entered into the Excel software and then data analyzed using the SPSS statistical software. Familiarity of nurses with the ADR center and it’s duties is the first step in training how to report ADR, and could help to enhance thire awareness. The use of lecture training for increasing the awareness of nurses was found to be very effective. Regression multivariable analyses showed that the knowledge of nurses, regarding previous familiarity with the ADR center is better than the others (r = 0.38, P = 0.01), and the attitude of female nurses is better than males (r = 0.27, P = 0.01). According to the statistical results, the knowledge of nurses before the seminar was significantly less than the knowledge after the seminar (P= 0.0001), but there was no significant effect on the attitude (P= 0.05). Regarding the submission place of ADR reports, only 3.4% of nurses pointed out to the ADR center. Before and after training, a limited duration of time was reported to be the most restricted factor for clinical recognition of adverse drugs. Based on the results of this study, it is necessary to offer continuous ADR educational program until we reach the point that voluntary reporting of adverse drug reactions becomes conventional and habitual among the nursing staff.
PMCID: PMC3862069  PMID: 24363728
Adverse drug reaction; Knowledge; Attitude; Practice; Nurses; Educational program; Voluntary reporting of ADRs
13.  Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons 
BMJ Open  2011;1(2):e000391.
Objectives
To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain.
Design and setting
Nationwide survey among spine surgeons in the Netherlands.
Participants
Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain.
Primary and secondary outcome measures
The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined.
Results
The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy.
Conclusions
The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.
Article summary
Article focus
What is the level of professional consensus among spine surgeons regarding spinal fusion surgery for chronic low back pain?
How are tests for patient selection appreciated and to what extent are they used in clinical practice?
Are prognostic patient factors incorporated in the process of surgical decision making for chronic low back pain?
Key messages
In clinical practice, there is no professional consensus on surgical treatment strategy for chronic low back pain.
Prognostic patient factors as well as tests for patient selection are not consistently used in clinical decision making for spinal fusion.
Because of a lack of consensus on spinal fusion strategy for chronic low back pain in clinical practice, no guidelines for proper patient counselling can be installed at present.
Strengths and limitations of this study
A survey among physicians provides valuable insight in the actual decision-making process in clinical practice. Understanding contributory factors in treatment strategy may help in the creation of consensus guidelines.
The introduction of an interviewer bias could be avoided by the use of a neutral intermediary instead of direct questions from peers in spine surgery.
This study focused on surgeon members of the Dutch Spine Society whose practice may not reflect that of all surgeons performing spinal fusion for chronic low back pain. Moreover, no information on conservative treatment options was acquired.
To define consensus, we chose for uniformity of opinion of at least 70%, which we considered to be sufficient for implementation in guidelines. Such a cut-off level remains arbitrary.
doi:10.1136/bmjopen-2011-000391
PMCID: PMC3278483  PMID: 22189352
14.  Reported use of strategies by surgeons to prevent transmission of bloodborne diseases. 
OBJECTIVE: To determine how often surgeons use strategies to prevent the transmission of bloodborne diseases and what factors are associated with the use of these strategies. DESIGN: Cross-sectional mail survey. SETTING: Secondary and tertiary care teaching hospitals affiliated with the University of Toronto. PARTICIPANTS: Of 539 active surgical staff and residents who were eligible, 503 (93.3%) responded. OUTCOME MEASURES: Current preventive practices, attitudes toward transmission of bloodborne diseases, perceived risk of infection and willingness to adopt preventive strategies. RESULTS: On average, surgeons reported using double- or triple-gloving in 32.2% of procedures, facial protection (including regular corrective eyewear) in 74.2% and goggles or face shields in 19.4%. Use of strategies to prevent sharp injuries, in addition to barrier precautions, was reported by 259 (51.5%) of the respondents. Factors associated with greater use of preventive strategies included resident position, subspecialty, greater number of years in surgical practice and a high perceived risk. Most of the respondents thought that patients should be routinely screened for HIV antibodies before surgery (68.2% [343/503]), that there was too little research into ways to reduce the risk of transmission of bloodborne diseases (55.3% [278/503]) and that there was too little effort on the part of organizations to reduce the risk of transmission (58.8% [296/503]). The perceived lifetime risk was reported to be moderate or high by 191 (38.0%) of the respondents and low or insignificant by 308 (61.2%). In all, 463 (92.0%) indicated a willingness to change the way they performed surgery to prevent transmission of bloodborne diseases. CONCLUSION: Surgeons expressed varying degrees of concern about the transmission of bloodborne diseases and reported infrequent use of preventive strategies. Efforts to reduce the risk of transmission between patients and surgeons will need to include informing surgeons of their personal risk and the availability of preventive strategies, improving the comfort of barrier precautions and minimizing how preventive strategies interfere with surgery.
PMCID: PMC1337656  PMID: 7712421
15.  Impact of Advanced Laparoscopy Courses on Present Surgical Practice 
Advanced laparoscopic workshops provide an efficacious instrument for educating surgeons in minimally invasive techniques.
Background and Objectives:
The introduction of new surgical techniques has made training in laparoscopic procedures a necessity for the practicing surgeon, but acquisition of new surgical skills is a formidable task. This study was conducted to assess the impact of advanced laparoscopic workshops on caseload patterns of practicing surgeons.
Methods:
After we obtained institutional review board approval, a survey of practicing surgeons who participated in advanced laparoscopic courses was distributed; the results were analyzed for statistical significance. The courses were held at the University of Nebraska Medical Center between January 2002 and December 2010. Questionnaires were mailed, faxed, and e-mailed to surgeons.
Results:
Of the 109 surgeons who participated in the advanced laparoscopy courses, 79 received surveys and 30 were excluded from the survey because of their affiliation with the University of Nebraska Medical Center. A total of 47 responses (59%) were received from 41 male and 6 female surgeons. The median response time from completion of the course to completion of the survey was 13.2 months (range, 6.8–19.1 months). The mean age of participating surgeons was 39.2 years (range, 29–51 years). The mean time since residency was 8.4 years (range, 0.8–21 years). Eleven surgeons had completed a minimal number of laparoscopic cases in residency (<50), 17 surgeons had completed a moderate number of laparoscopic procedures in residency (50–200), and 21 surgeons had completed a significant number of cases during residency (>200). Of the surgeons who responded, 94% were in private practice. Fifty-seven percent of the participating surgeons who responded reported a change in laparoscopic practice patterns after the courses. Of these surgeons, 24% had a limited residency laparoscopy exposure of <50 cases. Surgeons who were exposed to ≥50 laparoscopic cases during their residency showed a statistically significant increase in the number of laparoscopic procedures performed after their class compared with surgeons who did not receive ≥50 laparoscopic cases in residency (P = .03). In addition, regardless of the procedures learned in a specific class, surgeons with ≥50 laparoscopic cases in residency had a statistically significant increase in their laparoscopic colectomy and laparoscopic hernia procedure caseload (P < .01). However, there was no statistically significant difference in laparoscopic caseload between surgeons who had completed 50 to 200 laparoscopic residency cases and those who had completed greater than 200 laparoscopic residency cases (P = .31). Furthermore, the participant's age (P = .23), practice type (P = .61), and years in practice (P = .22) had no statistical significance with regard to the adoption of laparoscopic procedures after courses taken. This finding is congruent with the findings of other researchers. Future interest in advanced laparoscopy courses was noted in 70% of surgeons and was more pronounced in surgeons with ≥50 cases in residency.
Conclusion:
Advanced laparoscopic workshops provide an efficacious instrument in educating surgeons on minimally invasive surgical techniques. Participating surgeons significantly increased the number of course-specific procedures that they performed but also increased the number of other laparoscopic surgeries, suggesting that a certain proficiency in laparoscopic skills is translated to multiple surgical procedures. Laparoscopy experience of ≥50 cases during residency is a strong predictor of an increase in the number of advanced laparoscopic cases after attending courses.
doi:10.4293/108680813X13654754534503
PMCID: PMC3771781  PMID: 23925009
Laparoscopy; Training; Surgical courses; Colon; Hernia
16.  Can orthopedic trials change practice? 
Acta Orthopaedica  2010;81(1):122-125.
Background and purpose
The impact of large, randomized trials in orthopedic surgery on surgeons' preferences for a particular surgical approach remains unclear. We surveyed surgeons to assess whether they would change practice based upon results of a large, multicenter randomized controlled hip fracture trial.
Methods
We conducted a cross-sectional survey among International Hip Fracture Research Collaborative (IHFRC) surgeons and surgeons who were members of Arbeitsgemeinschaft fuer Osteosynthesefragen - Association for the Study of Internal Fixation (AO/ASIF) to determine the likelihood that they would change practice based on findings of a proposed large, multicenter randomized controlled trial (the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) study). We asked surgeons their current preferences for the management of displaced femoral neck fractures and whether a trial that definitively revealed a substantial improvement in function and quality of life with no difference in risk of revision surgery was important and would cause them to change practice.
Results
Of 883 surgeons surveyed, 210 responded from IHFRC and 586 from AO/ASIF (a response rate of 90%). Most surgeons (61%) preferred hemiarthroplasty (HA) for treating displaced femoral neck fractures. 72% of responding surgeons believed that a substantial improvement in patient function with total hip arthroplasty (THA) and no adverse effects on revision surgery would be an important finding. Moreover, of 483 surgeons who preferred hemiarthroplasty, 62% would change their practice based upon the findings of the trial.
Interpretation
Large clinical trials in orthopedics are worthwhile endeavors, as they have the potential to change practice among surgeons. Surgeons seem willing to adopt alternative surgical approaches if the evidence is compelling and sound.
doi:10.3109/17453671003587093
PMCID: PMC2856216  PMID: 20146638
17.  Completion imaging after carotid endarterectomy in the Vascular Study Group of New England 
Objectives
We studied surgeons’ practice patterns in the use of completion imaging (duplex or arteriography), and their association with 30-day stroke/death and 1-year restenosis after carotid endarterectomy (CEA).
Methods
Using a retrospective analysis of 6115 CEAs, we categorized surgeons based on use of completion imaging as rarely (<5% of CEAs), selective (5% to 90%), or routine (>90%). Crude and risk-adjusted 30-day stroke/death and 1-year restenosis rates were examined across surgeon practice patterns. Finally, we audited 90 operative reports of patients who underwent re-exploration and characterized findings and interventions. We analyzed the effect of re-exploration on outcomes.
Results
Practice patterns in completion imaging varied: 51% of surgeons performed completion imaging rarely, 22% selectively, and 27% routinely. Crude 30-day stroke/death rates were highest among surgeons who routinely used completion imaging (rarely: 1.7%; selectively: 1.2%, routinely: 2.4%; P = .05). However, after adjusting for patient characteristics predictive of stroke/death, the effect of surgeon practice pattern was not statistically significant (odds ratio [OR] for routine-use surgeons, 1.42; 95% CI, 0.93-2.17; P = .10; selective-use surgeons, 0.75; 95% CI, 0.40-1.41; P = .366). Stenosis >70% at 1 year showed a trend toward lowest rates for surgeons who performed completion imaging (rarely: 2.8%, selectively: 1.1%, and routinely: 1.1%; P = .09). This effect became statistically significant for selective-use surgeons after adjustment (hazard risk [HR] for selective-use surgeons, 0.52; 95% CI, 0.29-0.92; P = .02). Overall, 178 patients (2.9%) underwent operative re-exploration. Routine-use surgeons were most likely to perform re-exploration (7.6% routine, 0.8% selective, 0.9% rare; P < .001). An audit of 90 re-explored patients demonstrated technical problems, the most common being flap, debris, and plaque. Rates of stroke/death were higher among patients who underwent re-exploration (3.9% vs 1.7%; P = .03); however, this affect was attenuated after adjustment (OR, 2.1; 95% CI, 0.9-5.0; P = .08).
Conclusions
The use of completion imaging during CEA varies widely across our region. There is little evidence that surgeons who use completion imaging have lower rates of 30-day stroke/death, although selective use of completion imaging is associated with a small but a significant reduction in stenosis 1 year after surgery. We also demonstrate an association between re-exploration and higher risk of 30-day stroke/death, although this effect was attenuated after adjustment for patient-level predictors of stroke/death. Future work is needed to direct the selective use of completion imaging to prevent stroke, rather than cause unnecessary re-exploration.
doi:10.1016/j.jvs.2011.01.032
PMCID: PMC3237118  PMID: 21458209
18.  Exploring the role of organizational policies and procedures in promoting research utilization in registered nurses 
Background
Policies and procedures (P&Ps) have been suggested as one possible strategy for moving research evidence into practice among nursing staff in hospitals. Research in the area of P&Ps is limited, however. This paper explores: 1) nurses' use of eight specific research-based practices (RBPs) and RBP overall, 2) nurses' use and understanding of P&Ps, and 3) the role of P&Ps in promoting research utilization.
Methods
Staff nurses from the eight health regions governing acute care services across the Canadian province of Newfoundland and Labrador completed an anonymous questionnaire regarding their use of eight RBPs and associated P&Ps. Data were also obtained from authorities in six of the eight regions about existing relevant P&Ps. We used descriptive statistics and multivariate regression analysis to assess the relationship between key independent variables and self-reported use of RBP.
Results
Use of the eight RBPs ranged from 7.8% to 88.6%, depending on the practice. Nurses ranked P&P manuals as their number one source of practice knowledge. Most respondents (84.8%) reported that the main reason they consult the P&P manual is to confirm they are practicing according to agency rules. Multivariate regression analysis identified three significant predictors of being a user versus non-user of RBP overall: awareness, awareness by regular use, and persuasion. Six significant predictors of being a consistent versus less consistent user of RBP overall were also identified: perception of P&P existence, unit, nursing experience, personal experience as a source of practice knowledge, number of existing research-based P&Ps, and lack of time as a barrier to consulting P&P manuals.
Conclusion
Findings suggest that nurses use P&Ps to guide their practice. However, the mere existence of P&Ps is not sufficient to translate research into nursing practice. Individual and organizational factors related to nurses' understanding and use of P&Ps also play key roles. Thus, moving research evidence into practice will require careful interplay between the organization and the individual. P&Ps may be the interface through which this occurs.
doi:10.1186/1748-5908-2-17
PMCID: PMC1904235  PMID: 17550597
19.  Rural surgery in British Columbia: Is there anybody out there? 
Canadian Journal of Surgery  2008;51(3):179-184.
Objective
To document surgical procedures performed in British Columbia between 1996 and 2001 at rural hospital sites with no resident specialist surgeons and to define the scope of practice of general practitioner (GP)–surgeons at these small-volume surgical sites.
Methods
We obtained data from published information available in the medical directories for British Columbia and from the Population Utilization Rates and Referrals For Easy Comparative Tables database (versions 6.0 and 9.0) to conduct a retrospective study of all rural BC hospitals with surgical programs that had no resident specialist surgeon and relied on GP-surgeons for emergency surgical care between 1996 and 2001. We studied surgical programs at the 12 hospitals that met inclusion criteria and interviewed the physician or nurse responsible for the program. Outcomes were measured in terms of the types and volumes of surgical procedures (elective and emergency) from 1996 to 2001, including itinerant surgery.
Results
On average, 2690 surgical procedures were performed annually at the 12 hospitals included in the study. Endoscopy, hand surgery, cesarean section, herniorrhaphy, tonsillectomy and dilation and curettage (D&C) were among the top elective and emergency procedures. For each hospital, between 8 and 26 procedures of hand surgery, cesarean section, herniorrhaphy, D&C and appendectomy were performed each year. In the 12 communities studied, 19% of all surgery was emergency and 81% elective. There was significant overlap in the types of emergency and elective procedures. GP-surgeons carried out most of the emergency procedures, which nonetheless accounted for a small portion of their surgical work.
Conclusion
GP-surgeons still perform a significant number of emergency and elective surgical procedures in rural BC hospitals. This study defines useful procedures for GP-surgeons in communities without the population base to sustain a resident specialist surgeon. This information can be used to structure training programs for GP-surgeons that will adequately meet the needs of rural communities.
PMCID: PMC2496604  PMID: 18682764
20.  Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis 
Critical Care  2010;14(6):R218.
Introduction
Intensive care unit (ICU) patients and family members repeatedly note accurate and timely communication from health care providers to be crucial to high-quality ICU care. Practice guidelines recommend improving communication. However, few data, particularly in surgical ICUs, exist on health care provider opinions regarding whether communication is effective.
Methods
To evaluate ICU clinician perceptions regarding adequacy of communication regarding prognosis, we developed a survey and administered it to a cross section of surgical ICU nurses, surgical ICU physicians, nurse practitioners (NPs), and surgeons.
Results
Surgeons had a high satisfaction with communication regarding prognosis for themselves (90%), ICU nurses (85%), and ICU physicians and NPs (85%). ICU nurses noted high satisfaction with personal (82%) and ICU physician and NP (71%) communication, but low (2%) satisfaction with that provided by surgeons. ICU physicians and NPs noted high satisfaction with personal (74%) and ICU nurse (88%) communication, but lower (23%) satisfaction with that provided by surgeons. ICU nurses were the most likely (75%) to report speaking to patients and patient families regarding prognosis, followed by surgeons (40%), and then ICU physicians and NPs (33%). Surgeons noted many opportunities to speak to ICU nurses and ICU physicians and NPs about patient prognosis and noted that comments were often valued. ICU physicians and NPs and ICU nurses noted many opportunities to speak to each other but fewer opportunities to communicate with surgeons. ICU physicians and NPs thought that their comments were valued by ICU nurses but less valued by surgeons. ICU nurses thought that their comments were less valued by ICU physicians and NPs and surgeons.
Conclusions
ICU nurses, surgeons, and ICU intensivists and NPs varied widely in their satisfaction with communication relating to prognosis. Clinician groups also varied in whether they thought that they had opportunities to communicate prognosis and whether their concerns were valued by other provider groups. These results hint at the nuanced and complicated relationships present in surgical ICUs. Further validation studies and further evaluations of patient and family member perspectives are needed.
doi:10.1186/cc9346
PMCID: PMC3220002  PMID: 21114837
21.  Error, stress, and teamwork in medicine and aviation: cross sectional surveys 
BMJ : British Medical Journal  2000;320(7237):745-749.
Objectives:
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
Design:
Cross sectional surveys.
Setting:
Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
Participants:
1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
Main outcome measures:
Perceptions of error, stress, and teamwork.
Results:
Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Conclusions:
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
PMCID: PMC27316  PMID: 10720356
22.  A needs assessment study of undergraduate surgical education 
Canadian Journal of Surgery  2006;49(5):335-340.
Background
There is compelling evidence to suggest that undergraduate surgical education may fail to provide appropriate instruction in basic surgical principles and skills.
Methods
We completed a descriptive, cross-sectional survey of stakeholder groups (surgeon educators and recent medical school graduates) to assess the perceived relevance and learning for surgical principles, surgical skills, teaching environments and teaching interventions.
Results
Graduates returned 123 surveys, and surgeons returned 55 surveys (response rates: graduates 46%, surgeons 45%). Both graduates and surgeons considered 8 of 10 surgical principles highly relevant to current medical practice. Despite this, the surgical clerkship seemed to enable proficiency in far fewer principles (graduates: 3, surgeons: 5). Graduates believed that each of the 15 basic surgical skills is relevant to current medical practice, whereas surgeons indicated that more invasive skills (i.e., central venous lines, thoracentesis) are much less relevant. Graduates and surgeons indicated that medical students will achieve proficiency in only 3 basic skills areas as a result of the surgical clerkship. Graduates and surgeons considered each surgical specialty relevant and effective in undergraduate surgical education. According to graduates and surgeons, the most effective teaching environments are outpatient settings (emergency department, outpatient clinics). Graduates and surgeons ranked resident teaching as the most effective teaching intervention, and traditional interventions (grand rounds, formal rounds) and electronic resources (computer-assisted learning, web-based learning) were ranked the least effective.
Conclusions
In this study, we assessed the learning needs of contemporary medical students in surgery. The results suggest that respondent graduate students and surgeons believe that the level of proficiency achieved in surgical principles and basic skills through undergraduate surgical educations is much less than anticipated. Outpatient settings and resident teaching are believed to provide the most effective teaching for medical students. Information from this study has important implications for Canadian undergraduate surgery programs and curricula.
PMCID: PMC3207590  PMID: 17152571
23.  Minimally invasive surgical procedures for the treatment of lumbar disc herniation 
Introduction
In up to 30% of patients undergoing lumbar disc surgery for herniated or protruded discs outcomes are judged unfavourable. Over the last decades this problem has stimulated the development of a number of minimally-invasive operative procedures. The aim is to relieve pressure from compromised nerve roots by mechanically removing, dissolving or evaporating disc material while leaving bony structures and surrounding tissues as intact as possible. In Germany, there is hardly any utilisation data for these new procedures – data files from the statutory health insurances demonstrate that about 5% of all lumbar disc surgeries are performed using minimally-invasive techniques. Their real proportion is thought to be much higher because many procedures are offered by private hospitals and surgeries and are paid by private health insurers or patients themselves. So far no comprehensive assessment comparing efficacy, safety, effectiveness and cost-effectiveness of minimally-invasive lumbar disc surgery to standard procedures (microdiscectomy, open discectomy) which could serve as a basis for coverage decisions, has been published in Germany.
Objective
Against this background the aim of the following assessment is:
Based on published scientific literature assess safety, efficacy and effectiveness of minimally-invasive lumbar disc surgery compared to standard procedures. To identify and critically appraise studies comparing costs and cost-effectiveness of minimally-invasive procedures to that of standard procedures. If necessary identify research and evaluation needs and point out regulative needs within the German health care system. The assessment focusses on procedures that are used in elective lumbar disc surgery as alternative treatment options to microdiscectomy or open discectomy. Chemonucleolysis, percutaneous manual discectomy, automated percutaneous lumbar discectomy, laserdiscectomy and endoscopic procedures accessing the disc by a posterolateral or posterior approach are included.
Methods
In order to assess safety, efficacy and effectiveness of minimally-invasive procedures as well as their economic implications systematic reviews of the literature are performed. A comprehensive search strategy is composed to search 23 electronic databases, among them MEDLINE, EMBASE and the Cochrane Library. Methodological quality of systematic reviews, HTA reports and primary research is assessed using checklists of the German Scientific Working Group for Health Technology Assessment. Quality and transparency of cost analyses are documented using the quality and transparency catalogues of the working group. Study results are summarised in a qualitative manner. Due to the limited number and the low methodological quality of the studies it is not possible to conduct metaanalyses. In addition to the results of controlled trials results of recent case series are introduced and discussed.
Results
The evidence-base to assess safety, efficacy and effectiveness of minimally-invasive lumbar disc surgery procedures is rather limited:
Percutaneous manual discectomy: Six case series (four after 1998)Automated percutaneous lumbar discectomy: Two RCT (one discontinued), twelve case series (one after 1998)Chemonucleolysis: Five RCT, five non-randomised controlled trials, eleven case seriesPercutaneous laserdiscectomy: One non-randomised controlled trial, 13 case series (eight after 1998)Endoscopic procedures: Three RCT, 21 case series (17 after 1998)
There are two economic analyses each retrieved for chemonucleolysis and automated percutaneous discectomy as well as one cost-minimisation analysis comparing costs of an endoscopic procedure to costs for open discectomy.
Among all minimally-invasive procedures chemonucleolysis is the only of which efficacy may be judged on the basis of results from high quality randomised controlled trials (RCT). Study results suggest that the procedure maybe (cost)effectively used as an intermediate therapeutical option between conservative and operative management of small lumbar disc herniations or protrusions causing sciatica. Two RCT comparing transforaminal endoscopic procedures with microdiscectomy in patients with sciatica and small non-sequestered disc herniations show comparable short and medium term overall success rates. Concerning speed of recovery and return to work a trend towards more favourable results for the endoscopic procedures is noted. It is doubtful though, whether these results from the eleven and five years old studies are still valid for the more advanced procedures used today. The only RCT comparing the results of automated percutaneous lumbar discectomy to those of microdiscectomy showed clearly superior results of microdiscectomy. Furthermore, success rates of automated percutaneous lumbar discectomy reported in the RCT (29%) differ extremely from success rates reported in case series (between 56% and 92%).
The literature search retrieves no controlled trials to assess efficacy and/or effectiveness of laser-discectomy, percutaneous manual discectomy or endoscopic procedures using a posterior approach in comparison to the standard procedures. Results from recent case series permit no assessment of efficacy, especially not in comparison to standard procedures. Due to highly selected patients, modi-fications of operative procedures, highly specialised surgical units and poorly standardised outcome assessment results of case series are highly variable, their generalisability is low.
The results of the five economical analyses are, due to conceptual and methodological problems, of no value for decision-making in the context of the German health care system.
Discussion
Aside from low methodological study quality three conceptual problems complicate the interpretation of results.
Continuous further development of technologies leads to a diversity of procedures in use which prohibits generalisation of study results. However, diversity is noted not only for minimally-invasive procedures but also for the standard techniques against which the new developments are to be compared. The second problem refers to the heterogeneity of study populations. For most studies one common inclusion criterion was "persisting sciatica after a course of conservative treatment of variable duration". Differences among study populations are noted concerning results of imaging studies. Even within every group of minimally-invasive procedure, studies define their own in- and exclusion criteria which differ concerning degree of dislocation and sequestration of disc material. There is the non-standardised assessment of outcomes which are performed postoperatively after variable periods of time. Most studies report results in a dichotomous way as success or failure while the classification of a result is performed using a variety of different assessment instruments or procedures. Very often the global subjective judgement of results by patients or surgeons is reported. There are no scientific discussions whether these judgements are generalisable or comparable, especially among studies that are conducted under differing socio-cultural conditions. Taking into account the weak evidence-base for efficacy and effectiveness of minimally-invasive procedures it is not surprising that so far there are no dependable economic analyses.
Conclusions
Conclusions that can be drawn from the results of the present assessment refer in detail to the specified minimally-invasive procedures of lumbar disc surgery but they may also be considered exemplary for other fields where optimisation of results is attempted by technological development and widening of indications (e.g. total hip replacement).
Compared to standard technologies (open discectomy, microdiscectomy) and with the exception of chemonucleolysis, the developmental status of all other minimally-invasive procedures assessed must be termed experimental. To date there is no dependable evidence-base to recommend their use in routine clinical practice. To create such a dependable evidence-base further research in two directions is needed: a) The studies need to include adequate patient populations, use realistic controls (e.g. standard operative procedures or continued conservative care) and use standardised measurements of meaningful outcomes after adequate periods of time. b) Studies that are able to report effectiveness of the procedures under everyday practice conditions and furthermore have the potential to detect rare adverse effects are needed. In Sweden this type of data is yielded by national quality registries. On the one hand their data are used for quality improvement measures and on the other hand they allow comprehensive scientific evaluations. Since the year of 2000 a continuous rise in utilisation of minimally-invasive lumbar disc surgery is observed among statutory health insurers. Examples from other areas of innovative surgical technologies (e.g. robot assisted total hip replacement) indicate that the rise will probably continue - especially because there are no legal barriers to hinder introduction of innovative treatments into routine hospital care. Upon request by payers or providers the "Gemeinsamer Bundesausschuss" may assess a treatments benefit, its necessity and cost-effectiveness as a prerequisite for coverage by the statutory health insurance. In the case of minimally-invasive disc surgery it would be advisable to examine the legal framework for covering procedures only if they are provided under evaluation conditions. While in Germany coverage under evaluation conditions is established practice in ambulatory health care only (“Modellvorhaben") examples from other European countries (Great Britain, Switzerland) demonstrate that it is also feasible for hospital based interventions. In order to assure patient protection and at the same time not hinder the further development of new and promising technologies provision under evaluation conditions could also be realised in the private health care market - although in this sector coverage is not by law linked to benefit, necessity and cost-effectiveness of an intervention.
PMCID: PMC3011322  PMID: 21289928
24.  Evidence based practice beliefs and implementation among nurses: a cross-sectional study 
BMC Nursing  2014;13:8.
Background
Having a positive attitude towards evidence-based practice and being able to see the value of evidence-based practice for patients have been reported as important for the implementation of evidence-based practice among nurses.
The aim of this study was to map self-reported beliefs towards EBP and EBP implementation among nurses, and to investigate whether there was a positive correlation between EBP beliefs and EBP implementation.
Method
We carried out a cross-sectional study among 356 nurses at a specialist hospital for the treatment of cancer in Norway. The Norwegian translations of the Evidence-based Practice Belief Scale and the Evidence-based Practice Implementation Scale were used.
Results
In total, 185 nurses participated in the study (response rate 52%). The results showed that nurses were positive towards evidence-based practice, but only practised it to a small extent. There was a positive correlation (r) between beliefs towards evidence-based practice and implementation of evidence-based practice (r = 0.59, p = 0.001).
There was a statistical significant positive, but moderate correlation between all the four subscales of the EBP Beliefs Scale (beliefs related to: 1) knowledge, 2) resources, 3) the value of EBP and 4) difficulty and time) and the EBP Implementation Scale, with the highest correlation observed for beliefs related to knowledge (r = 0.38, p < .0001). Participants who had learned about evidence-based practice had significantly higher scores on the Evidence-based Practice Belief Scale than participants who were unfamiliar with evidence-based practice. Those involved in evidence-based practice working groups also reported significantly higher scores on the Evidence-based Practice Belief Scale than participants not involved in these groups.
Conclusion
This study shows that nurses have a positive attitude towards evidence-based practice, but practise it to a lesser extent. There was a positive correlation between beliefs about evidence-based practice and implementation of evidence-based practice. Beliefs related to knowledge appear to have the greatest effect on implementation of evidence-based practice. Having knowledge and taking part in evidence-based practice working groups seem important.
doi:10.1186/1472-6955-13-8
PMCID: PMC3987836  PMID: 24661602
Evidence-based practice; Beliefs; Behaviour; Implementation; Nurses; Survey
25.  Psychosocial Factors That Shape Patient and Carer Experiences of Dementia Diagnosis and Treatment: A Systematic Review of Qualitative Studies 
PLoS Medicine  2012;9(10):e1001331.
A systematic review of qualitative studies conducted by Frances Bunn and colleagues identifies and describes the experiences of patients and caregivers on receiving and adapting to a diagnosis of dementia.
Background
Early diagnosis and intervention for people with dementia is increasingly considered a priority, but practitioners are concerned with the effects of earlier diagnosis and interventions on patients and caregivers. This systematic review evaluates the qualitative evidence about how people accommodate and adapt to the diagnosis of dementia and its immediate consequences, to guide practice.
Methods and Findings
We systematically reviewed qualitative studies exploring experiences of community-dwelling individuals with dementia, and their carers, around diagnosis and the transition to becoming a person with dementia. We searched PubMed, PsychINFO, Embase, CINAHL, and the British Nursing Index (all searched in May 2010 with no date restrictions; PubMed search updated in February 2012), checked reference lists, and undertook citation searches in PubMed and Google Scholar (ongoing to September 2011). We used thematic synthesis to identify key themes, commonalities, barriers to earlier diagnosis, and support identified as helpful. We identified 126 papers reporting 102 studies including a total of 3,095 participants. Three overarching themes emerged from our analysis: (1) pathways through diagnosis, including its impact on identity, roles, and relationships; (2) resolving conflicts to accommodate a diagnosis, including the acceptability of support, focusing on the present or the future, and the use or avoidance of knowledge; and (3) strategies and support to minimise the impact of dementia. Consistent barriers to diagnosis include stigma, normalisation of symptoms, and lack of knowledge. Studies report a lack of specialist support particularly post-diagnosis.
Conclusions
There is an extensive body of qualitative literature on the experiences of community-dwelling individuals with dementia on receiving and adapting to a diagnosis of dementia. We present a thematic analysis that could be useful to professionals working with people with dementia. We suggest that research emphasis should shift towards the development and evaluation of interventions, particularly those providing support after diagnosis.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Dementia is a decline in mental ability severe enough to interfere with daily life. Alzheimer disease is the most common type of dementia. People with dementia usually have problems with two or more cognitive functions—thinking, language, memory, understanding, and judgment. Dementia is rare before the age of 65, but about a quarter of people over 85 have dementia. Because more people live longer these days, the number of patients with dementia is increasing. It is estimated that today between 40 and 50 million people live with dementia worldwide. By 2050, this number is expected to triple.
One way to study what dementia means to patients and their carers (most often spouses or other family members) is through qualitative research. Qualitative research aims to develop an in-depth understanding of individuals' experiences and behavior, as well as the reasons for their feelings and actions. In qualitative studies, researchers interview patients, their families, and doctors. When the studies are published, they usually contain direct quotations from interviews as well as summaries by the scientists who designed the interviews and analyzed the responses.
Why Was This Study Done?
This study was done to better understand the experiences and attitudes of patients and their carers surrounding dementia diagnosis. It focused on patients who lived and were cared for within the community (as opposed to people living in senior care facilities or other institutions). Most cases of dementia are progressive, meaning symptoms get worse over time. Diagnosis often happens at an advanced stage of the disease, and some patients never receive a formal diagnosis. This could have many possible reasons, including unawareness or denial of symptoms by patients and people close to them. The study was also trying to understand barriers to early diagnosis and what type of support is useful for newly diagnosed patients and carers.
What Did the Researchers Do and Find?
The researchers conducted a systematic search for published qualitative research studies that reported on the experience, beliefs, feelings, and attitudes surrounding dementia diagnosis. They identified and reviewed 102 such studies. Among the quotations and summaries of the individual studies, they looked for prominent and recurring themes. They also compared and contrasted the respective experiences of patients and carers.
Overall, they found that the complexity and variety of responses to a diagnosis of dementia means that making the diagnosis and conveying it to patients and carers is challenging. Negative connotations associated with dementia, inconsistent symptoms, and not knowing enough about the signs and symptoms were commonly reported barriers to early dementia diagnosis. It was often the carer who initiated the search for help from a doctor, and among patients, willingness and readiness to receive a diagnosis varied. Being told one had dementia had a big impact on a patient's identity and often caused feelings of loss, anger, fear, and frustration. Spouses had to adjust to increasingly unequal relationships and the transition to a role as carer. The strain associated with this often caused health problems in the carers as well. On the other hand, studies examining the experience of couples often reported that they found ways to continue working together as a team.
Adjusting to a dementia diagnosis is a complex process. Initially, most patients and carers experienced conflicts, for example, between autonomy and safety, between recognizing the need for help but reluctance to accept it, or between living in the present and dealing with anxiety about and preparing for the future. As these were resolved and as the disease progressed, the attitudes of patients and carers towards dementia often became more balanced and accepting. Many patients and their families adopted strategies to cope with the impact of dementia on their lives in order to manage the disease and maintain some sort of normal life. These included practical strategies involving reminders, social strategies such as relying on family support, and emotional strategies such as using humor. At some point many patients and carers reported that they were able to adopt positive mindsets and incorporate dementia in their lives.
The studies also pointed to an urgent need for support from outside the family, both right after diagnosis and subsequently. General practitioners and family physicians have important roles in helping patients and carers to get access to information, social and psychological support, and community care. The need for information was reported to be ongoing and varied, and meeting it required a variety of sources and formats. Key needs for patients and carers mentioned in the studies include information on financial aids and entitlements early on, and continued access to supportive professionals and specialists.
What Do These Findings Mean?
Qualitative studies to date on how patients and carers respond to a diagnosis of dementia provide a fairly detailed picture of their experiences. The summary provided here should help professionals to understand better the challenges patients and carers face around the time of diagnosis as well as their immediate and evolving needs. The results also suggest that future research should focus on the development and evaluation of ways to meet those needs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001331.
Wikipedia has pages on dementia and qualitative research (note that Wikipedia is a free online encyclopedia that anyone can edit)
Alzheimer Europe, an umbrella organization of 34 Alzheimer associations from 30 countries across Europe, has a page on the different approaches to research
The UK Department of Health has pages on dementia, including guidelines for carers of people with dementia
MedlinePlus also has information about dementia
doi:10.1371/journal.pmed.1001331
PMCID: PMC3484131  PMID: 23118618

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