Providers and patients are most likely to use and benefit from guidelines accompanied by implementation support. Guidelines published in 2007 and earlier assessed with the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument scored poorly for applicability, which reflects the inclusion of implementation instructions or tools. The purpose of this study was to examine the applicability of guidelines published in 2008 or later and identify factors associated with applicability.
Systematic review of studies that used AGREE to assess guidelines published in 2008 or later.
MEDLINE and EMBASE were searched from 2008 to July 2014, and the reference lists of eligible items. Two individuals independently screened results for English language studies that reviewed guidelines using AGREE and reported all domain scores, and extracted data. Descriptive statistics were calculated across all domains. Multilevel regression analysis with a mixed effects model identified factors associated with applicability.
Of 245 search results, 53 were retrieved as potentially relevant and 20 studies were eligible for review. The mean and median domain scores for applicability across 137 guidelines published in 2008 or later were 43.6% and 42.0% (IQR 21.8–63.0%), respectively. Applicability scored lower than all other domains, and did not markedly improve compared with guidelines published in 2007 or earlier. Country (UK) and type of developer (disease-specific foundation, non-profit healthcare system) appeared to be associated with applicability when assessed with AGREE II (not original AGREE).
Despite increasing recognition of the need for implementation tools, guidelines continue to lack such resources. To improve healthcare delivery and associated outcomes, further research is needed to establish the type of implementation tools needed and desired by healthcare providers and consumers, and methods for developing high-quality tools.
Healthcare professionals require training in knowledge translation (KT) to implement evidence-based healthcare innovations. Mentorship is an effective training strategy that could be used to develop KT capacity but it has largely been used to train clinicians. The purpose of this study was to explore preferences for KT mentorship design.
Interviews were conducted with 54 Canadian researchers and research users who varied by profession, department, career stage and sex. Participants were asked about KT needs, views on mentorship as a strategy to develop KT capacity, and suggestions for program design. Grounded theory technique and thematic analysis were used to collect and analyse data.
Participants uniformly expressed interest in mentorship over other forms of learning about KT because it would provide credible, tailored information when needed. A variety of options for program content, format and delivery were recommended, suggesting the need for flexibility according to KT needs. Leadership, infrastructure, culture change and incentives may also be needed to foster KT mentorship. Views were mixed on whether mentors should be KT experts or subject or clinical experts with KT experience, and embedded in, or external to organizations.
These findings can be used to develop or evaluate KT mentoring programs. Further research is needed to evaluate different models in which the mentor may be an internal or external KT expert or subject expert with experience in KT, and establish the core curriculum of a training program specific to KT and how it could best be reinforced with mentoring.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0863-7) contains supplementary material, which is available to authorized users.
Mentors; Quality improvement; Qualitative research
There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers.
A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies.
The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies.
While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-015-0247-8) contains supplementary material, which is available to authorized users.
Guidelines; Implementation; Implementation planning; Implementation strategies; Quality improvement; Systematic review
Developers, users and others have requested or advocated for guidance on how to plan for, and implement guidelines concurrent to their development given that existing resources are lacking such information. The purpose of this research was to develop a guideline implementation planning checklist.
Documents that described or evaluated the processes of planning or undertaking implementation were identified in several publications that had systematically identified such resources, and by searching medical literature databases (MEDLINE, EMBASE). Data that described implementation planning; how to develop guideline versions or tools that would support user implementation; and options and mechanisms for disseminating or implementing guidelines were independently extracted from eligible documents by the principal investigator and a trained research assistant. Data were integrated to create a unique list of guideline implementation planning processes and considerations.
Thirty-five documents were eligible. Of these, 16 (45.7%) provided sparse information on implementation planning, 25 (71.4%) mentioned different versions or tools for implementation, and 30 (85.7%) listed options for dissemination or implementation. None provided instructions for operationalizing implementation strategies. Data were integrated into a multi-item Guideline Implementation Planning Checklist including considerations for implementation planning (12), development of implementation tools (8), types of implementation tools (12), and options for dissemination (11) and implementation (12).
Developers or users can apply the Guideline Implementation Planning Checklist to prepare for and/or undertake guideline implementation. Further development of the checklist is warranted to elaborate on all components. In ongoing research, we will consult with the international guideline community to do so. At the same time, guideline implementation is complex, so developers and users would benefit from training, and by including knowledge translation experts and brokers on implementation planning committees.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-015-0205-5) contains supplementary material, which is available to authorized users.
Research shows that guidelines featuring implementation tools (GItools) are more likely to be used than those without GItools, however few guidelines offer GItools and guidance on developing GItools is lacking. The objective of this study was to identify common processes and considerations for developing GItools.
Interviews were conducted with developers of 4 types of GItools (implementation, patient engagement, point-of-care decision-making and evaluation) accompanying guidelines on various topics created in 2008 or later identified in the National Guideline Clearinghouse. Participants were asked to describe the GItool development process and related considerations. A descriptive qualitative approach was used to collect and analyze data.
Interviews were conducted with 26 GItool developers in 9 countries. Participants largely agreed on 11 broad steps, each with several tasks and considerations. Response variations identified issues lacking uniform approaches that may require further research including timing of GItool development relative to guideline development; decisions about GItool type, format and content; and whether and how to engage stakeholders. Although developers possessed few dedicated resources, they relied on partnerships to develop, implement and evaluate GItools.
GItool developers employed fairly uniform and rigorous processes for developing GItools. By supporting GItool development, the GItool methods identified here may improve guideline implementation and use.
Practice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC.
Rates of MVR were examined by observational study. Eligible patients were aged 20–74 years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods.
Factors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases.
Further research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.
Colorectal neoplasms; Multivisceral resection; Decision-making; Practice guideline adherence; Continuing education; Quality improvement
Collaboration among researchers (clinician, non-clinician) and decision makers (managers, policy-makers, clinicians), referred to as integrated knowledge translation (IKT), enhances the relevance and use of research, leading to improved decision-making, policies, practice, and health care outcomes. However IKT is not widely practiced due to numerous challenges. This research explored how context influenced IKT as a means of identifying how IKT could be strengthened.
This research investigated IKT in three health services programs for colon cancer screening, prostate cancer diagnosis, and the treatment of pancreatic cancer. Qualitative methods were used to explore contextual factors that influenced how IKT occurred, and its impact. Data were collected between September 1, 2012 and May 15, 2013 from relevant documents, observation of meetings, and interviews with researchers and decision-makers, analyzed using qualitative methods, and integrated.
Data were analyzed from 39 documents, observation of 6 meetings, and 36 interviews. IKT included interaction at meetings, joint undertaking of research, and development of guidelines. IKT was most prevalent in one program with leadership, clear goals, dedicated funding and other infrastructural resources, and an embedded researcher responsible for, and actively engaged in IKT. This program achieved a variety of social, research and health service outcomes despite mixed individual views about the value of IKT and the absence of a programmatic culture of IKT. Participants noted numerous challenges including lack of time and incentives, and recommendations to support IKT. A conceptual framework of factors that influence IKT and associated outcomes was generated, and can be used by others to plan or evaluate IKT.
The findings can be applied by researchers, clinicians, managers or policy-makers to plan or improve collaborative decision-making for health services planning, delivery, evaluation or quality improvement. Further research is needed to explore whether these findings are widespread, and further understand how IKT can be optimized.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0545-x) contains supplementary material, which is available to authorized users.
Integrated knowledge translation; Health services research; Collaboration; Qualitative methods
The surgical safety checklist (SSC) is meant to enhance patient safety but studies of its impact conflict. This study explored factors that influenced SSC adherence to suggest how its impact could be optimized.
Participants were recruited purposively by profession, region, hospital type and time using the SSC. They were asked to describe how the SSC was adopted, associated challenges, perceived impact, and suggestions for improving its use. Grounded theory and thematic analysis were used to collect and analyse data. Findings were interpreted using an implementation fidelity conceptual framework.
Fifty-one participants were interviewed (29 nurses, 13 surgeons, 9 anaesthetists; 18 small, 14 large and 19 teaching hospitals; 8 regions; 31 had used the SC for ≤12 months, 20 for 13+ months). The SSC was inconsistently reviewed, and often inaccurately documented as complete. Adherence was influenced by multiple issues. Extensive modification to accommodate existing practice patterns eliminated essential interaction at key time points to discuss patient management. Staff were often absent or not paying attention. They did not feel it was relevant to their work given limited evidence of its effectiveness, and because they were not engaged in its implementation. Organizations provided little support for implementation, training, monitoring and feedback, which are needed to overcome these, and other individual and team factors that challenged SSC adherence. Responses were similar across participants with different characteristics.
Multiple processes and factors influenced SSC adherence. This may explain why, in studies evaluating SSC impact, outcomes were variable. Recommendations included continuing education, time for pilot-testing, and engaging all staff in SSC review. Others may use the implementation fidelity framework to plan SSC implementation or evaluate SSC adherence. Further research is needed to establish which SSC components can be modified without compromising its effectiveness.
Knowledge translation (KT) supports use of evidence in healthcare decision making but is not widely practiced. Mentoring is a promising means of developing KT capacity. The purpose of this scoping systematic review was to identify essential components of mentoring that could be adapted for KT mentorship.
Key social sciences and management databases were searched from January 2002 to December 2011 inclusive. Empirical research in non-healthcare settings that examined mentorship design and impact for improving job-specific knowledge and skill were eligible. Members of the study team independently selected eligible studies, and extracted and summarized data.
Of 2,101 search results, 293 were retrieved and 13 studies were eligible for review. All but one reported improvements in knowledge, skill, or behavior. Mentoring program components included combining preliminary workshop-based training with individual mentoring provided either in person or remotely; training of mentors; and periodic mentoring for at least an hour over a minimum period of six months. Barriers included the need for infrastructure for recruitment, matching, and training; lack of clarity in mentoring goals; and limited satisfaction with mentors and their availability. Findings were analyzed against a conceptual framework of factors that influence mentoring design and impact to identify issues warranting further research.
This study identified key mentoring components that could be adapted for KT mentorship. Overall, few studies were identified. Thus further research should explore whether and how mentoring should be tailored to baseline knowledge or skill and individual KT needs; evaluate newly developed or existing KT mentorship programs based on the factors identified here; and examine whether and how KT mentorship develops KT capacity. The conceptual framework could be used to develop or evaluate KT mentoring programs.
Knowledge translation; Mentorship
Guidelines are the foundation for healthcare planning, delivery and quality improvement but are not consistently implemented. Few guidelines are accompanied by guideline implementation tools (GItools). Users have requested GItools, and developers have requested guidance on how to develop GItools. First it is necessary to characterize GItools. The purpose of this research was to generate a framework of desirable features of GItools.
Items representing desirable GItool features were generated by a cross-sectional survey of the international guideline community. Items were confirmed by 31 guideline developers, implementers and researchers in a two-round Delphi survey administered on the Internet. The resulting GItool framework was applied with a sample of GItools accompanying guidelines identified in the National Guideline Clearinghouse.
The cross-sectional survey was completed by 96 respondents from Australia, Canada, the United Kingdom, the United States, The Netherlands, and various other countries. Seven of nine items were rated by the majority as desirable. A total of 31 panelists from 10 countries including Australia, Canada, Germany, New Zealand, Peru, Saudi Arabia, Spain, the United Kingdom, and the United States took part in a two-round Delphi survey. Ten items achieved consensus as desirable GItool features in round #1, and two additional items in round #2. A total of 13 GItools for Resource Planning, Implementation and Evaluation were identified among 149 guidelines on a variety of clinical topics (8.7%). Many GItools did not possess features considered desirable.
Inclusion of higher quality GItools in guidelines is needed to support user adoption of guidelines. The GItool framework can serve as the basis for evaluating and adapting existing GItools, or developing new GItools. Further research is needed to validate the framework, develop and implement instruments by which developers can apply the framework, and specify which guidelines should be accompanied by GItools.
Inter-professional collaborative care (ICC) for cancer leads to multiple system, organizational, professional, and patient benefits, but is limited by numerous challenges. Empirical research on interventions that promote or enable ICC is sparse so guidance on how to achieve ICC is lacking. Research shows that ICC for diagnosis could be improved. Diagnostic assessment programs (DAPs) appear to be a promising model for enabling ICC. The purpose of this study was to explore how DAP structure and function enable ICC, and whether that may be associated with organizational and clinical outcomes.
A case study approach will be used to explore ICC among eight DAPs that vary by type of cancer (lung, breast), academic status, and geographic region. To describe DAP function and outcomes, and gather information that will enable costing, recommendations expressed in DAP standards and clinical guidelines will be assessed through retrospective observational study. Data will be acquired from databases maintained by participating DAPs and the provincial cancer agency, and confirmed by and supplemented with review of medical records. We will conduct a pilot study to explore the feasibility of estimating the incremental cost-effectiveness ratio using person-level data from medical records and other sources. Interviews will be conducted with health professionals, staff, and referring physicians from each DAP to learn about barriers and facilitators of ICC. Qualitative methods based on a grounded approach will be used to guide sampling, data collection and analysis.
Findings may reveal opportunities for unique structures, interventions or tools that enable ICC that could be developed, implemented, and evaluated through future research. This information will serve as a formative needs assessment to identify the nature of ongoing or required improvements, which can be directly used by our decision maker collaborators, and as a framework by policy makers, cancer system managers, and DAP managers elsewhere to strategically plan for and implement diagnostic cancer services.
Inter-professional collaborative care; Multidisciplinary care team; Inter-professional relations; Communication; Cooperative behavior; Diagnostic assessment program; Breast cancer; Lung cancer
Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy.
We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness.
We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13–54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration.
The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care.
Quality indicators (QI) are used in health care to measure quality of service and performance improvement. Health care professionals and organizations caring for patients with injuries need information regarding the quality of care provided and the outcomes experienced in order to target improvement efforts. However, very little is known about the quality of injury care provided to individual patients and populations and even less about patients’ perspectives on quality of care. The absence of QIs that incorporate patient or family preferences, needs or values has been identified as an important gap in the science and practice of injury quality improvement. The primary objective of this research protocol is to develop and evaluate the first set of patient and family-centred QIs of injury care for critically injured patients
This mixed methods study is comprised of three Sub-Studies. Sub-Study A will utilize focus group methodology to describe the preferences, needs and values of critically injured patients and their family members regarding the quality of health care delivered. Qualitative content analysis of the transcripts will begin after the first completed focus group and will draw on grounded theory using a process of open, axial and selective coding. A panel of stakeholders will be assembled during Sub-Study B to review the themes identified from the focus groups and develop a catalogue of potential patient and family-centred QIs of injury care using the RAND/UCLA Appropriateness Method (RAM). The QIs developed by the stakeholder panel will be pilot tested in Sub-Study C using surveys of patients and their family members to determine construct validity, intra-rater reliability and clinical sensibility.
Measuring the quality of injury care is but a first step towards improving patient outcomes. This research will develop the first set of patient and family-centred QIs of injury care. To improve patient care, we need accessible, reliable indicators of quality that are important to patients, and that can then be used to establish quality of care benchmarks, to flag potential problems or successes, follow trends over time and identify disparities across organizations, communities, populations and regions.
Injury; Patient-centred care; Quality improvement; Quality indicators; Trauma; Focus group; Consensus panel; Survey
Population based studies show that guidelines are underused. Surveys of international guideline developers found that many do not implement their guidelines. The purpose of this research was to interview guideline developers about implementation approaches and resources.
Semi-structured telephone interviews were conducted with representatives of guideline development agencies identified in the National Guideline Clearinghouse and sampled by country, type of developer, and guideline clinical indication. Participants were asked to comment on the benefits and resource implications of three approaches for guideline implementation that varied by responsibility: developers, intermediaries, or users.
Thirty individuals from seven countries were interviewed, representing government (n = 12) and professional (n = 18) organizations that produced guidelines for a variety of clinical indications. Organizations with an implementation mandate featured widely inconsistent funding and staffing models, variable approaches for choosing promotional strategies, and an array of dissemination activities. When asked to choose a preferred approach, most participants selected the option of including information within guidelines that would help users to implement them. Given variable mandate and resources for implementation, it was considered the most feasible approach, and therefore most likely to have impact due to potentially broad use.
While implementation approaches and strategies need not be standardized across organizations, the findings may be used by health care policy makers and managers, and guideline developers to generate strategic and operational plans that optimize implementation capacity. Further research is needed to examine how to optimize implementation capacity by guideline developers, intermediaries and users.
Guideline development; Guideline implementation; Qualitative research
A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.
A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.
Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%–90% of respondents, but less than 50% stated that these strategies were in place at their institutions.
Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.
Guidelines are important tools that inform healthcare delivery based on best available research evidence. Guideline use is in part based on quality of the guidelines, which includes advice for implementation and has been shown to vary. Others hypothesized this is due to limited instructions in guideline development manuals. The purpose of this study was to examine manual instructions for implementation advice.
We used a directed and summative content analysis approach based on an established framework of guideline implementability. Six manuals identified by another research group were examined to enumerate implementability domains and elements.
Manuals were similar in content but lacked sufficient detail in particular domains. Most frequently this was Accomodation, which includes information that would help guideline users anticipate and/or overcome organizational and system level barriers. In more than one manual, information was also lacking for Communicability, information that would educate patients or facilitate their involvement in shared decision making, and Applicability, or clinical parameters to help clinicians tailor recommendations for individual patients.
Most manuals that direct guideline development lack complete information about incorporating implementation advice. These findings can be used by those who developed the manuals to consider expanding their content in these domains. It can also be used by guideline developers as they plan the content and implementation of their guidelines so that the two are integrated. New approaches for guideline development and implementation may need to be developed. Use of guidelines might be improved if they included implementation advice, but this must be evaluated through ongoing research.
Guideline development; Guideline implementation; Implementability
Modifying the format and content of guidelines may facilitate their use and lead to improved quality of care. We reviewed the medical literature to identify features desired by different users and associated with guideline use to develop a framework of implementability and found that most guidelines do not contain these elements. Further research is needed to develop and evaluate implementability tools.
We are launching the Guideline Implementability Research and Application Network (GIRAnet) to enable the development and testing of implementability tools in three domains: Resource Implications, Implementation, and Evaluation. Partners include the Guidelines International Network (G-I-N) and its member guideline developers, implementers, and researchers. In phase one, international guidelines will be examined to identify and describe exemplar tools. Indication-specific and generic tools will populate a searchable repository. In phase two, qualitative analysis of cognitive interviews will be used to understand how developers can best integrate implementability tools in guidelines and how health professionals use them for interpreting and applying guidelines. In phase three, a small-scale pilot test will assess the impact of implementability tools based on quantitative analysis of chart-based behavioural outcomes and qualitative analysis of interviews with participants. The findings will be used to plan a more comprehensive future evaluation of implementability tools.
Infrastructure funding to establish GIRAnet will be leveraged with the in-kind contributions of collaborating national and international guideline developers to advance our knowledge of implementation practice and science. Needs assessment and evaluation of GIRAnet will provide a greater understanding of how to develop and sustain such knowledge-exchange networks. Ultimately, by facilitating use of guidelines, this research may lead to improved delivery and outcomes of patient care.
Guidelines; Guideline development; Guideline implementation; Research networks; Knowledge exchange
Qualitative research has the potential to inform and improve health care decisions but a study based on one year of publications suggests that it is not published in prominent health care journals. A more detailed, longitudinal analysis of its availability is needed. The purpose of this study was to identify, count and compare the number of qualitative and non-qualitative research studies published in high impact health care journals, and explore trends in these data over the last decade.
A bibliometric approach was used to identify and quantify qualitative articles published in 20 top general medical and health services and policy research journals from 1999 to 2008. Eligible journals were selected based on performance in four different ranking systems reported in the 2008 ISI Journal Citation Reports. Qualitative and non-qualitative research published in these journals were identified by searching MEDLINE, and validated by hand-searching tables of contents for four journals.
The total number of qualitative research articles published during 1999 to 2008 in ten general medical journals ranged from 0 to 41, and in ten health services and policy research journals from 0 to 39. Over this period the percentage of empirical research articles that were qualitative ranged from 0% to 0.6% for the general medical journals, and 0% to 6.4% for the health services and policy research journals.
This analysis suggests that qualitative research it is rarely published in high impact general medical and health services and policy research journals. The factors that contribute to this persistent marginalization need to be better understood.
Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines.
A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team.
The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic.
Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.
Patient involvement in healthcare represents the means by which to achieve a healthcare system that is responsive to patient needs and values. Characterization and evaluation of strategies for involving patients in their healthcare may benefit from a knowledge translation (KT) approach. The purpose of this knowledge synthesis is to develop a conceptual framework for patient-mediated KT interventions.
A preliminary conceptual framework for patient-mediated KT interventions was compiled to describe intended purpose, recipients, delivery context, intervention, and outcomes. A realist review will be conducted in consultation with stakeholders from the arthritis and cancer fields to explore how these interventions work, for whom, and in what contexts. To identify patient-mediated KT interventions in these fields, we will search MEDLINE, the Cochrane Library, and EMBASE from 1995 to 2010; scan references of all eligible studies; and examine five years of tables of contents for journals likely to publish quantitative or qualitative studies that focus on developing, implementing, or evaluating patient-mediated KT interventions. Screening and data collection will be performed independently by two individuals.
The conceptual framework of patient-mediated KT options and outcomes could be used by healthcare providers, managers, educationalists, patient advocates, and policy makers to guide program planning, service delivery, and quality improvement and by us and other researchers to evaluate existing interventions or develop new interventions. By raising awareness of options for involving patients in improving their own care, outcomes based on using a KT approach may lead to greater patient-centred care delivery and improved healthcare outcomes.
A study of the implementation in Canada of multidisciplinary cancer conferences—which can facilitate diagnosis and treatment discussions and optimize patient management—using grounded theory methodology.
Multidisciplinary cancer conferences (MCCs) provide an opportunity for health professionals to discuss diagnosis and treatment options to optimize patient management. The purpose of this study was to explore the barriers and facilitators in implementing MCCs in Canada.
This exploratory study used qualitative interviews and observation to explore the experiences of implementing MCCs in four hospitals in Ontario, Canada. Interviews were transcribed verbatim and analyzed using standard qualitative research methodology guided by grounded theory principles.
Thirty-seven MCCs for gastrointestinal cancer were observed across three hospital sites, and 48 interviews were conducted among a range of clinical specialists and administrators. The dominant theme suggested that MCCs can most effectively be implemented if administrators and health professionals see value in MCCs, despite the time and effort required. A number of factors (eg, provincial policy, hospital administrative and clinician support, and an efficient MCC process) influenced whether MCCs were valued.
Variation exists in the enthusiasm of health professionals and the administrative capacity of institutions regarding routine implementation of MCCs. A systematic implementation plan for MCCs is needed involving both cancer care providers and administrators.
Although magnetic resonance imaging (MRI) is an important imaging modality for pre-operative staging and surgical planning of rectal cancer, to date there has been little investigation on the completeness and overall quality of MRI reports. This is important because optimal patient care depends on the quality of the MRI report and clear communication of these reports to treating physicians. Previous work has shown that the use of synoptic pathology reports improves the quality of pathology reports and communication between physicians.
The aims of this project are to develop a synoptic MRI report for rectal cancer and determine the enablers and barriers toward the implementation of a synoptic MRI report for rectal cancer in the clinical setting. A three-step Delphi process with an expert panel will extract the key criteria for the MRI report to guide pre-operative chemoradiation and surgical planning following a review of the literature, and a synoptic template will be developed. Furthermore, standardized qualitative research methods will be used to conduct interviews with radiologists to determine the enablers and barriers to the implementation and sustainability of the synoptic MRI report in the clinic setting.
Synoptic MRI reports for rectal cancer are currently not used in North America and may improve the overall quality of MRI report and communication between physicians. This may, in turn, lead to improved patient care and outcomes for rectal cancer patients.
Surgical site infections (SSIs) are common surgical complications that can be prevented with antibiotic prophylaxis. Research shows poor adherence to guidelines for this practice. We conducted a scoping review to identify factors or interventions that influence antibiotic prophylaxis administration.
An investigator with informatics training searched indexed (MEDLINE, Cochrane Library) and nonindexed (Internet) sources from January 1996 to February 2007. Selected studies were English-language, peer-reviewed, quantitative or qualitative studies describing factors or interventions influencing adherence to SSI-prevention guidelines or SSI rates in general surgery. Two investigators independently reviewed citations and full-text articles and extracted data, and met to compare selections or data and resolve differences through discussion. We extracted data on type of surgery, study design, intervention or factors examined and key findings. We then examined the quantity and type of studies and their findings.
Nineteen of 192 studies met the eligibility criteria. Seven studies investigated predictors of appropriate antibiotic use through descriptive or exploratory means. Twelve evaluated adherence to antibiotic prophylaxis recommendations by comparing patient cohorts before and after the introduction of quality-improvement strategies. Individual knowledge, attitudes, beliefs and practice; team communication and allocation of responsibilities; and institutional support for promoting and monitoring practice appear to influence practice.
Larger and multisite studies included in our review favour implementation of multidisciplinary pathways, individualized performance data and written or computerized order sets as quality-improvement strategies, but further research is warranted to more rigorously evaluate the effectiveness of these strategies on antibiotic prophylaxis practice.
Research funders, educators, investigators and decision makers worldwide have identified the need to improve the quality of health care by building capacity for knowledge translation (KT) research and practice. Peer-based mentorship represents a vehicle to foster KT capacity. The purpose of this exploratory study is to identify mentoring models that could be used to build KT capacity, consult with putative mentee stakeholders to understand their KT mentorship needs and preferences, and generate recommendations for the content and format of KT mentorship strategies or programs, and how they could be tested through future research.
A conceptual framework was derived based on mentoring goals, processes and outcomes identified in the management and social sciences literature, and our research on barriers and facilitators of academic mentorship. These concepts will inform data collection and analysis. To identify useful models by which to design, implement and evaluate KT mentorship, we will review the social sciences, management, and nursing literature from 1990 to current, browse tables of contents of relevant journals, and scan the references of all eligible studies. Eligibility screening and data extraction will be performed independently by two investigators. Semi-structured interviews will be used to collect information about KT needs, views on mentorship as a knowledge sharing strategy, preferred KT mentoring program elements, and perceived barriers from clinician health services researchers representing different disciplines. Qualitative analysis of transcripts will be performed independently by two investigators, who will meet to compare findings and resolve differences through discussion. Data will be shared and discussed with the research team, and their feedback incorporated into final reports.
These findings could be used by universities, research institutes, funding agencies, and professional organizations in Canada and elsewhere to develop, implement, and evaluate mentorship for KT research and practice. This research will establish a theoretical basis upon which we and others can compare the cost-effectiveness of interventions that enhance KT mentorship. If successful, this program of research may increase knowledge about, confidence in, and greater utilization of KT processes, and the quality and quantity of KT research, perhaps ultimately leading to better implementation and adoption of recommended health care services.