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1.  Effectiveness of implementation strategies in improving physician adherence to guideline recommendations in heart failure: a systematic review protocol 
BMJ Open  2016;6(3):e009364.
The uptake of Clinical Practice Guideline (CPG) recommendations that improve outcomes in heart failure (HF) remains suboptimal. We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations, those with clear evidence that benefits outweigh the risks. We will use American, Canadian and European HF guidelines as our reference.
Methods and analysis
We will conduct a literature search in the databases of MEDLINE, EMBASE, HEALTHSTAR, CINAHL, Cochrane Library, Campbell Collaboration, Joanna Briggs Institute Evidence Based Practice, Centre for Reviews and Dissemination and Evidence Based Practice Centres. We will include prospective studies evaluating implementation interventions aimed at improving uptake of class I CPG recommendations in HF. We will extract data in duplicate. We will classify interventions according to their level of application (ie, provider, organisation, systems level) and common underlying characteristics (eg, education, decision-support, financial incentives) using the Cochrane Effective Practice and Organisation of Care Taxonomy. We will assess the impact of the intervention on adherence to the CPGs. Outcomes will include proportion of eligible patients who were: prescribed a CPG-recommended pharmacological treatment; referred for device consideration; provided self-care education at discharge; and provided left ventricular function assessment. We will include clinical outcomes such as hospitalisations, readmissions and mortality, if data is available. We will identify the common elements of successful and failing interventions, and examine the context in which they were applied, using the Process Redesign contextual framework. We will synthesise the results narratively and, if appropriate, will pool results for meta-analysis.
Discussion and dissemination
In this review, we will assess the impact of implementation strategies and contextual factors on physician adherence to HF CPGs. We will explore why some interventions may succeed in one setting and fail in another. We will disseminate our findings through briefing reports, publications and presentations.
Trial registration number
PMCID: PMC4823399  PMID: 27033956
implementation science; knowledge translation
2.  Collective action for implementation: a realist evaluation of organisational collaboration in healthcare 
Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation.
A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds.
The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations’ architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that ‘what’s in it for me’ resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation.
These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation.
PMCID: PMC4748518  PMID: 26860631
Implementation; Collaboration; Evidence; Co-production; Knowledge; Realist
3.  Identifying the domains of context important to implementation science: a study protocol 
There is growing recognition that “context” can and does modify the effects of implementation interventions aimed at increasing healthcare professionals’ use of research evidence in clinical practice. However, conceptual clarity about what exactly comprises “context” is lacking. The purpose of this research program is to develop, refine, and validate a framework that identifies the key domains of context (and their features) that can facilitate or hinder (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions.
A multi-phased investigation of context using mixed methods will be conducted. The first phase is a concept analysis of context using the Walker and Avant method to distinguish between the defining and irrelevant attributes of context. This phase will result in a preliminary framework for context that identifies its important domains and their features according to the published literature. The second phase is a secondary analysis of qualitative data from 13 studies of interviews with 312 healthcare professionals on the perceived barriers and enablers to their application of research evidence in clinical practice. These data will be analyzed inductively using constant comparative analysis. For the third phase, we will conduct semi-structured interviews with key health system stakeholders and change agents to elicit their knowledge and beliefs about the contextual features that influence the effectiveness of implementation interventions and healthcare professionals’ use of evidence in clinical practice. Results from all three phases will be synthesized using a triangulation protocol to refine the context framework drawn from the concept analysis. The framework will then be assessed for content validity using an iterative Delphi approach with international experts (researchers and health system stakeholders/change agents).
This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals’ use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term “context” for advancing implementation science, improving healthcare professionals’ use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts.
PMCID: PMC4584460  PMID: 26416206
4.  Hiding in plain sight: communication theory in implementation science 
Poor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms.
We conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists.
Implementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.
PMCID: PMC4410585  PMID: 25903662
Communication; Physician-nurse relations; Theoretical models; Knowledge translation
5.  Backwards design or looking sideways? knowledge translation in the real world 
El-Jardali and Fadllallah provide an excellent summary of the many dimensions of knowledge use, and the breath of issues and activities that must be considered if knowledge is to be put into practice. However, reliance on a continuum (rather than a cyclical, multidirectional, systems) model creates a number of limitations, particularly when promoting evidence-informed action in the areas of health policy and management, where diverse forms of knowledge must be synthesized and decisions made in a rapidly evolving context. We propose a paradigm shift - from viewing Knowledge Translation (KT) as a linear ‘knowledge transfer’ activity, to a commitment to full stakeholder engagement in knowledge production, dissemination and implementation.
PMCID: PMC4529046  PMID: 26340396
Knowledge Translation (KT); Engaged Scholarship; Evidence Use
6.  Knowledge synthesis and the Canadian Institutes of Health Research 
Systematic Reviews  2012;1:6.
The Canadian Institutes of Health Research (CIHR) is Canada's premier health-research funding agency. We fund nearly 14,000 researchers and trainees in four theme areas: biomedical, clinical, health services, and population and public-health research. Our mandate is 'to excel according to international standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system'. Knowledge synthesis is a key element of the knowledge-translation objectives of CIHR, as outlined in our definition of knowledge-translation.
PMCID: PMC3351743  PMID: 22587985
7.  “Entrenched practices and other biases”: unpacking the historical, economic, professional, and social resistance to de-implementation 
In their article on “Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices,” Prasad and Ioannidis (IS 9:1, 2014) referred to extra-scientific “entrenched practices and other biases” that hinder evidence-based de-implementation.
Using the case example of the de-implementation of radical mastectomy, we disaggregated “entrenched practices and other biases” and analyzed the historical, economic, professional, and social forces that presented resistance to de-implementation. We found that these extra-scientific factors operated to sustain a commitment to radical mastectomy, even after the evidence slated the procedure for de-implementation, because the factors holding radical mastectomy in place were beyond the control of individual clinicians.
We propose to expand de-implementation theory through the inclusion of extra-scientific factors. If the outcome to which we aim is appropriate and timely de-implementation, social scientific analysis will illuminate the context within which the healthcare practitioner practices and, in doing so, facilitate de-implementation by pointing to avenues that lead to systems change. The implications of our analysis lead us to contend that intervening in the broader context in which clinicians work—the social, political, and economic realms—rather than focusing on healthcare professionals’ behavior, may indeed be a fruitful approach to effect change.
PMCID: PMC4339245  PMID: 25889285
De-implementation; Social science; Evidence-based medicine
11.  Research funder required research partnerships: a qualitative inquiry 
Researchers and funding agencies are increasingly showing interest in the application of research findings and focusing attention on engagement of knowledge-users in the research process as a means of increasing the uptake of research findings. The expectation is that research findings derived from these researcher-knowledge-user partnerships will be more readily applied when they became available. The objective of this study was to investigate the experiences, perceived barriers, successes, and opinions of researchers and knowledge-users funded under the Canadian Institutes of Health Research’s integrated Knowledge Translation funding opportunities for a better understanding of these collaborations.
Participants, both researchers and knowledge-users, completed an online survey followed by an individual semi-structured phone interview supporting a mixed methods study. The interviews were analyzed qualitatively using a modified grounded theory approach.
Survey analysis identified three major partnership types: token, asymmetric, and egalitarian. Interview analysis revealed trends in perceived barriers and successes directly related to the partnership formation and style. While all partnerships experienced barriers, token partnerships had the most challenges and general poor perception of partnerships. The majority of respondents found that common goals and equality in partnerships did not remove barriers but increased participants’ ability to look for solutions.
We learned of effective mechanisms and strategies used by researchers and knowledge-users for mitigating barriers when collaborating. Funders could take a larger role in helping facilitate, nurture, and sustain the partnerships to which they award grants.
PMCID: PMC4260257  PMID: 25430813
Grants; Partnership; Qualitative research
12.  Presenting Evidence to Patients Online: What Do Web Users Think of Consumer Summaries of Cochrane Musculoskeletal Reviews? 
The Internet has the potential to be an effective medium for delivering health care knowledge to consumers. While computer usability research makes recommendations about how to present Web-based information generally, there remains no clear guidance on how to present specific forms of health care research evidence online in a way that facilitates understanding and good health care decision making.
The two goals of this study were to describe the Cochrane Musculoskeletal Group’s (CMSG’s) process for developing online patient-focused summaries of systematic reviews and to evaluate the impressions of these summaries formed by users.
A process for summarizing the results of systematic reviews via consumer summaries has evolved over 15 years. An evaluation of this approach took the form of Internet surveys on the Arthritis Society of Canada website and surveys of members of the Canadian Arthritis Patient Alliance (CAPA). Respondents provided information on background, relationship to the decision, their satisfaction with and preparation for decision making, and suggestions for improvements to the summaries. Survey data were collected between August 1, 2005, and February 28, 2006.
A total of 261 respondents completed the survey. The majority (226/261 or 87%) of respondents reported having an arthritis-related condition. The consumer summary approach was generally reviewed favorably by respondents, with most agreeing that the summary provided appropriate information (177/261 or 68%), would be useful to others (160/261 or 61%), was well laid out (159/261 or 61%), was easy to learn from (157/261 or 60%), and was useful to the reader (153/261 or 59%). Areas of potential improvement were indicated by relatively fewer respondents agreeing that they could easily find all the information they wanted (118/261 or 45%), by a substantial proportion being unable to judge whether the providers of the information are reliable (80/261 or 31%), and by a similar proportion being unable to determine whether the information presented was the best available (68/261 or 26%).
The CMSG has developed an approach to summarizing the results of often-technical systematic reviews into public-friendly consumer summaries. Our online survey showed that this approach was generally well liked but identified specific areas for improvement. Feedback from this survey will help to reshape and improve the current template for consumer summaries used by the CMSG.
PMCID: PMC3221355  PMID: 21247863
Decision support techniques; health care surveys; Internet; patient education; patient satisfaction; patient-centered care; musculoskeletal diseases
13.  Development of the AGREE II, part 1: performance, usefulness and areas for improvement 
We undertook research to improve the AGREE instrument, a tool used to evaluate guidelines. We tested a new seven-point scale, evaluated the usefulness of the original items in the instrument, investigated evidence to support shorter, tailored versions of the tool, and identified areas for improvement.
We report on one component of a larger study that used a mixed design with four factors (user type, clinical topic, guideline and condition). For the analysis reported in this article, we asked participants to read a guideline and use the AGREE items to evaluate it based on a seven-point scale, to complete three outcome measures related to adoption of the guideline, and to provide feedback on the instrument’s usefulness and how to improve it.
Guideline developers gave lower-quality ratings than did clinicians or policy-makers. Five of six domains were significant predictors of participants’ outcome measures (p < 0.05). All domains and items were rated as useful by stakeholders (mean scores > 4.0) with no significant differences by user type (p > 0.05). Internal consistency ranged between 0.64 and 0.89. Inter-rater reliability was satisfactory. We received feedback on how to improve the instrument.
Quality ratings of the AGREE domains were significant predictors of outcome measures associated with guideline adoption: guideline endorsements, overall intentions to use guidelines, and overall quality of guidelines. All AGREE items were assessed as useful in determining whether a participant would use a guideline. No clusters of items were found more useful by some users than others. The measurement properties of the seven-point scale were promising. These data contributed to the refinements and release of the AGREE II.
PMCID: PMC2900328  PMID: 20513780
14.  Development of the AGREE II, part 2: assessment of validity of items and tools to support application 
We established a program of research to improve the development, reporting and evaluation of practice guidelines. We assessed the construct validity of the items and user’s manual in the β version of the AGREE II.
We designed guideline excerpts reflecting high-and low-quality guideline content for 21 of the 23 items in the tool. We designed two study packages so that one low-quality and one high-quality version of each item were randomly assigned to each package. We randomly assigned 30 participants to one of the two packages. Participants reviewed and rated the guideline content according to the instructions of the user’s manual and completed a survey assessing the manual.
In all cases, content designed to be of high quality was rated higher than low-quality content; in 18 of 21 cases, the differences were significant (p < 0.05). The manual was rated by participants as appropriate, easy to use, and helpful in differentiating guidelines of varying quality, with all scores above the mid-point of the seven-point scale. Considerable feedback was offered on how the items and manual of the β-AGREE II could be improved.
The validity of the items was established and the user’s manual was rated as highly useful by users. We used these results and those of our study presented in part 1 to modify the items and user’s manual. We recommend AGREE II (available at as the revised standard for guideline development, reporting and evaluation.
PMCID: PMC2900368  PMID: 20513779
15.  Clinical Practice Guidelines and Consensus Statements in Oncology – An Assessment of Their Methodological Quality 
PLoS ONE  2014;9(10):e110469.
Consensus statements and clinical practice guidelines are widely available for enhancing the care of cancer patients. Despite subtle differences in their definition and purpose, these terms are often used interchangeably. We systematically assessed the methodological quality of consensus statements and clinical practice guidelines published in three commonly read, geographically diverse, cancer-specific journals. Methods Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine’s standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents.
Consensus statements and clinical practice guidelines published between January 2005 and September 2013 in Current Oncology, European Journal of Cancer and Journal of Clinical Oncology were evaluated. Each publication was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) rigour of development and editorial independence domains. For assessment of transparency of document development, 7 additional items were taken from the Institute of Medicine's standards for practice guidelines and the Journal of Clinical Oncology guidelines for authors of guidance documents.
Thirty-four consensus statements and 67 clinical practice guidelines were evaluated. The rigour of development score for consensus statements over the three journals was 32% lower than that of clinical practice guidelines. The editorial independence score was 15% lower for consensus statements than clinical practice guidelines. One journal scored consistently lower than the others over both domains. No journals adhered to all the items related to the transparency of document development. One journal’s consensus statements endorsed a product made by the sponsoring pharmaceutical company in 64% of cases.
Guidance documents are an essential part of oncology care and should be subjected to a rigorous and validated development process. Consensus statements had lower methodological quality than clinical practice guidelines using AGREE II. At a minimum, journals should ensure that that all consensus statements and clinical practice guidelines adhere to AGREE II criteria. Journals should consider explicitly requiring guidelines to declare pharmaceutical company sponsorship and to identify the sponsor’s product to enhance transparency.
PMCID: PMC4201546  PMID: 25329669
16.  GRAIDs: a framework for closing the gap in the availability of health promotion programs and interventions for people with disabilities 
Evidence-based health promotion programs developed and tested in the general population typically exclude people with disabilities. To address this gap, a set of methods and criteria were created to adapt evidence-based health promotion programs for people with disabilities. In this first study, we describe a framework for adapting evidence-based obesity prevention strategies for people with disabilities. We illustrate how the framework has been used to adapt the U.S. Centers for Disease Control and Prevention’s (CDC) obesity prevention strategies for individuals with physical and developmental disabilities.
The development of inclusion guidelines, recommendations and adaptations for obesity prevention (referred to as GRAIDs – Guidelines, Recommendations, Adaptations Including Disability) consists of five components: (i) a scoping review of the published and grey literature; (ii) an expert workgroup composed of nationally recognized leaders in disability and health promotion who review, discuss and modify the scoping review materials and develop the content into draft GRAIDs; (iii) focus groups with individuals with disabilities and their family members (conducted separately) who provide input on the potential applicability of the proposed GRAIDs in real world settings; (iv) a national consensus meeting with 21 expert panel members who review and vote on a final set of GRAIDs; and (v) an independent peer review of GRAIDs by national leaders from key disability organizations and professional groups through an online web portal.
This is an ongoing project, and to date, the process has been used to develop 11 GRAIDs to coincide with 11 of the 24 CDC obesity prevention strategies.
A set of methods and criteria have been developed to allow researchers, practitioners and government agencies to promote inclusive health promotion guidelines, strategies and practices for people with disabilities. Evidence-based programs developed for people without disabilities can now be adapted for people with disabilities using the GRAIDs framework.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0100-5) contains supplementary material, which is available to authorized users.
PMCID: PMC4148531  PMID: 25123550
Disability; Health promotion; Guideline adaptation; Obesity
17.  Looking inside the black box: results of a theory-based process evaluation exploring the results of a randomized controlled trial of printed educational messages to increase primary care physicians’ diabetic retinopathy referrals [Trial registration number ISRCTN72772651] 
Theory-based process evaluations conducted alongside randomized controlled trials provide the opportunity to investigate hypothesized mechanisms of action of interventions, helping to build a cumulative knowledge base and to inform the interpretation of individual trial outcomes. Our objective was to identify the underlying causal mechanisms in a cluster randomized trial of the effectiveness of printed educational materials (PEMs) to increase referral for diabetic retinopathy screening. We hypothesized that the PEMs would increase physicians’ intention to refer patients for retinal screening by strengthening their attitude and subjective norm, but not their perceived behavioral control.
Design: A theory based process evaluation alongside the Ontario Printed Educational Material (OPEM) cluster randomized trial. Postal surveys based on the Theory of Planned Behavior were sent to a random sample of trial participants two months before and six months after they received the intervention. Setting: Family physicians in Ontario, Canada. Participants: 1,512 family physicians (252 per intervention group) from the OPEM trial were invited to participate, and 31.3% (473/1512) responded at time one and time two. The final sample comprised 437 family physicians fully completing questionnaires at both time points. Main outcome measures: Primary: behavioral intention related to referring patient for retinopathy screening; secondary: attitude, subjective norm, perceived behavioral control.
At baseline, family physicians reported positive intention, attitude, subjective norm, and perceived behavioral control to advise patients about retinopathy screening suggesting limited opportunities for improvement in these constructs. There were no significant differences on intention, attitude, subjective norm, and perceived behavioral control following the intervention. Respondents also reported additional physician- and patient-related factors perceived to influence whether patients received retinopathy screening.
Lack of change in the primary and secondary theory-based outcomes provides an explanation for the lack of observed effect of the main OPEM trial. High baseline levels of intention to advise patients to attend retinopathy screening suggest that post-intentional and other factors may explain gaps in care. Process evaluations based on behavioral theory can provide replicable and generalizable insights to aid interpretation of randomized controlled trials of complex interventions to change health professional behavior.
Trial registration
Electronic supplementary material
The online version of this article (doi:10.1186/1748-5908-9-86) contains supplementary material, which is available to authorized users.
PMCID: PMC4261878  PMID: 25098442
Process evaluation; Theory of planned behavior; Printed educational material; Healthcare professional behavior; Behavior change
18.  Managerial leadership for research use in nursing and allied health care professions: a narrative synthesis protocol 
Systematic Reviews  2014;3:57.
Nurses and allied health care professionals (physiotherapists, occupational therapists, speech and language pathologists, dietitians) form more than half of the clinical health care workforce and play a central role in health service delivery. There is a potential to improve the quality of health care if these professionals routinely use research evidence to guide their clinical practice. However, the use of research evidence remains unpredictable and inconsistent. Leadership is consistently described in implementation research as critical to enhancing research use by health care professionals. However, this important literature has not yet been synthesized and there is a lack of clarity on what constitutes effective leadership for research use, or what kinds of intervention effectively develop leadership for the purpose of enabling and enhancing research use in clinical practice. We propose to synthesize the evidence on leadership behaviours amongst front line and senior managers that are associated with research evidence by nurses and allied health care professionals, and then determine the effectiveness of interventions that promote these behaviours.
Using an integrated knowledge translation approach that supports a partnership between researchers and knowledge users throughout the research process, we will follow principles of knowledge synthesis using a systematic method to synthesize different types of evidence involving: searching the literature, study selection, data extraction and quality assessment, and analysis. A narrative synthesis will be conducted to explore relationships within and across studies and meta-analysis will be performed if sufficient homogeneity exists across studies employing experimental randomized control trial designs.
With the engagement of knowledge users in leadership and practice, we will synthesize the research from a broad range of disciplines to understand the key elements of leadership that supports and enables research use by health care practitioners, and how to develop leadership for the purpose of enhancing research use in clinical practice.
Trial registration
PROSPERO CRD42014007660.
PMCID: PMC4072612  PMID: 24903267
Dietetics,implementation science; Knowledge translation; Leadership; Management; Nursing; Occupational therapy; Physiotherapy; Research use; Speech and language pathology
19.  Patient perceptions and expectations regarding imaging for metastatic disease in early stage breast cancer 
SpringerPlus  2014;3:176.
The probability of detecting radiologically evident metastatic disease in asymptomatic women with newly diagnosed operable breast cancer is low. Despite the recommendations of most practice guidelines imaging is still frequently performed. Relatively little is known about what patients believe is important when it comes to radiologic staging.
Patients with early stage breast cancer who had completed their definitive breast surgery were surveyed about their personal experiences, perceptions, and expectations on the issue of perioperative imaging for distant metastatic disease.
Over a 3 month period, 245 women with primary operable breast cancer completed the questionnaire (87.0% response rate) and 80.8% indicated having had at least one imaging test for distant metastatic disease. These were either of the thorax (72.2%), abdomen (55.9%) or skeleton (65.3%) with a total of 701 imaging tests (average of 3.5 tests per patient imaged) performed. Overall, 57.1% indicated that they would want imaging done if the chance of detecting metastases was ≤10%. Although 80.0% of patients indicated that, “doing whatever their doctor recommended” was important to them, 70.4% also noted that they would be uncomfortable if their physician did not order imaging, even if this was in keeping with practice guidelines.
Most patients with early stage breast cancer recall having imaging tests for distant metastases. Given the choice, most would prefer having imaging performed, even if this is not in line with current guidelines. If patient expectations are, in part, driving excessive imaging, new strategies addressing this are required.
Electronic supplementary material
The online version of this article (doi:10.1186/2193-1801-3-176) contains supplementary material, which is available to authorized users.
PMCID: PMC4000356  PMID: 24790821
Imaging; Metastases; Operable breast cancer; Guidelines; Patient perceptions
21.  Core Competencies for Shared Decision Making Training Programs: Insights From an International, Interdisciplinary Working Group 
Shared decision making is now making inroads in health care professionals’ continuing education curriculum, but there is no consensus on what core competencies are required by clinicians for effectively involving patients in health-related decisions. Ready-made programs for training clinicians in shared decision making are in high demand, but existing programs vary widely in their theoretical foundations, length, and content. An international, interdisciplinary group of 25 individuals met in 2012 to discuss theoretical approaches to making health-related decisions, compare notes on existing programs, take stock of stakeholders concerns, and deliberate on core competencies. This article summarizes the results of those discussions. Some participants believed that existing models already provide a sufficient conceptual basis for developing and implementing shared decision making competency-based training programs on a wide scale. Others argued that this would be premature as there is still no consensus on the definition of shared decision making or sufficient evidence to recommend specific competencies for implementing shared decision making. However, all participants agreed that there were 2 broad types of competencies that clinicians need for implementing shared decision making: relational competencies and risk communication competencies. Further multidisciplinary research could broaden and deepen our understanding of core competencies for shared decision making training.
PMCID: PMC3911960  PMID: 24347105 CAMSID: cams3819
shared decision making; education; patient-centered care; implementation science; theory; risk communication
22.  The development of a guideline implementability tool (GUIDE-IT): a qualitative study of family physician perspectives 
BMC Family Practice  2014;15:19.
The potential of clinical practice guidelines has not been realized due to inconsistent adoption in clinical practice. Optimising intrinsic characteristics of guidelines (e.g., its wording and format) that are associated with uptake (as perceived by their end users) may have potential. Using findings from a realist review on guideline uptake and consultation with experts in guideline development, we designed a conceptual version of a future tool called Guideline Implementability Tool (GUIDE-IT). The tool will aim to involve family physicians in the guideline development process by providing a process to assess draft guideline recommendations. This feedback will then be given back to developers to consider when finalizing the recommendations. As guideline characteristics are best assessed by end-users, the objectives of the current study were to explore how family physicians perceive guideline implementability, and to determine what components should comprise the final GUIDE-IT prototype.
We conducted a qualitative study with family physicians inToronto, Ontario. Two experienced investigators conducted one-hour interviews with family physicians using a semi-structured interview guide to 1) elicit feedback on perceptions on guideline implementability; 2) to generate a discussion in response to three draft recommendations; and 3) to provide feedback on the conceptual GUIDE-IT. Sessions were audio taped and transcribed verbatim. Data collection and analysis were guided by content analyses.
20 family physicians participated. They perceived guideline uptake according to facilitators and barriers across 6 categories of guideline implementability (format, content, language, usability, development, and the practice environment). Participants’ feedback on 3 draft guideline recommendations were grouped according to guideline perception, cognition, and agreement. When asked to comment on GUIDE-IT, most respondents believed that the tool would be useful, but urged to involve “regular” or community family physicians in the process, and suggested that an online system would be the most efficient way to deliver it.
Our study identified facilitators and barriers of guideline implementability from the perspective of community and academic family physicians that will be used to build our GUIDE-IT prototype. Our findings build on current knowledge by showing that family physicians perceive guideline uptake mostly according to factors that are in the control of guideline developers.
PMCID: PMC4016596  PMID: 24476491
Guideline implementability; Family practice; Knowledge translation; Qualitative
23.  Factors influencing the adoption of blood alternatives to minimize allogeneic transfusion: the perspective of eight Ontario hospitals 
Canadian Journal of Surgery  2002;45(2):132-140.
To identify and describe the factors influencing the use and nonuse of blood-sparing methods such as preoperative autologous donation, acute normovolemic hemodilution, and the use of cell salvage devices, hemostatic agents and erythropoietin.
An interview survey.
Eight Ontario hospitals.
Interviews were conducted with chiefs of surgery, orthopedics, cardiac surgery and anesthesia, and with heads of transfusion medicine and pharmacy. Hospitals were selected using the qualitative sampling strategy of maximum variation based on their use of the methods (as reported in a previous mail survey).
Use of blood-sparing methods was influenced by diverse factors often operating simultaneously. These included the following: characteristics of the method (e.g., evidence of its effectiveness, ease of use, cost); perceptions and experiences of the potential adopters (experience with the method, perception of the current safety of allogeneic blood, perceived convenience or inconvenience of using the method); aspects of the practice setting (inability to move resources between hospital departments, presence of a local clinical champion); and the external environment (patient and public expectations, funding of the blood system, blood shortages).
More rational and evidence-based use of blood-sparing methods could be promoted by the adoption of an interdisciplinary, comprehensive, coordinated approach tailored to each patient’s needs.
PMCID: PMC3686936  PMID: 11939657
25.  What is the quality of drug therapy clinical practice guidelines in Canada? 
The Canadian Medical Association maintains a national online database of clinical practice guidelines developed, endorsed or reviewed by Canadian organizations within 5 years of the current date. This study was designed to identify and describe guidelines in the database that make recommendations related to the use of drug therapy, and to assess their quality using a standardized guideline appraisal instrument.
Drug therapy guidelines in the database were identified with the use of search terms and hand searching. Descriptive information about the developers, endorsement by other organizations, publication status, disease and drug focus was abstracted. Each guideline was independently assessed by 3 appraisers (a physician, a pharmacist and a methodologist) with the use of the Appraisal Instrument for Clinical Guidelines. Conditions were classified according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems.
We identified 217 drug therapy guidelines produced or reviewed from 1994 to 1998. Guideline developers included national organizations (47.0%), paragovernment organizations (39.6%) and professional associations (30.9%); 31.3% of the guidelines were published, and 10.6% stated drug company sponsorship. The most common conditions addressed by the guidelines were infections and parasitic diseases (39.6%), neoplasms (11.5%) and diseases of the circulatory system (11.5%). Drugs most commonly cited were anti-infective agents (42.9%), antiviral agents (15.2%) and cardiovascular drugs (16.1%). Eleven organizations produced 176 (81.1%) of the guidelines. In all, 14.7% of the guidelines met half or more of the 20 items assessing rigour of guideline development on the appraisal instrument (mean quality score 30.0% [95% confidence interval (CI) 27.5%–32.6%]), 61.8% met half or more of the 12 items assessing guideline context and content (mean score 57.0% [95% CI 54.6%–59.3%]), and none met half or more of the 5 items assessing guideline application (mean score 5.6% [95% CI 4.7%–6.5%]). Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. The quality of the guidelines assessed varied significantly by developer, publication status and drug company sponsorship. No substantial improvement in guideline quality was observed over the 5-year study period.
Developers of Canadian drug therapy guidelines are producing guidelines that are often perceived to be clinically useful to physicians and pharmacists, although the methods (or the description of the methods) by which they are developed need to be more rigorous and thorough.
PMCID: PMC81282  PMID: 11501454

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