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1.  Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions 
BMC Geriatrics  2014;14:22.
Falls and chronic disease are both important health issues in older adults. The objectives of this study were to quantify the prevalence of falls and multi-morbidity (≥2 chronic conditions) in Canadian older adults; examine associations between falls and number of chronic conditions; and explore whether certain patterns of chronic disease were associated with a greater risk of falling.
Data were derived from the Canadian Community Health Survey- Healthy Aging. Primary outcomes from 16,357 community-dwelling adults aged 65 years and over were self-reported falls in the previous 12 months and presence of 13 chronic conditions. Prevalence estimates were calculated with normalized sampling weights, and hierarchical cluster analysis was used to identify clusters based on chronic condition patterns, and tested for association to falls with logistic regression.
Overall prevalence of falling and multi-morbidity were 19.8% and 62.0% respectively. Fall risk was significantly greater in individuals with one, two, four, five and six or more chronic conditions relative to those with none (all p < 0.05). A seven-cluster model was selected, including groups with low prevalence of chronic disease, or high prevalence of hypertension and arthritis, visual impairment, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, or heart disease and hypertension. Only the hypertension cluster (Odds Ratio [OR] = 1.2) and COPD cluster (OR = 1.6) were significantly associated with increased falls relative to the low prevalence group.
Both the number and pattern of chronic conditions were related to falls. COPD emerged as a significant predictor of falls despite affecting a smaller proportion of respondents. Continued study is warranted to verify this association and determine how to incorporate consideration of chronic disease and multi-morbidity into fall risk assessments.
PMCID: PMC3928582  PMID: 24529293
2.  Characteristics of Successful and Failed Mentoring Relationships: A Qualitative Study Across Two Academic Health Centers 
To explore the mentor–mentee relationship with a focus on determining the characteristics of effective mentors and mentees and understanding the factors influencing successful and failed mentoring relationships.
The authors completed a qualitative study through the Departments of Medicine at the University of Toronto Faculty of Medicine and the University of California, San Francisco, School of Medicine between March 2010 and January 2011. They conducted individual, semistructured interviews with faculty members from different career streams and ranks and analyzed transcripts of the interviews, drawing on grounded theory.
The authors completed interviews with 54 faculty members and identified a number of themes, including the characteristics of effective mentors and mentees, actions of effective mentors, characteristics of successful and failed mentoring relationships, and tactics for successful mentoring relationships. Successful mentoring relationships were characterized by reciprocity, mutual respect, clear expectations, personal connection, and shared values. Failed mentoring relationships were characterized by poor communication, lack of commitment, personality differences, perceived (or real) competition, conflicts of interest, and the mentor’s lack of experience.
Successful mentorship is vital to career success and satisfaction for both mentors and mentees. Yet challenges continue to inhibit faculty members from receiving effective mentorship. Given the importance of mentorship on faculty members’ careers, future studies must address the association between a failed mentoring relationship and a faculty member’s career success, how to assess different approaches to mediating failed mentoring relationships, and how to evaluate strategies for effective mentorship throughout a faculty member’s career.
PMCID: PMC3665769  PMID: 23165266
3.  Histamine H2 receptor antagonists for decreasing gastrointestinal harms in adults using acetylsalicylic acid: systematic review and meta-analysis 
Open Medicine  2012;6(3):e109-e117.
It is unclear if histamine H2 receptor antagonists (H2 blockers) prevent a variety of gastrointestinal harms among patients taking acetylsalicylic acid (ASA) over long periods.
Electronic databases (e.g., MEDLINE, Embase and Cochrane Central Register of Controlled Trials; from inception to November 2010) and reference lists of retrieved articles were searched. Randomized placebo-controlled trials (RCTs) assessing the efficacy of H2 blockers in reducing gastrointestinal harms (bleeding, ulcers) among adults taking ASA for 2 weeks or longer were included. Two reviewers independently abstracted study and patient characteristics and appraised study quality using the Cochrane risk-of-bias tool. Peto odds ratio (OR) meta-analysis was performed, 95% confidence intervals (CIs) were calculated, and statistical heterogeneity was assessed using the I2 and χ2 statistics.
Six RCTs (4 major publications and 2 companion reports) with a total of 498 participants (healthy volunteers or patients with arthritis, cardiovascular or cerebrovascular disease, or diabetes mellitus) were included. One trial adequately reported allocation concealment and sequence generation, with the other 3 trials being judged as unclear for both aspects. In one RCT, no statistically significant differences for gastrointestinal hemorrhage requiring admission to hospital (p = 0.14) or blood transfusion (p = 0.29) were observed between the group receiving concomitant famotidine and ASA and the group receiving concomitant placebo and ASA. After a median of 8 weeks’ follow-up, H2 blockers were more effective than placebo in reducing gastrointestinal hemorrhage (2 RCTs, total of 447 patients, OR 0.07, 95% CI 0.02–0.23) and peptic ulcers (3 RCTs, total of 465 patients, OR 0.21, 95% CI 0.12–0.36) among patients taking ASA for 2 weeks or longer. Despite substantial clinical heterogeneity across the studies, including types of H2 blockers, dosing of ASA and underlying conditions, no statistical heterogeneity was observed.
H2 blockers reduced gastrointestinal harm among patients taking ASA for 2 weeks or longer. These results should be interpreted with caution, because of the small number of studies identified for inclusion.
PMCID: PMC3654505  PMID: 23687524
4.  Efficacy and safety of cognitive enhancers for patients with mild cognitive impairment: a systematic review and meta-analysis  
Cognitive enhancers, including cholinesterase inhibitors and memantine, are used to treat dementia, but their effectiveness for mild cognitive impairment is unclear. We conducted a systematic review to examine the efficacy and safety of cognitive enhancers for mild cognitive impairment.
Our eligibility criteria were studies of the effects of donepezil, rivastigmine, galantamine or memantine on mild cognitive impairment reporting cognition, function, behaviour, global status, and mortality or harms. We identified relevant material by searching electronic databases (e.g., MEDLINE, Embase), the references of included studies, trial registries and conference proceedings, and by contacting experts. Two reviewers independently screened the results of the literature search, abstracted data and appraised risk of bias using the Cochrane risk-of-bias tool.
We screened 15 554 titles and abstracts and 1384 full-text articles. Eight randomized clinical trials and 3 companion reports met our inclusion criteria. We found no significant effects of cognitive enhancers on cognition (Mini–Mental State Examination: 3 randomized clinical trials [RCTs], mean difference [MD] 0.14, 95% confidence interval [CI] −0.22 to 0.50; Alzheimer’s Disease Assessment Scale — cognition subscale: 3 RCTs, standardized MD −0.07, 95% CI−0.16 to 0.01]) or function (Alzheimer’s Disease Cooperative Study activities of daily living inventory: 2 RCTs, MD 0.30, 95% CI −0.26 to 0.86). Cognitive enhancers were associated with higher risks of nausea, diarrhea and vomiting than placebo.
Cognitive enhancers did not improve cognition or function among patients with mild cognitive impairment and were associated with a greater risk of gastrointestinal harms. Our findings do not support the use of cognitive enhancers for mild cognitive impairment.
doi: 10.1503/cmaj.130451
PMCID: PMC3826344  PMID: 24043661
5.  What do letters to the editor publish about randomized controlled trials? A cross-sectional study 
BMC Research Notes  2013;6:414.
To identify published letters to the editor (LTE) written in response to randomized controlled trials (RCTs), determine the topics addressed in the letters, and to examine if these topics were affected by the characteristics and results of the RCTs.
Comparative cross-sectional study of a representative sample of RCTs from a set of high-impact medical journals (BMJ, Lancet, NEJM, JAMA, and Annals of Internal Medicine). RCTs and their published LTE were searched from these 5 journals in 2007. Data were collected on RCTs and their characteristics (author affiliation, funding source, intervention, and effect on the primary outcome) and the topics addressed in published LTE related to these RCTs. Analysis included chi-square and regression analysis (RCT characteristics) and thematic analysis (LTE topics).
Of 334 identified RCTs, 175 trials had at least one LTE. Of these, 381 published LTE were identified. Most RCTs, tested drug interventions (68%), were funded by government (54%) or industry (33%), and described an intervention that had a positive impact on the primary outcome (62%). RCT authors were primarily affiliated with an academic centre (78%). Ninety percent of the 623 LTE topics concerned methodological issues regarding the analysis, intervention, and population in the RCT. There was a significant association between funding source and impact on outcomes (p = 0.002) or type of intervention tested (p = 0.001) in these trials. Clinical and “Other” LTE topics were more likely to be published in response to a government funded RCT (p = 0.005 and p = 0.033, respectively); no other comparisons were significant.
This study showed that most LTE are about methodological topics, but found little evidence to support that these topics are affected by the characteristics or results of the RCTs. The lack of association may be explained by editorial censorship as a small proportion of LTE that are submitted are actually published.
PMCID: PMC3852599  PMID: 24124753
Letters to the editor; Randomized controlled trials; Journalogy
6.  Determinants of implementation of maternal health guidelines in Kosovo: mixed methods study 
One of the challenges to implementing clinical practice guidelines is the need to adapt guidelines to the local context and identify barriers to their uptake. Several models of framework are available to consider for use in guideline adaptation.
We completed a multiphase study to explore the implementation of maternal health guidelines in Kosovo, focusing on determinants of uptake and methods to contextualize for local use. The study involved a survey, individual interviews, focus groups, and a consensus meeting with relevant stakeholders, including clinicians (obstetricians, midwives), managers, researchers, and policy makers from the national Ministry of Health and the World Health Organization office in Pristina, Kosovo.
Participants identified several important barriers to implementation. First, lack of communication between clinicians and ministry representatives was seen as leading to duplication of effort in creating or adapting guidelines, as well as substantial mistrust between clinicians and policy makers. Second, there was a lack of communication across clinical groups that provide obstetric care and a lack of integration across the entire healthcare system, including rural and urban centers. This fragmentation was thought to have directly resulted from the war in 1998 – 1999. Third, the conflict substantially and adversely affected the healthcare infrastructure in Kosovo, which has resulted in an inability to monitor quality of care across the country. Furthermore, the impact on infrastructure has affected the ability to access required medications consistently and to smoothly transfer patients from rural to urban centers. Another issue raised during this project was the appropriateness of including guideline recommendations perceived to be ‘aspirational’.
Implementing clinical practice guidelines in low- and middle-income countries (LMICs) requires consideration of several specific barriers. Particularly pertinent to this study were the effects of recent conflict and the resulting fragmentation of healthcare and communication strategies among relevant stakeholders. However, as Kosovo rebuilds and invests in infrastructure after the conflict, there is a tremendous opportunity to create comprehensive, thoughtful strategies to monitor and improve quality of care. To avoid duplication of effort, it may be beneficial for LMICs to share information on assessing barriers as well as on guideline implementation strategies.
PMCID: PMC3846581  PMID: 24016149
Guideline implementation; Determinants of evidence uptake
7.  Evaluation of a multisite educational intervention to improve mobilization of older patients in hospital: protocol for mobilization of vulnerable elders in Ontario (MOVE ON) 
Functional decline is a common adverse outcome of hospitalization in older people. Often, this decline is not related to the illness that precipitated admission, but to the process of care delivered in hospital. The association between immobility and adverse consequences is well established, yet older inpatients spend significant amounts of time supine in bed. We aim to implement and evaluate the impact of an evidence-based strategy to promote early mobilization and prevent functional decline in older patients admitted to university-affiliated acute care hospitals in Ontario, Canada. We will implement a multi-component educational intervention to support a change in practice to enhance mobilization of older patients.
Implementation of our early mobilization strategy is guided by the Knowledge to Action Cycle. Through focus groups with frontline staff, we will identify barriers and facilitators to early mobilization. We will tailor the intervention at each site to the identified barriers and facilitators, focusing on the following key messages: to complete a mobility assessment and care plan within 24 hours of the decision to admit patients aged 65 years and older; to achieve mobilization at least 3 times per day; and, to ensure that mobilization is scaled and progressive. The primary outcome, number of patients observed out of bed, will be documented three times per day (in the morning, at lunch and in the afternoon), two days each week. This data collection will occur over 3 phases: pre-implementation (10 weeks), implementation (8 weeks), and post-implementation (20 weeks).
This is the first large, multisite study to evaluate the impact of a multi-component knowledge translation strategy on rates of mobilization of older patients in hospital. Our implementation is framed by the Knowledge to Action Cycle, and the intervention is being adapted to the local context. These unique features render our intervention approach more generalizable to multiple practice settings. Contextualization of the intervention has also facilitated engagement of participants from multiple hospitals. Upon completion of this study, we will better understand the barriers and facilitators to implementing an early mobilization strategy across a spectrum of hospitals, as well as the impact of a mobilization strategy.
PMCID: PMC3704763  PMID: 23822563
Mobilization; Frail; Older adult; Hospital; Quality improvement
8.  Safety of serotonin (5-HT3) receptor antagonists in patients undergoing surgery and chemotherapy: protocol for a systematic review and network meta-analysis 
Systematic Reviews  2013;2:46.
Serotonin (5-HT3) receptor antagonists are a class of antiemetic medications often used to prevent nausea and vomiting among patients undergoing chemotherapy, radiotherapy or surgery. However, recent studies suggest that these agents might be associated with increased cardiac harm. To examine this further, we are proposing to conduct a systematic review and network meta-analysis on the comparative safety of 5-HT3 receptor antagonists among patients undergoing chemotherapy or surgery.
Studies reporting one or more safety outcomes of interest for 5-HT3 receptor antagonists compared with each other, placebo, and/or other anti-emetic agents (for example, benzamides, phenothiazines, butyrophenones, antihistamines, and anticholinergics) among children and adult patients undergoing surgery or chemotherapy will be included. Our primary outcome of interest is arrhythmia. Our secondary outcomes include cardiac death, QT prolongation, PR prolongation, all-cause mortality, nausea, and vomiting. We will include experimental studies, quasi-experimental studies (namely controlled before-after and interrupted time series), and observational studies (namely cohort studies). We will not limit inclusion by publication status, time period, duration of follow-up or language of dissemination.
Electronic databases (for example, MEDLINE, EMBASE) will be searched from inception onwards. These main searches will be supplemented by searching for difficult to locate and unpublished studies, such as dissertations, and governmental reports. The eligibility criteria will be pilot-tested and subsequently used to screen the literature search results by two reviewers in duplicate. A similar process will be followed for full-text screening, data abstraction, and risk of bias/methodological quality appraisal. The Cochrane Risk of Bias tool will be used to appraise experimental and quasi-experimental studies, and cohort studies will be assessed using the Newcastle Ottawa Scale. If the data allows, random effects meta-analysis and a network (that is, mixed treatment comparisons) meta-analysis will be conducted. All analyses will be conducted separately for different study designs, patient populations (for example, children and adults), and reason for administering 5-HT3 receptor antagonists (for example, post-surgery and chemotherapy).
Our results will help inform patients, clinicians, and health policy-makers about the potential safety concerns, as well as the comparative safety, of using these antiemetic agents.
Trial registration
PROSPERO registry number:CRD42013003564
PMCID: PMC3702491  PMID: 23810058
9.  Six of the top achievements in Canadian health research 
PMCID: PMC2761464  PMID: 19786478
10.  Celebrating 8 projects that improved our world 
PMCID: PMC2761461  PMID: 19786479
11.  Development of two shortened systematic review formats for clinicians 
Systematic reviews provide evidence for clinical questions, however the literature suggests they are not used regularly by physicians for decision-making. A shortened systematic review format is proposed as one possible solution to address barriers, such as lack of time, experienced by busy clinicians. The purpose of this paper is to describe the development process of two shortened formats for a systematic review intended for use by primary care physicians as an information tool for clinical decision-making.
We developed prototypes for two formats (case-based and evidence-expertise) that represent a summary of a full-length systematic review before seeking input from end-users. The process was composed of the following four phases: 1) selection of a systematic review and creation of initial prototypes that represent a shortened version of the systematic review; 2) a mapping exercise to identify obstacles described by clinicians in using clinical evidence in decision-making; 3) a heuristic evaluation (a usability inspection method); and 4) a review of the clinical content in the prototypes.
After the initial prototypes were created (Phase 1), the mapping exercise (Phase 2) identified components that prompted modifications. Similarly, the heuristic evaluation and the clinical content review (Phase 3 and Phase 4) uncovered necessary changes. Revisions were made to the prototypes based on the results.
Documentation of the processes for developing products or tools provides essential information about how they are tailored for the intended user. One step has been described that we hope will increase usability and uptake of these documents to end-users.
PMCID: PMC3691647  PMID: 23767771
Review literature as topic; Evidence-based medicine
12.  Sustainability of knowledge translation interventions in healthcare decision-making: protocol for a scoping review 
BMJ Open  2013;3(5):e002970.
Knowledge translation (KT also known as research utilisation, translational medicine and implementation science) is a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health. After the implementation of KT interventions, their impact on relevant outcomes should be monitored. The objectives of this scoping review are to: (1) conduct a systematic search of the literature to identify the impact on healthcare outcomes beyond 1 year, or beyond the termination of funding of the initiative of KT interventions targeting chronic disease management for end-users including patients, clinicians, public health officials, health services managers and policy-makers; (2) identify factors that influence sustainability of effective KT interventions; (3) identify how sustained change from KT interventions should be measured; and (4) develop a framework for assessing sustainability of KT interventions.
Methods and analysis
Comprehensive searches of relevant electronic databases (eg, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), websites of funding agencies and websites of healthcare provider organisations will be conducted to identify relevant material. We will include experimental, quasi-experimental and observational studies providing information on the sustainability of KT interventions targeting chronic disease management in adults and focusing on end-users including patients, clinicians, public health officials, health services managers and policy-makers. Two reviewers will pilot-test the screening criteria and data abstraction form. They will then screen all citations, full articles and abstract data in duplicate independently. The results of the scoping review will be synthesised descriptively and used to develop a framework to assess the sustainability of KT interventions.
Discussion and dissemination
Our results will help inform end-users (ie, patients, clinicians, public health officials, health services managers and policy-makers) regarding the sustainability of KT interventions. Our dissemination plan includes publications, presentations, website posting and a stakeholder meeting.
PMCID: PMC3657660  PMID: 23674448
knowledge translation; sustainability; implementation; research utilization; fidelity
13.  Risk of heart failure and edema associated with the use of pregabalin: a systematic review 
Systematic Reviews  2013;2:25.
Pregabalin is used in the treatment of postherpetic neuralgia, diabetic neuropathic pain, partial seizures, anxiety disorders and fibromyalgia. Recognized adverse effects associated with its use include cognitive impairment, somnolence and dizziness. Heart failure associated with pregabalin has been described, however the strength of this association has not been well characterized. To examine this further, we will conduct a systematic review of the risk of heart failure and edema associated with use of pregabalin.
We will include all studies (experimental, quasi-experimental, observational, case series/reports, drug regulatory reports) that examine the use of pregabalin compared to placebo, gabapentin or conventional care. Our primary outcome is heart failure and the secondary outcomes include edema and weight gain. We will search electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), and grey literature sources (trial registries, conference abstracts) to identify relevant studies. To ensure literature saturation, we will contact drug manufacturers, conduct forward citation searching, and scan the reference lists of key articles and included studies. We will not restrict inclusion by language or publication status.
Two reviewers will screen citations (titles and abstracts) and full-text articles, conduct data abstraction, and appraise risk of bias. Random-effects meta-analysis will be conducted if the studies are deemed heterogeneous in terms of clinical, statistical and methodological factors but still suitable for meta-analysis.
The results of this review will assist physicians to better appreciate pregabalin’s risk for edema or congestive heart failure and will be pertinent to the thousands of patients worldwide who are administered this medication.
Our protocol was registered in the PROSPERO database (CRD42012002948).
PMCID: PMC3655846  PMID: 23641821
Edema; Heart failure; Observational studies; Pregabalin; Randomized controlled trials; Systematic review
14.  Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada 
Balance impairment is common in multiple clinical populations, and comprehensive assessment is important for identifying impairments, planning individualized treatment programs, and evaluating change over time. However, little information is available regarding whether clinicians who treat balance are satisfied with existing assessment tools. In 2010 we conducted a cross-sectional survey of balance assessment practices among physiotherapists in Ontario, Canada, and reported on the use of standardized balance measures (Sibley et al. 2011 Physical Therapy; 91: 1583-91). The purpose of this study was to analyse additional survey data and i) evaluate satisfaction with current balance assessment practices and standardized measures among physiotherapists who treat adult or geriatric populations with balance impairment, and ii) identify factors associated with satisfaction.
The questionnaire was distributed to 1000 practicing physiotherapists. This analysis focuses on questions in which respondents were asked to rate their general perceptions about balance assessment, the perceived utility of individual standardized balance measures, whether they wanted to improve balance assessment practices, and why. Data were summarized with descriptive statistics and utility of individual measures was compared across clinical practice areas (orthopaedic, neurological, geriatric or general rehabilitation).
The questionnaire was completed by 369 respondents, of which 43.4% of respondents agreed that existing standardized measures of balance meet their needs. In ratings of individual measures, the Single Leg Stance test and Berg Balance Scale were perceived as useful for clinical decision-making and evaluating change over time by over 70% of respondents, and the Timed Up-and-Go test was perceived as useful for decision-making by 56.9% of respondents and useful for evaluating change over time by 62.9% of respondents, but there were significant differences across practice groups. Seventy-nine percent of respondents wanted to improve their assessments, identifying individual, environmental and measure-specific barriers. The most common barriers were lack of time and knowledge.
This study offers new information on issues affecting the evaluation of balance in clinical settings from a broad sample of physiotherapists. Continued work to address barriers by specific practice area will be critical for the success of any intervention attempting to implement optimal balance assessment practices in the clinical setting.
PMCID: PMC3606836  PMID: 23510277
15.  Impact of quality improvement strategies on the quality of life and well-being of individuals with spinal cord injury: a systematic review protocol 
Systematic Reviews  2013;2:14.
After a spinal cord injury, quality of life, as well as the determinants of quality of life, has been widely assessed. However, to date, there have been no systematic reviews on the impact of quality improvement strategies, including self-management strategies, on the quality of life and well-being of individuals with a spinal cord injury. The current protocol outlines a strategy for a systematic review that aims to identify, assess, and synthesize evidence on the impact of quality improvement strategies on the quality of life and physical and psychological well-being of individuals with spinal cord injury.
All study designs, except qualitative studies will be included. Studies reporting on quality improvement including audit and feedback, case management, team changes, electronic patient registries, clinician education, clinical reminders, facilitated relay of clinical information to clinicians, patient education, (promotion of) self-management, patient reminder systems, and continuous quality improvement among individuals with spinal cord injury will be included. The primary outcome is quality of life. The secondary outcomes are physical and psychological well-being. Studies will be included regardless of publication status, year of dissemination, or language of dissemination. Potentially relevant articles not written in English will be translated. We will search Medline, CINAHL, EMBASE, and PsycINFO. The use of these databases will be supplemented by other data sources, including unpublished data. Two independent reviewers will conduct all levels of screening, data abstraction, and quality appraisal. Results will be grouped according to the target group of the varying quality improvement strategies (that is, health system, health-care professionals, or patients) and/or by any other noteworthy grouping variable, such as etiology of spinal cord condition or by sex. If deemed appropriate, a meta-analysis will be conducted.
This systematic review will identify those quality improvement strategies aimed at the health system, health-care professionals, and patients that impact the quality of life and well-being of individuals with spinal cord injury. Knowledge and application of such quality improvement strategies may reduce inappropriate health-care utilization costs, such as acute care inpatient readmission in the years post injury. Prospero registry number: CRD42012003058.
PMCID: PMC3599324  PMID: 23432954
Quality of life; Well-being; Spinal cord injury; Quality improvement; Systematic review; Protocol
16.  Developing a patient and family-centred approach for measuring the quality of injury care: a study protocol 
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.
PMCID: PMC3570378  PMID: 23351430
Injury; Patient-centred care; Quality improvement; Quality indicators; Trauma; Focus group; Consensus panel; Survey
17.  The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence 
The electronic medical record (EMR)/electronic health record (EHR) is becoming an integral component of many primary-care outpatient practices. Before implementing an EMR/EHR system, primary-care practices should have an understanding of the potential benefits and limitations.
The objective of this study was to systematically review the recent literature around the impact of the EMR/EHR within primary-care outpatient practices.
Materials and methods
Searches of Medline, EMBASE, CINAHL, ABI Inform, and Cochrane Library were conducted to identify articles published between January 1998 and January 2010. The gray literature and reference lists of included articles were also searched. 30 studies met inclusion criteria.
Results and discussion
The EMR/EHR appears to have structural and process benefits, but the impact on clinical outcomes is less clear. Using Donabedian's framework, five articles focused on the impact on healthcare structure, 21 explored healthcare process issues, and four focused on health-related outcomes.
PMCID: PMC3197985  PMID: 21659445
Clinical informatics; quality of healthcare; systematic review; machine learning; health data standards; vocabulary; ontology; scientific information and health data policy; consumer health/patient education information; information retrieval; NLP; public health informatics; clinical trials; electronic medical records; primary care; systematic review
18.  Less Than Ideal: How Oncologists Practice With Limited Drug Access 
Journal of Oncology Practice  2012;8(3):190-195.
Canadian medical oncologists are struggling to provide optimal care for their patients with metastatic colorectal cancer as a result of differential access to preferred therapeutic drugs.
To evaluate Canadian medical oncologists' perspectives on how barriers to accessing new expensive cancer drugs have affected their practice and their opinions on the drug approval and funding processes.
Canadian medical oncologists treating colorectal cancer (CRC) were surveyed by means of a self-administered, cross-sectional survey.
Of the 164 eligible oncologists, there were 68 respondents (41.4% response rate). Only 29.4% of physicians felt they had been using the ideal first-line chemotherapy regimen for patients with metastatic CRC. Although all considered bevacizumab to be a component of the ideal first-line regimen, only 18% could use bevacizumab routinely, and less than half (44.8%) always discussed its role with their patients. In terms of accessing unfunded drugs, most physicians agreed that private payment should be allowed for drugs to be delivered at their own centers (76.1%) or private infusion clinics (52.2%). Ninety-seven percent of physicians reported major concerns about the drug approval and funding processes, and 85% of physicians supported the establishment of a national drug formulary.
Canadian medical oncologists are struggling to provide optimal cancer care for their patients with metastatic CRC as a result of nonuniform access to preferred therapeutic drugs. In face of these challenges, physicians have had to use clinical trials and private infusion clinics and, at times, may avoid discussing drugs with limited access. Many oncologists are dissatisfied with the existing funding mechanism and approval processes and support private payment for unfunded drugs.
PMCID: PMC3396809  PMID: 22942815
19.  Impact of H1N1 on Socially Disadvantaged Populations: Systematic Review 
PLoS ONE  2012;7(6):e39437.
The burden of H1N1 among socially disadvantaged populations is unclear. We aimed to synthesize hospitalization, severe illness, and mortality data associated with pandemic A/H1N1/2009 among socially disadvantaged populations.
Methods/Principal Findings
Studies were identified through searching MEDLINE, EMBASE, scanning reference lists, and contacting experts. Studies reporting hospitalization, severe illness, and mortality attributable to laboratory-confirmed 2009 H1N1 pandemic among socially disadvantaged populations (e.g., ethnic minorities, low-income or lower-middle-income economy countries [LIC/LMIC]) were included. Two independent reviewers conducted screening, data abstraction, and quality appraisal (Newcastle Ottawa Scale). Random effects meta-analysis was conducted using SAS and Review Manager.
Sixty-two studies including 44,777 patients were included after screening 787 citations and 164 full-text articles. The prevalence of hospitalization for H1N1 ranged from 17–87% in high-income economy countries (HIC) and 11–45% in LIC/LMIC. Of those hospitalized, the prevalence of intensive care unit (ICU) admission and mortality was 6–76% and 1–25% in HIC; and 30% and 8–15%, in LIC/LMIC, respectively. There were significantly more hospitalizations among ethnic minorities versus non-ethnic minorities in two studies conducted in North America (1,313 patients, OR 2.26 [95% CI: 1.53–3.32]). There were no differences in ICU admissions (n = 8 studies, 15,352 patients, OR 0.84 [0.69–1.02]) or deaths (n = 6 studies, 14,757 patients, OR 0.85 [95% CI: 0.73–1.01]) among hospitalized patients in HIC. Sub-group analysis indicated that the meta-analysis results were not likely affected by confounding. Overall, the prevalence of hospitalization, severe illness, and mortality due to H1N1 was high for ethnic minorities in HIC and individuals from LIC/LMIC. However, our results suggest that there were little differences in the proportion of hospitalization, severe illness, and mortality between ethnic minorities and non-ethnic minorities living in HIC.
PMCID: PMC3382581  PMID: 22761796
20.  Interventions Encouraging the Use of Systematic Reviews in Clinical Decision-Making: A Systematic Review 
Systematic reviews have the potential to inform clinical decisions, yet little is known about the impact of interventions on increasing the use of systematic reviews in clinical decision-making.
To systematically review the evidence on the impact of interventions for seeking, appraising, and applying evidence from systematic reviews in decision-making by clinicians.
Data Sources
Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and LISA were searched from the earliest date available until July 2009.
Study Selection and Data Extraction
Two independent reviewers selected studies for inclusion if the intervention intended to increase seeking, appraising, or applying evidence from systematic reviews by a clinician. Information about the study population, features of each intervention, methods used to measure the use of systematic reviews and those used to measure professional performance or health care outcomes, existence and use of statistical tests, study outcomes, and comparative data were extracted.
Data Synthesis
A total of 8,104 titles and abstracts were reviewed, leading to retrieval of 189 full-text articles for assessment; five of these studies met all inclusion criteria. All five studies reported on professional performance behavior; none reported on patient health outcomes. One study reported positive outcomes in improving preventive care. Three studies focused on obstetrical care, with two reporting no impact on professional practice change, and one study reporting increases in the use of prophylactic oxytocin and episiotomy. One study found no improvement in the sealant rate of newly erupted molars among dentists in Scotland.
The small number of studies available for examination indicates the difficulty in summarizing and identifying key aspects in successful strategies that encourage clinicians to use systematic reviews in decision-making. Other concerns lay in selective reporting and lack of blinding during data collection.
The limited empirical data render the strength of evidence weak for the effectiveness and types of interventions that encourage clinicians to use systematic reviews in clinical decision making.
PMCID: PMC3055967  PMID: 20953729
systematic review; evidence-based practice; decision-making; review literature as a topic
21.  Systematic review and evaluation of web-accessible tools for management of diabetes and related cardiovascular risk factors by patients and healthcare providers 
To identify and evaluate the effectiveness, clinical usefulness, sustainability, and usability of web-compatible diabetes-related tools.
Data sources
Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, world wide web.
Study selection
Studies were included if they described an electronic audiovisual tool used as a means to educate patients, care givers, or clinicians about diabetes management and assessed a psychological, behavioral, or clinical outcome.
Data extraction
Study abstraction and evaluation for clinical usefulness, sustainability, and usability were performed by two independent reviewers.
Of 12616 citations and 1541 full-text articles reviewed, 57 studies met inclusion criteria. Forty studies used experimental designs (25 randomized controlled trials, one controlled clinical trial, 14 before–after studies), and 17 used observational designs. Methodological quality and ratings for clinical usefulness and sustainability were variable, and there was a high prevalence of usability errors. Tools showed moderate but inconsistent effects on a variety of psychological and clinical outcomes including HbA1c and weight. Meta-regression of adequately reported studies (12 studies, 2731 participants) demonstrated that, although the interventions studied resulted in positive outcomes, this was not moderated by clinical usefulness nor usability.
This review is limited by the number of accessible tools, exclusion of tools for mobile devices, study quality, and the use of non-validated scales.
Few tools were identified that met our criteria for effectiveness, usefulness, sustainability, and usability. Priority areas include identifying strategies to minimize website attrition and enabling patients and clinicians to make informed decisions about website choice by encouraging reporting of website quality indicators.
PMCID: PMC3384097  PMID: 22215057
Diabetes mellitus; medical informatics; medical education; patient education; endocrinology; knowledge translation; quality improvement; process redesign; CPOE; information; EMR
22.  Core competencies in the science and practice of knowledge translation: description of a Canadian strategic training initiative 
Globally, healthcare systems are attempting to optimize quality of care. This challenge has resulted in the development of implementation science or knowledge translation (KT) and the resulting need to build capacity in both the science and practice of KT.
We are attempting to meet these challenges through the creation of a national training initiative in KT. We have identified core competencies in this field and have developed a series of educational courses and materials for three training streams. We report the outline for this approach and the progress to date.
We have prepared a strategy to develop, implement, and evaluate a national training initiative to build capacity in the science and practice of KT. Ultimately through this initiative, we hope to meet the capacity demand for KT researchers and practitioners in Canada that will lead to improved care and a strengthened healthcare system.
PMCID: PMC3292943  PMID: 22152223
23.  What is the value and impact of quality and safety teams? A scoping review 
The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.
Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.
Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.
Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.
PMCID: PMC3189393  PMID: 21861911
24.  Evaluation of a clinical decision support tool for osteoporosis disease management: protocol for an interrupted time series design 
Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems. Although guidelines on assessing and managing osteoporosis are available, many patients are not receiving appropriate diagnostic testing or treatment. Findings from a systematic review of osteoporosis interventions, a series of mixed-methods studies, and advice from experts in osteoporosis and human-factors engineering were used collectively to develop a multicomponent tool (targeted to family physicians and patients at risk for osteoporosis) that may support clinical decision making in osteoporosis disease management at the point of care.
A three-phased approach will be used to evaluate the osteoporosis tool. In phase 1, the tool will be implemented in three family practices. It will involve ensuring optimal functioning of the tool while minimizing disruption to usual practice. In phase 2, the tool will be pilot tested in a quasi-experimental interrupted time series (ITS) design to determine if it can improve osteoporosis disease management at the point of care. Phase 3 will involve conducting a qualitative postintervention follow-up study to better understand participants' experiences and perceived utility of the tool and readiness to adopt the tool at the point of care.
The osteoporosis tool has the potential to make several contributions to the development and evaluation of complex, chronic disease interventions, such as the inclusion of an implementation strategy prior to conducting an evaluation study. Anticipated benefits of the tool may be to increase awareness for patients about osteoporosis and its associated risks and provide an opportunity to discuss a management plan with their physician, which may all facilitate patient self-management.
PMCID: PMC3152529  PMID: 21781318
25.  Understanding the relationship between the perceived characteristics of clinical practice guidelines and their uptake: protocol for a realist review 
Clinical practice guidelines have the potential to facilitate the implementation of evidence into practice, support clinical decision making, specify beneficial therapeutic approaches, and influence public policy. However, these potential benefits have not been consistently achieved. The limited impact of guidelines can be attributed to organisational constraints, the complexity of the guidelines, and the lack of usability testing or end-user involvement in their development. Implementability has been referred to as the perceived characteristics of guidelines that predict the relative ease of their implementation at the clinical level, but this concept is as yet poorly defined. The objective of our study is to identify guideline attributes that affect uptake in practice by considering evidence from four disciplines (medicine, psychology, management, human factors engineering) to determine the relationship between the perceived characteristics of recommendations and their uptake and to develop a framework of implementability.
A realist-review approach to knowledge synthesis will be used to understand attributes of guidelines (e.g., its text and content) and how changing these elements might impact clinical practice and clinical decision making. It also allows for the exploration of 'what works for whom, in what circumstances, and in what respects'. The realist review will be structured according to Pawson's five practical steps in realist reviews: (1) clarifying the scope of the review, (2) determining the search strategy, (3) ensuring proper article selection and study quality assessment, (4) extracting and organising data, and (5) synthesising the evidence and drawing conclusions. Data will be synthesised according to a two-stage analysis: (1) we will extract and define all relevant guideline attributes from the different disciplines, then create a shortlist of unique attributes and investigate their relationships with uptake, and (2) we will compare and contrast the attributes and guideline uptake within each and between the four disciplines to create a robust framework of implementability.
Creating guidelines that are designed to maximise uptake may be a potentially effective and inexpensive way of increasing their impact. However, this is best achieved by a comprehensive framework to inform the design of guidelines drawing on a range of disciplines that study behaviour change. This study will use a customised realist-review approach to synthesising the literature to better understand and operationalise a complex and under-theorised concept.
PMCID: PMC3224565  PMID: 21733160

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