Evidence summaries (decision boxes) to prepare clinicians for shared decision-making with patients: a mixed methods implementation study

Background

Decision boxes (Dboxes) provide clinicians with research evidence about management options for medical questions that have no single best answer. Dboxes fulfil a need for rapid clinical training tools to prepare clinicians for clinician-patient communication and shared decision-making. We studied the barriers and facilitators to using the Dbox information in clinical practice.

Methods

We used a mixed methods study with sequential explanatory design. We recruited family physicians, residents, and nurses from six primary health-care clinics. Participants received eight Dboxes covering various questions by email (one per week). For each Dbox, they completed a web questionnaire to rate clinical relevance and cognitive impact and to assess the determinants of their intention to use what they learned from the Dbox to explain to their patients the advantages and disadvantages of the options, based on the theory of planned behaviour (TPB). Following the 8-week delivery period, we conducted focus groups with clinicians and interviews with clinic administrators to explore contextual factors influencing the use of the Dbox information.

Results

One hundred clinicians completed the web surveys. In 54% of the 496 questionnaires completed, they reported that their practice would be improved after having read the Dboxes, and in 40%, they stated that they would use this information for their patients. Of those who would use the information for their patients, 89% expected it would benefit their patients, especially in that it would allow the patient to make a decision more in keeping with his/her personal circumstances, values, and preferences. They intended to use the Dboxes in practice (mean 5.6 ± 1.2, scale 1–7, with 7 being “high”), and their intention was significantly related to social norm, perceived behavioural control, and attitude according to the TPB (P < 0.0001). In focus groups, clinicians mentioned that co-interventions such as patient decision aids and training in shared decision-making would facilitate the use of the Dbox information. Some participants would have liked a clear “bottom line” statement for each Dbox and access to printed Dboxes in consultation rooms.

Conclusions

Dboxes are valued by clinicians. Tailoring of Dboxes to their needs would facilitate their implementation in practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0144-6) contains supplementary material, which is available to authorized users.

Plasma polychlorinated biphenyl and organochlorine pesticide concentrations in dementia: the Canadian Study of Health and Aging

BACKGROUND

Even though polychlorinated biphenyls (PCBs) and organochlorine (OC) pesticides are recognized as neurotoxicants, few studies have investigated their associations with dementia. Here, we assess associations of plasma PCB and OC pesticide concentrations with all-cause dementia and Alzheimer's disease (AD).

METHODS

Analyses are based on data from the Canadian Study of Health and Aging, a population-based study of men and women aged 65+ years at baseline. PCB and OC pesticide concentrations were measured in 2023 participants who had complete clinical evaluations and blood samples; 574 had dementia, including 399 cases of AD. Concentrations were log-transformed and used as continuous variables in logistic regression models to assess their individual associations with dementia and AD.

RESULTS

After adjustment for blood collection period, total plasma lipids, age, sex, education, apolipoprotein E e4 allele (ApoE4), tobacco and alcohol use, rural/urban residence, and comorbidities, elevated plasma PCB concentrations were not associated with increased prevalence of dementia and AD. Elevated concentrations of some OC pesticides and metabolites such as hexachlorobenzene, cis-nonachlor and 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane were significantly associated with a reduced prevalence of dementia. A significant reduced prevalence of AD was also observed with elevated hexachlorobenzene concentrations. Other OC pesticides and metabolites were not associated with the prevalence of dementia or AD. No effect modification by sex and ApoE4 was observed for either dementia or AD.

CONCLUSIONS

Elevated plasma PCB and OC pesticide concentrations were not associated with higher prevalence of all-cause dementia and AD. The possibility of modest reductions in prevalence with specific OC pesticides remains to be further investigated given the cross-sectional design of this study.

Use of rivastigmine or galantamine and risk of adverse cardiac events: a database study from the Netherlands

BACKGROUND

Two cholinesterase inhibitors (ChEIs), rivastigmine and galantamine, are used to treat Alzheimer disease in the Netherlands. Several adverse cardiac events have been reported for these medications.

OBJECTIVE

We aimed to assess if the use of ChEIs increased the risk of cardiac events in the Netherlands.

METHODS

A cohort crossover study of the PHARMO Record Linking System database included patients who initiated ChEIs at age 50 years or older, had at least 1 dispensing of a ChEI drug between 1998 and 2008, a 1-year history in PHARMO, and 1 subsequent dispensing of any medication. Two outcomes were assessed: a first hospitalization for syncope or atrioventricular block. Poisson and Cox regression were used to calculate incidence densities and hazard ratios for cardiac events during periods with ChEI use, compared with periods without ChEI use.

RESULTS

During the complete observation period of 8.9 years (interquartile range 6.7 to 10.2) there were 132 first hospitalizations for atrioventricular block and 17 first hospitalizations for syncope among 3358 patients. The adjusted incidence densities were significantly increased during ChEI exposure for syncope and atrioventricular block, when compared with the background incidence densities in the roughly 5 years before the last year before ChEI initiation. However, when exposed periods were compared with the unexposed periods 1 year before ChEI initiation and times after exposure, the adjusted hazard ratios remained increased for syncope and atrioventricular block, but increases were not significant anymore.

CONCLUSIONS

Exposure to ChEIs might increase the risk of adverse cardiac events, but small numbers of cases limit conclusions about the risk in this population and research on larger study samples is needed.

Interventions to improve continuity of care in the follow-up of patients with cancer

BACKGROUND

Care from the family physician is generally interrupted when patients with cancer come under the care of second-line and third-line healthcare professionals who may also manage the patient's comorbid conditions. This situation may lead to fragmented and uncoordinated care, and results in an increased likelihood of not receiving recommended preventive services or recommended care.

OBJECTIVES

To classify, describe and evaluate the effectiveness of interventions aiming to improve continuity of cancer care on patient, healthcare provider and process outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organization of Care Group (EPOC) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, and PsycINFO, using a strategy incorporating an EPOC Methodological filter. Reference lists of the included study reports and relevant reviews were also scanned, and ISI Web of Science and Google Scholar were used to identify relevant reports having cited the studies included in this review.

SELECTION CRITERIA

Randomised controlled trials (including cluster trials), controlled clinical trials, controlled before and after studies and interrupted time series evaluating interventions to improve continuity of cancer care were considered for inclusion. We included studies that involved a majority (> 50%) of adults with cancer or healthcare providers of adults with cancer. Primary outcomes considered for inclusion were the processes of healthcare services, objectively measured healthcare professional, informal carer and patient outcomes, and self-reported measures performed with scales deemed valid and reliable. Healthcare professional satisfaction was included as a secondary outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers described the interventions, extracted data and assessed risk of bias. The authors contacted several investigators to obtain missing information. Interventions were regrouped by type of continuity targeted, model of care or interventional strategy and were compared to usual care. Given the expected clinical and methodological diversity, median changes in outcomes (and bootstrap confidence intervals) among groups of studies that shared specific features of interest were chosen to analyse the effectiveness of included interventions.

MAIN RESULTS

Fifty-one studies were included. They used three different models, namely case management, shared care, and interdisciplinary teams. Six additional interventional strategies were used besides these models: (1) patient-held record, (2) telephone follow-up, (3) communication and case discussion between distant healthcare professionals, (4) change in medical record system, (5) care protocols, directives and guidelines, and (6) coordination of assessments and treatment.Based on the median effect size estimates, no significant difference in patient health-related outcomes was found between patients assigned to interventions and those assigned to usual care. A limited number of studies reported psychological health, satisfaction of providers, or process of care measures. However, they could not be regrouped to calculate median effect size estimates because of a high heterogeneity among studies.

AUTHORS' CONCLUSIONS

Results from this Cochrane review do not allow us to conclude on the effectiveness of included interventions to improve continuity of care on patient, healthcare provider or process of care outcomes. Future research should evaluate interventions that target an improvement in continuity as their primary objective and describe these interventions with the categories proposed in this review. Also of importance, continuity measures should be validated with persons with cancer who have been followed in various settings.

Polychlorinated biphenyls and organochlorine pesticides in plasma of older Canadians

No nationwide study has ever measured polychlorinated biphenyl (PCB) and organochlorine pesticide (OCP) body burden in Canadians aged 65 years and over. The objective of this study was to determine plasma concentrations of PCB congeners and OCPs in participants from a sub-cohort of the Canadian Study of Health and Aging and to examine the effects of socio-demographic, anthropometric and lifestyle characteristics on selected organochlorine concentrations. Archived plasma samples collected from 2023 subjects were analyzed by gas chromatography-mass spectrometry using negative chemical ionization for 15 PCB congeners and 11 OCPs. Descriptive statistics were used to report PCB congeners and OCP plasma concentrations. Multivariate models were used to study whether age at blood collection, sex, education, body mass index, rural residence, geographic region, smoking status and alcohol intake influences PCB 153, the most abundant congener, and the major OCP (beta-hexachlorocyclohexane, hexachlorobenzene, trans-nonachlor, p,p'-DDE) plasma concentrations. Statistical analyses were restricted to 1979 subjects and 17 organochlorine compounds for which at least 50% of the samples had concentrations above the limit of detection. Of these, 775 were men (mean age: 82.2 years) and 1204 were women (mean age: 84.6 years). The median concentrations (ng/g lipid) of PCB 153 in the plasma of men and women were 70.9 and 75.4, respectively. The levels of the sum of PCBs and the sum of dioxin-like PCBs were 276 and 31.3 for men, and 300 and 45.5 for women, respectively. The median concentrations (ng/g lipid) of p,p'-DDE, the most abundant OCP, were 565 for men and 828 for women. All compounds were positively and significantly intercorrelated (rs=0.39-0.99; p<0.001). Except for trans-nonachlor, the multivariate models revealed that age and male sex were the determining characteristics that showed, respectively, strongly positive and negative associations with selected organochlorine concentrations. These plasma concentrations from a large population based study can be considered as baseline data for body burdens of older Canadians.

Patients' perceptions of the quality of care after primary care reform: Family medicine groups in Quebec

OBJECTIVE

To evaluate how a primary care reform, which aimed to promote interprofessional and interorganizational collaborative practices, affected patients' experiences of the core dimensions of primary care.

DESIGN

Before-and-after comparison of patients' perceptions of care at the beginning of family medicine group (FMG) implementation (15 to 20 months after accreditation) and 18 months later.

SETTING

Five FMGs in the province of Quebec from various settings and types of practice.

PARTICIPANTS

A random sample of patients was selected in each FMG; a total of 1046 participants completed both the baseline and follow-up questionnaires.

MAIN OUTCOME MEASURES

Patients' perceptions of relational and informational continuity, organizational and first-contact accessibility, attitude and efficiency of the clinic's personnel and waiting times (service responsiveness), physician-nurse and primary care physician-specialist coordination, and intra-FMG collaboration were assessed over the telephone, mostly using a modified version of the Primary Care Assessment Tool. Additional items covered patients' opinions about consulting nurses, patients' use of emergency services, and patients' recall of health promotion and preventive care received.

RESULTS

A total of 1275 patients were interviewed at the study baseline, and 82% also completed the follow-up interviews after 18 months (n = 1046). Overall, perceptions of relational and informational continuity increased significantly (P < .05), whereas organizational and first-contact accessibility and service responsiveness did not change significantly. Perception of physician-nurse coordination remained unchanged, but perception of primary care physician-specialist coordination decreased significantly (P < .05). The proportion of participants reporting visits with nurses and reporting use of FMGs' emergency services increased significantly from baseline to follow-up (P < .05).

CONCLUSION

This reorganization of primary care services resulted in considerable changes in care practices, which led to improvements in patients' experiences of the continuity of care but not to improvements in their experiences of the accessibility of care.

Differentiation of the pattern of cognitive impairment between depressed and non-depressed patients with dementia living in long-term care facilities

OBJECTIVE

The principal objective of this study is to examine the cognitive profile of patients with dementia plus (D+ group) and without (D- group) concomitant depression.

METHOD

The D+ (N = 61) and D- (N = 89) patients were recruited in long-term care facilities. The depression status of the participants was determined using the Cornell Scale for Depression in Dementia. Cognitive functioning was assessed using the Hierarchic Dementia Scale (HDS).

RESULTS

The analyses first indicated that on the total HDS score, patients of the D+ group exhibited more severe cognitive impairment compared to those of the D- group. Further analyses revealed that the difference between groups pertained to perception, attention/memory, calculation, and language functions. Moreover, secondary analyses revealed that the cognitive deficits of the D+ group were associated with behavioral (agitation and retardation, in particular), but not with mood-related, symptoms of depression. Interestingly, ideational symptoms of depression (suicide and self-depreciation, in particular) were positively correlated with cognitive impairment.

CONCLUSION

These findings add to those of previous studies showing that D+ and D- patients differ not only regarding the presence or absence of depressive symptoms, but also regarding cognitive manifestations. This study thus reinforces the need to detect and treat accurately depression in dementia.

Examination of the multifactorial model of delirium among long-term care residents with dementia

The multifactorial model of delirium was developed to explain the interrelationship between predisposing and precipitating factors for delirium. Although validated among hospitalized patients, this model has never been tested among long-term care residents with dementia. We undertook this secondary data analysis to investigate the combined effect of predisposing and precipitating factors on the likelihood of having delirium among this population. Delirium was defined as meeting the Confusion Assessment Method criteria for definite or probable delirium. Risk factors considered in the study were those found significantly associated with delirium in the original study. Participants (N=155) were classified into risk groups. Prevalence of delirium for the low, moderate, and high predisposing risk groups were 32%, 78.4%, and 98.1%, respectively, and 37.9%, 67.2%, and 86.8% for the precipitating factors risk groups. When both variables were included in the same model, only predisposing factors remained statistically associated with delirium. Predisposing factors play a key role in the likelihood of having delirium among this population. Increased awareness of these factors among nurses could improve the care of these residents by targeting modifiable risk factors.

Omega-3 fatty acids and risk of dementia: the Canadian Study of Health and Aging

BACKGROUND

Omega-3 polyunsaturated fatty acids (n-3 PUFAs) may protect against dementia, although epidemiologic studies have yielded inconclusive results. Fish is the main dietary source of n-3 PUFAs and is sometimes contaminated with mercury. This neurotoxicant may modify the association with dementia.

OBJECTIVE

We evaluated the association of erythrocyte membrane total n-3 PUFAs, docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and blood mercury with the incidence of dementia and Alzheimer disease (AD) in the Canadian Study of Health and Aging (CSHA) with adjustment for confounders including apolipoprotein E epsilon4 (APOE epsilon4) status.

DESIGN

The CSHA is a cohort study of a representative sample of persons aged > or =65 y, conducted from 1991 to 2002. A subsample of 663 nondemented CSHA subjects with a complete clinical examination, blood samples, and follow-up information was eligible for prospective analyses on laboratory measurements. Of these, 149 were incident cases of dementia, including 105 with AD.

RESULTS

In adjusted Cox regression models with age as the time scale, there were no associations between total n-3 PUFAs, DHA, or EPA and dementia or AD. In contrast, a mercury concentration in the highest quartile was associated with a reduced risk of dementia (hazard ratio: 0.53; 95% CI: 0.33, 0.88). However, significant risk reductions were limited to subjects with concentrations of both n-3 PUFAs and mercury that were above the median. There was no modification of risk by APOE epsilon4 status.

CONCLUSIONS

No associations between n-3 PUFAs and dementia or AD were found. The results regarding mercury may indicate a spurious association.

Predisposing factors associated with delirium among demented long-term care residents

This was a cross-sectional study to investigate predisposing factors associated with delirium among demented long-term-care residents and to assess the cumulative effect of these factors on the likelihood of having delirium. Of the 155 participants, 109 (70.3%) were found delirious according to the confusion assessment method. Among these individuals, age (OR = 1.07; 95% CI = 1.05-1.10) and severity of dementia (OR = 1.05; 95% CI = 1.03-1.07) were the most associated factors of delirium. The likelihood of being in delirium increased with the number of associated predisposing factors present (OR = 1.67; 95% CI = 1.11-2.51). Associated factors identified were level of functional autonomy, pain, depression, behavioral disturbances, number of medications, dehydration, fever, and malnutrition. Identification of predisposing factors will help nurses in detecting those residents in long-term care settings who are at high-risk for delirium, as well as in designing preventive intervention strategies for delirium, based on these factors.

Detecting delirium and subsyndromal delirium using different diagnostic criteria among demented long-term care residents

OBJECTIVES

To evaluate the impact of using different diagnostic criteria on prevalence rates of delirium and subsyndromal delirium (SSD) among demented long-term care (LTC) residents.

DESIGN

Descriptive study.

SETTING

LTC settings in Quebec City, Canada.

PARTICIPANTS

Participants were 155 individuals aged 65 and older, with dementia.

MEASUREMENTS

(1) Prevalence rates of delirium according to: (a) the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, and DSM-IV) and (b) the Confusion Assessment Method (CAM) algorithms for definite and probable delirium; and (2) prevalence rates of SSD employing 2 definitions described in previous studies.

RESULTS

Prevalence rates of delirium according to each set of criteria were 26.5% for DSM-III; 29% for DSM-IV-TR; 41.3% for DSM-III-R; 45.8% for CAM algorithm for definite delirium; and 70.3% for CAM algorithm for probable delirium. A total of 109 subjects (70.3%) were identified as delirious consistent with at least one classification and 37 (23.9%) met all the sets of criteria considered. Prevalence rates for SSD were 75 (48.4%) and 78 (50.3%) depending on the definition employed.

CONCLUSION

Prevalence rates for delirium are much affected by the diagnostic formulations used. The use of DSM-IV-TR among this population could result in fewer cases being identified as delirious and thus compromise proper care for those individuals. Considering that SSD was prevalent among this population, a systematic implementation of protocols targeting risk factors of delirium might be beneficial among demented LTC residents.

Detection of delirium by nurses among long-term care residents with dementia

Background

Delirium is a prevalent problem in long-term care (LTC) facilities where advanced age and cognitive impairment represent two important risk factors for this condition. Delirium is associated with numerous negative outcomes including increased morbidity and mortality. Despite its clinical importance, delirium often goes unrecognized by nurses. Although rates of nurse-detected delirium have been studied among hospitalized older patients, this issue has been largely neglected among demented older residents in LTC settings. The goals of this study were to determine detection rates of delirium and delirium symptoms by nurses among elderly residents with dementia and to identify factors associated with undetected cases of delirium.

Methods

In this prospective study (N = 156), nurse ratings of delirium were compared to researcher ratings of delirium. This procedure was repeated for 6 delirium symptoms. Sensitivity, specificity, positive and negative predictive values were computed. Logistic regressions were conducted to identify factors associated with delirium that is undetected by nurses.

Results

Despite a high prevalence of delirium in this cohort (71.5%), nurses were able to detect the delirium in only a minority of cases (13%). Of the 134 residents not identified by nurses as having delirium, only 29.9% of them were correctly classified. Detection rates for the 6 delirium symptoms varied between 39.1% and 58.1%, indicating an overall under-recognition of symptoms of delirium. Only the age of the residents (≥ 85 yrs) was associated with undetected delirium (OR: 4.1; 90% CI: [1.5–11.0]).

Conclusion

Detection of delirium is a major issue for nurses that clearly needs to be addressed. Strategies to improve recognition of delirium could result in a reduction of adverse outcomes for this very vulnerable population.

Impact of gene expression data pre-processing on expression quantitative trait locus mapping

We evaluate the impact of three pre-processing methods for Affymetrix microarray data on expression quantitative trait locus (eQTL) mapping, using 14 CEPH Utah families (GAW Problem 1 data). Different sets of expression traits were chosen according to different selection criteria: expression level, variance, and heritability. For each gene, three expression phenotypes were obtained by different pre-processing methods. Each quantitative phenotype was then submitted to a whole-genome scan, using multipoint variance component LODs. Pre-processing methods were compared with respect to their linkage outcomes (number of linkage signals with LODs greater than 3, consistencies in the location of the trait-specific linkage signals, and type of cis/trans-regulating loci). Overall, we found little agreement between linkage results from the different pre-processing methods: most of the linkage signals were specific to one pre-processing method. However, agreement rates varied according to the criteria used to select the traits. For instance, these rates were higher in the set of the most heritable traits. On the other hand, the pre-processing method had little impact on the relative proportion of detected cis and trans-regulating loci. Interestingly, although the number of detected cis-regulating loci was relatively small, pre-processing methods agreed much better in this set of linkage signals than in the trans-regulating loci. Several potential factors explaining the discordance observed between the methods are discussed.