Barriers and facilitators to the dissemination of DECISION+, a continuing medical education program for optimizing decisions about antibiotics for acute respiratory infections in primary care: a study protocol

Background

In North America, acute respiratory infections are the main reason for doctors' visits in primary care. Family physicians and their patients overuse antibiotics for treating acute respiratory infections. In a pilot clustered randomized trial, we showed that DECISION+, a continuing medical education program in shared decision making, has the potential to reduce the overuse of antibiotics for treating acute respiratory infections. DECISION+ learning activities consisted of three interactive sessions of three hours each, reminders at the point of care, and feedback to doctors on their agreement with patients about comfort with the decision whether to use antibiotics. The objective of this study is to identify the barriers and facilitators to physicians' participation in DECISION+ with the goal of disseminating DECISION+ on a larger scale.

Methods/design

This descriptive study will use mixed methods and retrospective and prospective components. All analyses will be based on an adapted version of the Ottawa Model of Research Use. First, we will use qualitative methods to analyze the following retrospective data from the pilot study: the logbooks of eight research assistants, the transcriptions of 15 training sessions, and 27 participant evaluations of the DECISION+ training sessions. Second, we will collect prospective data in semi-structured focus groups composed of family physicians to identify barriers and facilitators to the dissemination of a future training program similar to DECISION+. All 39 family physicians exposed to DECISION+ during the pilot project will be eligible to participate. We will use a self-administered questionnaire based on Azjen's Theory of Planned Behaviour to assess participants' intention to take part in future training programs similar to DECISION+.

Discussion

Barriers and facilitators identified in this project will guide modifications to DECISION+, a continuing medical education program in shared decision making regarding the use of antibiotics in acute respiratory infections, to facilitate its dissemination in primary care on a large scale. Our results should help continuing medical educators develop a continuing medical education program in shared decision making for other clinically relevant topics. This will help optimize clinical decisions in primary care.

When the business of sharing treatment decisions is not the same as shared decision making: A discourse analysis of decision sharing in general practice

Although shared decision making (SDM) in general practice continues to be promoted as a highly desirable means of conducting consultations it is rarely observed in practice. The aim of this study is to identify the discursive features and conversational strategies particular to the negotiation and sharing of treatment decisions in order to understand why SDM is not yet embedded into routine practice. Consultations from Scottish general practices were examined using discourse analysis. Two themes were identified as key components for when the doctor and the patient were intent on sharing decisions: the generation of patient involvement using first-person pronouns, and successful and unsuccessful patient requesting practices. This article identifies a number of conversational activities found to be successful in supporting doctors’ agendas and reducing their responsibility for decisions made. Doctor’s use of ‘partnership talk’ was found to minimize resistance and worked to invite consensus rather than involvement. The information from this study provides new insight into the consultation process by identifying how treatment decisions are arrived at through highlighting the complexities involved. Notably, shared decision making does not happen with the ease implied by current models and appears to work to maintain a biomedical ‘GP as expert’ approach rather than one in which the patient is truly involved in partnership. We suggest that further research on the impact of conversational activities is likely to benefit our understanding of shared decision making and hence training in and the practice of SDM.

Individual determinants of research utilization by nurses: a systematic review update

BACKGROUND

Interventions that have a better than random chance of increasing nurses' use of research are important to the delivery of quality patient care. However, few reports exist of successful research utilization in nursing interventions. Systematic identification and evaluation of individual characteristics associated with and predicting research utilization may inform the development of research utilization interventions.

OBJECTIVE

To update the evidence published in a previous systematic review on individual characteristics influencing research utilization by nurses.

METHODS

As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted. Randomized controlled trials, clinical trials, and observational study designs examining the association between individual characteristics and nurses' use of research were eligible for inclusion. Studies were limited to those published in the English, Danish, Swedish, and Norwegian languages. A vote counting approach to data synthesis was taken.

RESULTS

A total of 42,770 titles were identified, of which 501 were retrieved. Of these 501 articles, 45 satisfied our inclusion criteria. Articles assessed research utilization in general (n = 39) or kinds of research utilization (n = 6) using self-report survey measures. Individual nurse characteristics were classified according to six categories: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and socio-demographic/socio-economic characteristics. A seventh category, critical thinking, emerged in studies examining kinds of research utilization. Positive relationships, at statistically significant levels, for general research utilization were found in four categories: beliefs and attitudes, information seeking, education, and professional characteristics. The only characteristic assessed in a sufficient number of studies and with consistent findings for the kinds of research utilization was attitude towards research; this characteristic had a positive association with instrumental and overall research utilization.

CONCLUSIONS

This review reinforced conclusions in the previous review with respect to positive relationships between general research utilization and: beliefs and attitudes, and current role. Furthermore, attending conferences/in-services, having a graduate degree in nursing, working in a specialty area, and job satisfaction were also identified as individual characteristics important to research utilization. While these findings hold promise as potential targets of future research utilization interventions, there were methodological problems inherent in many of the studies that necessitate their findings be replicated in further research using more robust study designs and multivariate assessment methods.

Project Masihambisane: a cluster randomised controlled trial with peer mentors to improve outcomes for pregnant mothers living with HIV

BACKGROUND

Pregnant women living with HIV (WLH) face daily challenges maintaining their own and their babies' health and mental health. Standard Prevention of Maternal to Child Transmission (PMTCT) programs are not designed to address these challenges.

METHODS/DESIGN

As part of a cluster randomized controlled trial, WLH are invited to attend four antenatal and four postnatal small group sessions led by a peer WLH (a Peer Mentor). The WLH and their babies are assessed during pregnancy and at one week, six months, and twelve months post-birth. Mobile phones are used to collect routine information, complete questionnaires and remain in contact with participants over time. Pregnant WLH (N = 1200) are randomly assigned by clinic (N = 8 clinics) to an intervention program, called Masihambisane (n = 4 clinics, n = 600 WLH) or a standard care PMTCT control condition (n = 4 clinics; n = 600 WLH).

DISCUSSION

Data collection with cellular phones are innovative and effective in low-resource settings. Standard PMTCT programs are not designed to address the daily challenges faced by WLH; Peer Mentors may be useful in supporting WLH to cope with these challenges.

TRIAL REGISTRATION

ClinicalTrials.gov registration # NCT00972699.

Implementing quality improvement in small, autonomous primary care practices: implications for the patient-centred medical home

BACKGROUND

Implementing improvement programmes to enhance quality of care in primary care clinics is complex. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient centred medical homes (PCMH). This study examined practice members' perceptions of the opportunities and challenges associated with implementing changes in their practice.

METHODS

Semi-structured interviews were conducted with a sample of 56 individuals working in 16 small, community based primary care practices. The interviews consisted of open-ended questions focused on participants' perceptions of: (1) practice vision, (2) perceived need for practice improvement and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analysed.

RESULTS

Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients' involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking and follow-up, standardisation of processes of care and overall clinic documentation. Changes related to patients' involvement in their care included improving (a) health education, and (b) self-care management. Among the internal barriers were: staff readiness for change, poor communication and relationship difficulties among team members. External barriers were insurance regulations, finances and patient health literacy.

CONCLUSIONS

Transforming practices to more patient-centred models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programmes. Successful strategies for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members' perceived needs and planned improvement efforts.

The impact of a novel computer-based decision aid on shared decision making for colorectal cancer screening: a randomized trial

BACKGROUND

Eliciting patients' preferences within a framework of shared decision making (SDM) has been advocated as a strategy for increasing colorectal cancer (CRC) screening adherence. Our objective was to assess the effectiveness of a novel decision aid on SDM in the primary care setting.

METHODS

An interactive, computer-based decision aid for CRC screening was developed and evaluated within the context of a randomized controlled trial. A total of 665 average-risk patients (mean age, 57 years; 60% female; 63% black, 6% Hispanic) were allocated to 1 of 2 intervention arms (decision aid alone, decision aid plus personalized risk assessment) or a control arm. The interventions were delivered just prior to a scheduled primary care visit. Outcome measures (patient preferences, knowledge, satisfaction with the decision-making process [SDMP], concordance between patient preference and test ordered, and intentions) were evaluated using prestudy/poststudy visit questionnaires and electronic scheduling.

RESULTS

Overall, 95% of patients in the intervention arms identified a preferred screening option based on values placed on individual test features. Mean cumulative knowledge, SDMP, and intention scores were significantly higher for both intervention groups compared with the control group. Concordance between patient preference and test ordered was 59%. Patients who preferred colonoscopy were more likely to have a test ordered than those who preferred an alternative option (83% v. 70%; P < 0.01). Intention scores were significantly higher when the test ordered reflected patient preferences.

CONCLUSIONS

Our interactive computer-based decision aid facilitates SDM, but overall effectiveness is determined by the extent to which providers comply with patient preferences.

Attitudes toward shared decision-making and risk communication practices in residents and their teachers

BACKGROUND

Health professionals' attitudes toward shared decision-making (SDM) are an important facilitator of SDM, but information on these attitudes is limited.

AIMS

The purpose of this study is to examine attitudes, education and practices around SDM and risk communication in residents and their teachers.

METHOD

A questionnaire was mailed to residents in Swiss hospitals in postgraduate medical training programs assessing risk communication education and SDM. In an Internet survey, teachers of the medical training programs answered questions on SDM and risk communication practices. Data were analyzed with ANOVAs and paired samples t-tests.

RESULTS

Significant differences in residents' and teachers' opinions regarding SDM were found between specialties and number of residents in a residency (1-3, 4-10, ≥11 residents). Teachers showed a high use of verbal risk communication. Neither residents nor teachers expressed a strong feeling that they lacked the time for decision-making. Residents were significantly more negative about the ability of patients to participate in decision-making compared to their teachers.

CONCLUSIONS

As residents are more negative about SDM compared to teachers and teachers do not always use the preferred and best methods for risk communication, more education for teachers and residents is needed to improve communication practices in the future.

Global research priorities in rheumatic fever and rheumatic heart disease

We now stand at a critical juncture for rheumatic fever (RF) and rheumatic heart disease (RHD) control. In recent years, we have seen a surge of interest in these diseases in regions of the world where RF/RHD mostly occur. This brings real opportunities to make dramatic progress in the next few years, but also real risks if we miss these opportunities. Most public health and clinical approaches in RF/RHD arose directly from programmes of research. Many unanswered questions remain, including those around how to implement what we know will work, so research will continue to be essential in our efforts to bring a global solution to this disease. Here we outline our proposed research priorities in RF/RHD for the coming decade, grouped under the following four challenges: Translating what we know already into practical RHD control; How to identify people with RHD earlier, so that preventive measures have a higher chance of success; Better understanding of disease pathogenesis, with a view to improved diagnosis and treatment of ARF and RHD; and Finding an effective approach to primary prevention. We propose a mixture of basic, applied, and implementation science. With concerted efforts, strong links to clinical and public health infrastructure, and advocacy and funding support from the international community, there are good prospects for controlling these RF and RHD over the next decade.

Viewpoint: Economic evaluation of package of care interventions employing clinical guidelines

Increasingly attention is shifting towards delivering essential packages of care, often based on clinical practice guidelines, as a means to improve maternal, child and newborn survival in low-income settings. Cost effectiveness analysis (CEA), allied to the evaluation of less complex intervention, has become an increasingly important tool for priority setting. Arguably such analyses should be extended to inform decisions around the deployment of more complex interventions. In the discussion, we illustrate some of the challenges facing the extension of CEA to this area. We suggest that there are both practical and methodological challenges to overcome when conducting economic evaluation for packages of care interventions that incorporate clinical guidelines. Some might be overcome by developing specific guidance on approaches, for example clarity in identifying relevant costs. Some require consensus on methods. The greatest challenge, however, lies in how to incorporate, as measures of effectiveness, process measures of service quality. Questions on which measures to use, how multiple measures might be combined, how improvements in one area might be compared with those in another and what value is associated with improvement in health worker practices are yet to be answered.

The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review

BACKGROUND

The prevalence of diabetes mellitus is ubiquitous. Complications and costs of diabetes are rising and are depleting limited resources. It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions. An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit. Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting.

OBJECTIVES

The review objective was to conduct a systematic review and meta-analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c, blood pressure and cholesterol measurements/levels for adult patients with type II diabetes in outpatient settings.

SEARCH STRATEGY

A three-step literature search for studies in English language from 1990 to 2010 was conducted utilising (a) a primary search of Medline, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials, (b) a secondary search of non-indexed databases, and (c) a search of the grey literature. In addition, a manual review of the reference lists of all identified reports and articles was performed to identify additional studies.

INCLUSION CRITERIA

All randomised and quasi-experimental studies of adult patients (>18) with type II diabetes mellitus seen in outpatient health settings were considered if they met one or more of the following diagnostic outcome measurements: haemoglobin A1c, systolic and diastolic blood pressure, and low density lipoprotein cholesterol.

CRITICAL APPRAISAL, DATA COLLECTION AND ANALYSIS

Each of the eligible articles was reviewed by two independent reviewers. Disagreements between the reviewers were resolved through discussion, or with a third reviewer. Studies that met the inclusion criteria were assessed for methodological quality using the JBI standardized critical appraisal tools. Data extraction was undertaken using the standardised data extraction tool from JBI-MAStARI.

MAIN RESULTS

The search strategy identified 2,040 articles in the published and unpublished literature. Of these, 11 randomised controlled trials and 4 quasi-experimental trials met the inclusion criteria and represented 2240 patients included in the final review.There are clear benefits of group medical visits for patients' HbA1c levels which are consistent in the post-intervention and change from baseline effect sizes. The most significant effect observed is with the change from baseline results. Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe. There is no evidence that group visits improve LDL cholesterol values of the group visit participants.

CONCLUSIONS

Group medical visits should be considered by clinicians as an effective non-pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure.

IMPLICATIONS FOR PRACTICE

The evidence suggests that the most powerful model of Group medical visits (GMV) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs.

IMPLICATIONS FOR RESEARCH

Future research should include this GMV intervention in randomised controlled trials across different health systems and socio-economic and ethnic groups.

Helping high-risk youth move through high-risk periods: personally controlled health records for improving social and health care transitions

BACKGROUND

New patient-centered information technologies are needed to address risks associated with health care transitions for adolescents and young adults with diabetes, including systems that support individual and structural impediments to self- and clinical-care.

METHODS

We describe the personally controlled health record (PCHR) system platform and its key structural capabilities and assess its alignment with tenets of the chronic care model (CCM) and the social-behavioral and health care ecologies within which adolescents and young adults with diabetes mature.

RESULTS

Configured as Web-based platforms, PCHRs can support a new class of patient-facing applications that serve as monitoring and support systems for adolescents navigating complex social, developmental, and health care transitions. The approach can enable supportive interventions tailored to individual patient needs to boost adherence, self-management, and monitoring.

CONCLUSIONS

The PCHR platform is a paradigm shift for the organization of health information systems and is consistent with the CCM and conceptualizations of patient- and family-centered care for diabetes. Advancing the approach augers well for improvement around health care transitions for youth and also requires that we address (i) structural barriers impacting diabetes care for maturing youth; (ii) challenges around health and technology literacy; (iii) privacy and confidentiality issues, including sharing of health information within family and institutional systems; and (iv) needs for evaluation around uptake, impacts, and outcomes.

Moving toward synergy: lessons learned in developing and sustaining community-academic partnerships

BACKGROUND

Community-academic partnerships are an increasingly popular approach to addressing community health problems and engaging vulnerable populations in research. Despite these altruistic foci, however, partnerships often struggle with fundamental issues that thwart sustainability, effectiveness, and efficiency.

OBJECTIVES

We adapted a synergy-promoting model to guide the development and evaluation of a community-academic partnership and share lessons learned along the way.

METHODS

We analyzed the partnership process over time to determine the interaction of trust, collaboration, and engagement in creating partnership synergy and promoting sustainability.

LESSONS LEARNED

Few community-academic partnerships use a conscious and systematic approach to guide and evaluate their progress. We argue that this is an important first step in creating a partnership, sustaining a milieu of open dialogue, and developing strategies that promote trust and equalize power dynamics. Still, as we learned, the best laid plans can go awry, challenging partnership synergy throughout its lifespan.

Development and Psychometric Qualities of the SEIPS Survey to Evaluate CPOE/EHR Implementation in ICUs

Health Information Technology (IT) implementation can fail or meet high levels of user resistance for a variety of reasons, including lack of attention to users' needs and the significant workflow changes induced and required by the technology. End-user satisfaction is a critical factor in health IT implementation. In this paper we describe the process of developing and testing a questionnaire to evaluate health IT implementation, in particular Computerized Provider Order Entry (CPOE) and Electronic Health Record (EHR) technologies. Results showed evidence for the validity and reliability of the questionnaire. The Systems Engineering Initiative for Patient Safety (SEIPS) questionnaire is relatively easy to administer and allows researchers to evaluate different aspects of health IT implementation. Results of this research can be used for benchmarking results of future studies evaluating health IT implementation.

Psychometrics of the Computer-Based Relationships With Health Care Provider Scale in Older Adults

The type and quality of the provider–patient health care relationship impacts patient adherence. The study purpose was to convert the 5-item paper and pencil Relationships With Health Care Provider Scale (RHCPS) to a reliable and valid computer-based scale for use with older adults. Outpatient adults (N = 121) older than 59 years were recruited. The RHCPS underwent several iterations documenting internal consistency reliability, content and factorial validity, and scale usability in a computer tablet format. A total of 5 expert judges rated all 5 items as valid, which resulted in a scale content validity index of 1. Cronbach’s standardized alpha was .81. Principal components analysis extracted 1 factor (eigenvalue > 1; confirmed by scree plot) as anticipated. Computer-based RHCPS has the potential to reveal valuable clinical and scientific data on patient–provider relationships among older adults.

Knowledge brokering in children's rehabilitation organizations: perspectives from administrators

INTRODUCTION

Administrators must balance the demands of delivering therapy services with the need to provide staff with educational opportunities promoting evidence-based practice. Increasingly, the use of multifaceted, interactive knowledge translation strategies, such as knowledge brokering, is suggested as an effective way to encourage clinician behavior changes and implement new knowledge. The purpose of this qualitative study is to describe administrators' perceptions of the successes and challenges in using a knowledge broker (KB) to promote the use of evidence-based measures of motor function for children with cerebral palsy.

METHODS

Administrators from 27 pediatric facilities completed a semi-structured telephone interview following 6 months of knowledge brokering within their organizations. Using thematic analysis, interview transcripts were reviewed to identify common themes.

RESULTS

Six interview themes were identified: "Efficient and Effective," "Stimulating Peer-to-Peer Learning Environment," "Committed and Respected Knowledge Brokers," "Sharing Beyond," "Organizational Beliefs and Values," and "The Dilemma of Moving Forward". Administrators were positive about the KB experience, acknowledging its efficiency and effectiveness. They commented on the stimulating peer-to-peer and interdisciplinary learning environment that the KB process encouraged. Administrators referred to their organizational beliefs and values when discussing their need to make priorities for limited resources, which influenced their decisions about whether to continue with a KB after the study was completed.

DISCUSSION

Although administrators were philosophically supportive of knowledge brokering, they identified funding and resource constraints and the absence of evidence of the effectiveness of knowledge brokering as major barriers to the continuation of a KB role in their facility.

Reflections on knowledge brokering within a multidisciplinary research team

Knowledge brokering (KB) may be one approach of helping researchers and decision makers effectively communicate their needs and abilities, and move toward increased use of evidence in health care. A multidisciplinary research team in Nova Scotia, Canada, has created a dedicated KB position with the goal of improving access to quality colorectal cancer care. The purpose of this paper is to provide an in-progress perspective on KB within this large research team. A KB position ("knowledge broker") was created to perform two primary tasks: (1) facilitate ongoing communication among team members; and (2) develop and maintain collaborations between researchers and decision makers to establish partnerships for the transfer and use of research findings. In this article, we discuss our KB model and its implementation, describe the broker's functions and activities, and present preliminary outcomes. The primary functions of the KB position have included: sustaining team members' engagement; harnessing members' expertise and sharing it with others; developing and maintaining communication tools/strategies; and establishing collaborations between team members and other stakeholders working in cancer care. The broker has facilitated an integrated knowledge translation approach to research conduct and led to the development of new collaborations with external stakeholders and other cancer/health services researchers. KB roles will undoubtedly differ across contexts. However, descriptive assessments can help others determine whether such an approach could be valuable for their research programs and, if so, what to expect during the process.

Implementing dementia care models in primary care settings: The Aging Brain Care Medical Home

OBJECTIVES

The purpose of this article is to describe our experience in implementing a primary care-based dementia and depression care program focused on providing collaborative care for dementia and late-life depression.

METHODS

Capitalizing on the substantial interest in the US on the patient-centered medical home concept, the Aging Brain Care Medical Home targets older adults with dementia and/or late-life depression in the primary care setting. We describe a structured set of activities that laid the foundation for a new partnership with the primary care practice and the lessons learned in implementing this new care model. We also provide a description of the core components of this innovative memory care program.

RESULTS

Findings from three recent randomized clinical trials provided the rationale and basic components for implementing the new memory care program. We used the reflective adaptive process as a relationship building framework that recognizes primary care practices as complex adaptive systems. This framework allows for local adaptation of the protocols and procedures developed in the clinical trials. Tailored care for individual patients is facilitated through a care manager working in collaboration with a primary care physician and supported by specialists in a memory care clinic as well as by information technology resources.

CONCLUSIONS

We have successfully overcome many system-level barriers in implementing a collaborative care program for dementia and depression in primary care. Spontaneous adoption of new models of care is unlikely without specific attention to the complexities and resource constraints of health care systems.

Navigating patient navigation: crossing health services research and clinical boundaries

As health care delivery becomes increasingly focused on patient-centered models, interventions such as patient navigation that have the potential to improve care coordination garner interest from health care managers and clinicians. The ability to understand how and to what extent patient navigation is successful in addressing coordination issues, however, is hampered by multiple definitions, vague boundaries, and different contextual implementations of patient navigation. Using a systematic review strategy and classification method, we review both the conceptual and empirical literature regarding navigation in multiple clinical contexts. We then describe and conceptualize variation in how patient navigation has been defined, implemented, and theorized to affect outcomes. This review suggests that patient navigation varies along multiple dimensions and that the variation is related to differing resources, constraints, and goals. We propose a conceptual model to frame further research and suggest that research in this area must carefully account for this variation in order to accurately assess the benefits of patient navigation and provide actionable knowledge for managers.

Examining implementer fidelity: Conceptualizing and measuring adherence and competence

The large gap between intervention outcomes demonstrated in efficacy trials and the apparent ineffectiveness of these same programs in community settings has prompted investigators and practitioners to look closely at implementation fidelity. Critically important, but often overlooked, are the implementers who deliver evidence-based programs -- the effectiveness of programs cannot surpass skill levels of the people implementing them. This article distinguishes fidelity at the programmatic level from implementer fidelity. Two components of implementer fidelity are defined. Implementer adherence and competence are proposed to be related but unique constructs that can be reliably measured for training¸ monitoring, and outcomes research. Observational measures from a school-based preventive intervention are provided and the unique contributions of implementer adherence and competence are illustrated. Distinguishing implementer adherence to the manual and competence in program delivery is a critical next step in child mental health program implementation research.

Partnerships for knowledge translation and exchange in the context of continuing professional development

Continuing professional development (CPD) is an important vehicle for knowledge translation (KT); however, selecting CPD strategies that will impact health professionals' behavior and improve patient outcomes is complex. In response, we, KT researchers and CPD knowledge users, have recently formed a partnership known as the National Network for Patient-Centered Evidence-Based Continuing Professional Development. The partnership was initiated in 2006 with a series of CIHR Knowledge Translation: Planning, Meetings and Dissemination grants. The objectives of these grants were to bring members of the CPD and KT communities together, determine their interest in working together, identify similarities and differences in the fields of CPD and KT, and develop working groups to inform larger collaborative initiatives to support knowledge translation and exchange. The vision for this partnership is to become a premiere knowledge translation collaboration and a cutting-edge implementation network that informs the provision of CPD across Canada and abroad. This paper reports on the development and outcomes of this network to date.

Tailoring interventions: examining the evidence and identifying gaps

INTRODUCTION

Numerous population-based studies highlight the need to improve health care delivery and outcomes. Many single and combined interventions are available but their impact is limited and inconsistent. Tailoring may enhance their impact, but the best way to do so remains unclear. The purpose of this exploratory analysis was to identify potential ways to tailor these interventions that could enhance their effectiveness.

METHODS

Interventions were chosen according to those included in a recent systematic review, which found that their impact was enhanced through tailoring. The most recent syntheses of research on the effectiveness of these interventions were identified in MEDLINE and examined for details of intervention design or delivery that influenced impact.

RESULTS

Possible tailoring mechanisms were identified for 2 interventions. The impact of educational meetings could be enhanced by focusing on topics involving less complex behavior, offering a series of events, and including interactive components. The impact of audit and feedback could be enhanced by offering a series of events. Recent systematic reviews on the effectiveness of 3 interventions-self-assessment, public reporting of performance data, and opinion leaders-did not identify factors influencing their impact that could be used for tailoring.

DISCUSSION

This exploratory review revealed few ways to potentially improve the effectiveness of interventions among the plethora of available trials. Nontraditional systematic reviews that consider research from different disciplines and featuring a variety of designs are recommended. More immediately, educators, professional associations, and health care managers could use this information to structure, implement, and support interventions that improve health care delivery and outcomes.

Identifying the educationally influential physician: a systematic review of approaches

INTRODUCTION

Previous studies have indicated that educationally influential physicians' (EIPs) interactions with peers can lead to practice changes and improved patient outcomes. However, multiple approaches have been used to identify and investigate EIPs' informal or formal influence on practice, which creates study outcomes that are difficult to compare. The purposes of this systematic literature review were to (1) compare approaches used to identify EIPs and (2) identify and compare shared characteristics of EIPs as defined by the included studies.

METHODS

Articles in English were obtained from PubMed, CINAHL Plus, ERIC, PsycINFO, Web of Science, Google Scholar databases, and reference lists of identified articles. Studies were compared and contrasted based on terminology, identification approach, selection criteria, and EIP characteristics according to Cresswell's 5 steps in conducting a literature review.

RESULTS

Thirty-one studies met the inclusion criteria. Sociometric questionnaires and peer informants were used most frequently to identify EIPs. Multiple and varied criteria, including physician ranking, nomination by peers, percentage of nominations received, and number of votes were used by researchers to select physicians who were classified as EIPs. The identified characteristics of EIPs varied by study, with some researchers adhering to characteristics previously described by Hiss, and others adding to or deviating from those characteristics, at times based on physician specialty.

CONCLUSION

Selection of an EIP identification approach requires agreement on EIPs' characteristics, consistent approaches and identification criteria, and common terms and definitions. Additional research is needed to compare characteristics of EIPs and study outcomes based on the identification method employed.

Awareness of the Care Team in Electronic Health Records

OBJECTIVE: To support collaboration and clinician-targeted decision support, electronic health records (EHRs) must contain accurate information about patients' care providers. The objective of this study was to evaluate two approaches for care provider identification employed within a commercial EHR at a large academic medical center. METHODS: We performed a retrospective review of EHR data for 121 patients in two cardiology wards during a four-week period. System audit logs of chart accesses were analyzed to identify the clinicians who were likely participating in the patients' hospital care. The audit log data were compared with two functions in the EHR for documenting care team membership: 1) a vendor-supplied module called "Care Providers", and 2) a custom "Designate Provider" order that was created primarily to improve accuracy of the attending physician of record documentation. RESULTS: For patients with a 3-5 day hospital stay, an average of 30.8 clinicians accessed the electronic chart, including 10.2 nurses, 1.4 attending physicians, 2.3 residents, and 5.4 physician assistants. The Care Providers module identified 2.7 clinicians/patient (1.8 attending physicians and 0.9 nurses). The Designate Provider order identified 2.1 clinicians/patient (1.1 attending physicians, 0.2 resident physicians, and 0.8 physician assistants). Information about other members of patients' care teams (social workers, dietitians, pharmacists, etc.) was absent. CONCLUSIONS: The two methods for specifying care team information failed to identify numerous individuals involved in patients' care, suggesting that commercial EHRs may not provide adequate tools for care team designation. Improvements to EHR tools could foster greater collaboration among care teams and reduce communication-related risks to patient safety.

Online communities of practice to support collaborative mental health practice in rural areas

The provision of quality mental health services in rural areas continues to be an ongoing challenge for nurses and the patients they serve. The use of computer mediated communication to construct collaborative learning environments similar to those suggested in Wenger's community of practice framework has the potential to mitigate a number of the difficulties faced by rural health care providers. The author presents a brief discussion of social learning theories, the communities of practice framework, and related concepts. Examples of current online communities of practice used as a means for knowledge construction in various professional disciplines are presented in building the case for the fit between online communities of practice and the needs of nurses in rural mental health. Nurses providing mental health care in rural areas have documented needs for interdisciplinary teamwork, access to a collaborative learning environment, and ongoing contact with expert resources. The construction of online communities of practice could potentially address a multitude of concerns identified by nurses practicing mental health care in rural areas.

Putting the "evidence" in evidence-based practice: meeting research challenges in community psychiatric settings

Every psychiatric client deserves access to treatments that have evidence of efficacy, but in psychiatric nursing, this evidence remains sparse. To address this deficit, researchers must commit to conducting high quality, community-based psychiatric nursing intervention investigations. In service of this goal, the authors draw upon their research experiences in community psychiatric settings to suggest options for overcoming system-, clinician-, and client-related research barriers in community psychiatric settings.

Physician preferences for accredited online continuing medical education

INTRODUCTION

The need for up-to-date and high-quality continuing medical education (CME) is growing while the financial investment in CME is shrinking. Despite online technology's potential to efficiently deliver electronic CME (eCME) to large numbers of users, it has not yet displaced traditional CME. The purpose of this study was to explore what health care providers want in eCME and how they want to use it.

METHODS

This was a qualitative study. Two 3-hour focus groups were held with physicians in both academic and community practices as well as trainees knowledgeable in the hypertension clinical practice guidelines with a willingness to discuss eCME. Content/thematic analysis was used to examine the data.

RESULTS

Three main themes emerged: credibility, content/context, and control. Credibility was the most consistent and dominant theme. Affiliations with medical organizations and accreditation were suggested as methods by which eCME can gain credibility. The content and need for discussion of the content emerged as a key pivot point between eCME and traditional CME: a greater need for discussion was linked to a preference for traditional face-to-face CME. Control over the content and how it was accessed was an emergent theme, giving learners the ability to control the depth of learning and the time spent. They valued the ability to quickly find information that was in a format (podcast, video, mobile device) that best suited their learning needs or preferences at the time.

DISCUSSION

This study provides insight into physician preferences for eCME and hypotheses that can be used to guide further research.

Barriers and enablers in the implementation of a provider-based intervention to stimulate culturally appropriate hypertension education

OBJECTIVE

to identify barriers and enablers influencing the implementation of an intervention to stimulate culturally appropriate hypertension education (CAHE) among health care providers in primary care.

METHODS

the intervention was piloted in three Dutch health centers. It consists of a toolkit for CAHE, training, and feedback meetings for hypertension educators. Data were collected from 16 hypertension educators (nurse practitioners and general practice assistants) during feedback meetings and analyzed using qualitative content analysis.

RESULTS

perceived barriers to the implementation of the intervention fell into three main categories: political context (health care system financing); organizational factors (ongoing organizational changes, work environment, time constraints and staffing) and care provider-related factors (routines, attitudes, computer and educational skills, and cultural background). Few barriers were specifically related to the delivery of CAHE (e.g. resistance to registering ethnicity). Enabling strategies addressing these barriers consisted of reorganizing practice procedures, team coordination, and providing reminders and additional instructions to hypertension educators.

CONCLUSION AND PRACTICE IMPLICATIONS

the adoption of a tool for CAHE by care providers can be accomplished if barriers are identified and addressed. The majority of these barriers are commonly associated with the implementation of health care innovations in general and do not indicate resistance to providing culturally appropriate care.

Enhancing practice improvement by facilitating practitioner interactivity: new roles for providers of continuing medical education

Research into networking and interactivity among practitioners is providing new information that has the potential to enhance the effectiveness of practice improvement initiatives. This commentary reviews the evidence that practitioner interactivity can facilitate emergent learning and behavior change that lead to practice improvements. Insights from learning theories provide a framework for understanding emergent learning as the product of interactions between individuals in trusted relationships, such as occurs in communities of practice. This framework helps explain why some groups respond more favorably to improvement initiatives than others. Failure to take advantage of practitioner interactivity may explain in part the disappointingly low mean rates of practice improvement reported in studies of the effectiveness of practice improvement projects. Examples of improvement models in primary care settings that explicitly use relationship building and facilitation techniques to enhance practitioner interactivity are provided. Ingredients of a curriculum to teach relationship building in communities of practice and facilitation skills to enhance learning in small group education sessions are explored. Sufficient evidence exists to support the roles of relationships and interactivity in practice improvement initiatives such that we recommend the development of training programs to teach these skills to CME providers.

Using problem-based case studies to learn about knowledge translation interventions: an inside perspective

Knowledge translation (KT) interventions can facilitate the successful implementation of best practices by engaging and actively involving various stakeholders in the change process. However, for novices, the design of KT interventions can be overwhelming. In this article, we describe our experience as participants in a problem-based case study on planning a KT intervention and reflect on the use of problem-based learning (PBL) to develop knowledge and skills relevant to the KT process. Participants were six fellows and two faculty members attending the 2009 Canadian Institutes of Health Research KT Summer Institute. Participants received a case study asking them to develop a KT intervention with the goal of implementing a stroke response protocol for hospital inpatients. The group was given 5 hours spread over 2 days to complete the learning task. As the members of the small group reflected on their experience with the case study, 4 themes emerged: (1) balancing engaging stakeholders with moving forward; (2) exploring the research gaps and role of the Knowledge-to-Action Framework; (3) investigating methodological approaches for KT research; and (4) experiencing a supportive training environment. Participation in the problem-based case study allowed participants to expand their individual understanding of KT, while fostering the learning experiences of other group members. In a supportive learning environment, participants were able to identify influential stakeholders for the stroke response protocol implementation, discuss potential barriers by stakeholder group, and consider effective KT interventions. Future training initiatives focusing on strengthening KT capacity and knowledge should consider using small-group problem-based case study to facilitate learning.

Primary care characteristics and population-orientated health care across Europe: an observational study

BACKGROUND

The number of patients with chronic diseases is increasing which poses a challenge to healthcare organisations. A proactive, structured, and population-orientated approach is needed: the chronic care model (CCM) provides such a framework.

AIM

To assess organisational conditions for providing structured chronic care according to the CCM across different healthcare systems.

DESIGN OF STUDY

International observational study.

SETTING

A stratified sample of 315 primary care practices in 10 European countries and Israel in 2008 and 2009.

METHOD

Practice questionnaires and interviews. Outcome measures were mean practice scores on CCM domains per country, as a percentage of the maximum score, and the influence of practice size and urbanisation on these scores.

RESULTS

Practice size showed large differences with the largest practices in Spain, England, Finland, and Israel. These countries, with a strong primary care orientation, had most physicians and staff involved per practice. The CCM domains 'clinical information systems' and 'decision support' had total practice means of 90%; other domains scored about 50%. Spain and England scored above average on almost all domains. Practice size and urbanisation had little impact.

CONCLUSION

Characteristics for chronic care delivery differed for most CCM domains. The most common characteristics related to computerisation, providing a good starting point and high potential everywhere. All countries showed room for improvement. Further research should focus on relations between practice characteristics, organisational features, including health system and primary care orientation, and outcomes. Primary care seems suited for chronic care delivery; however, a stronger primary care was associated with better scores.

Knowledge translation research: the science of moving research into policy and practice

Research findings will not change health outcomes unless health care organizations, systems, and professionals adopt them in practice. Knowledge translation research is the scientific study of the methods to promote the uptake of research findings by patients, health care providers, managers, and policy makers. Many forms of enquiry addressing different questions are needed to develop the evidence base for knowledge translation. In this paper we will present a description of the broad scope of knowledge translation research with a reflection on activities needed to further develop the science of knowledge translation. Consideration of some of the shared research challenges facing the fields of knowledge translation and continuing professional development will also be presented.

Perceived need for mental health care and barriers to care in the Netherlands and Australia

PURPOSE

This study of Australian and Dutch people with anxiety or depressive disorder aims to examine people's perceived needs and barriers to care, and to identify possible similarities and differences.

METHODS

Data from the Australian National Survey of Mental Health and Well-Being and the Netherlands Study of Depression and Anxiety were combined into one data set. The Perceived Need for Care Questionnaire was taken in both studies. Logistic regression analyses were performed to check if similarities or differences between Australia and the Netherlands could be observed.

RESULTS

In both countries, a large proportion had unfulfilled needs and self-reliance was the most frequently named barrier to receive care. People from the Australian sample (N = 372) were more likely to perceive a need for medication (OR 1.8; 95% CI 1.3-2.5), counselling (OR 1.4; 95% CI 1.0-2.0) and practical support (OR 1.8; 95% CI 1.2-2.7), and people's overall needs in Australia were more often fully met compared with those of the Dutch sample (N = 610). Australians were more often pessimistic about the helpfulness of medication (OR 3.8; 95% CI 1.4-10.7) and skills training (OR 3.0; 95% CI 1.1-8.2) and reported more often financial barriers for not having received (enough) information (OR 2.4; 95% CI 1.1-5.5) or counselling (OR 5.9; 95% CI 2.9-11.9).

CONCLUSIONS

In both countries, the vast majority of mental health care needs are not fulfilled. Solutions could be found in improving professionals' skills or better collaboration. Possible explanations for the found differences in perceived need and barriers to care are discussed; these illustrate the value of examining perceived need across nations and suggest substantial commonalities of experience across the two countries.

AMDIS Case Conference: Implementing Electronic Health Records in a Small Subspecialty Practice

Electronic health record adoption has failed to achieve critical mass in small private practices in no small part due to lack of leadership; the challenge of cultural change; and the difficulty of adapting to new automated workflows. We present one small practice that successfully navigated these obstacles, and examine its accomplishments through the lens of organizational psychology.

CPD and KT: models used and opportunities for synergy

The two fields of continuing professional development (CPD) and knowledge translation (KT) within the health care sector, and their related research have developed as somewhat parallel paths with limited points of overlap or intersection. This is slowly beginning to change. The purpose of this paper is to describe and compare the dominant conceptual models informing each field with the view of increasing understanding and appreciation of the two fields, how they are similar and where they differ, and the current and potential points of intersection. The models include the "knowledge-to-action'' (KTA) cycle informing KT, models informing CPD curriculum design and individual self-directed learning, and the Kirkpatrick model for evaluating educational outcomes. When compared through the perspectives of conceptual designs, processes, and outcomes, the models overlap. We also identify shared gaps in both fields (eg, the need to explore the influence of the context in which CPD and KT interventions take place) and suggest opportunities for synergies and for moving forward.

Mixed method designs in implementation research

This paper describes the application of mixed method designs in implementation research in 22 mental health services research studies published in peer-reviewed journals over the last 5 years. Our analyses revealed 7 different structural arrangements of qualitative and quantitative methods, 5 different functions of mixed methods, and 3 different ways of linking quantitative and qualitative data together. Complexity of design was associated with number of aims or objectives, study context, and phase of implementation examined. The findings provide suggestions for the use of mixed method designs in implementation research.

Public health: disconnections between policy, practice and research

BACKGROUND

Public health includes policy, practice and research but to sufficiently connect academic research, practice and public health policy appears to be difficult. Collaboration between policy, practice and research is imperative to obtaining more solid evidence in public health. However, the three domains do not easily work together because they emanate from three more or less independent 'niches'.Work cycles of each niche have the same successive steps: problem recognition, approach formulation, implementation, and evaluation, but are differently worked out. So far, the research has focused on agenda-setting which belongs to the first step, as expressed by Kingdon, and on the use of academic knowledge in policy makers' decision-making processes which belongs to the fourth step, as elaborated by Weiss. In addition, there are more steps in the policy-making process where exchange is needed.

METHOD

A qualitative descriptive research was conducted by literature search. We analyzed the four steps of the policy, practice and research work cycles. Next, we interpreted the main conflicting aspects as disconnections for each step.

RESULTS

There are some conspicuous differences that strengthen the niche character of each domain and hamper integration and collaboration. Disconnections ranged from formulating priorities in problem statements to power roles, appraisal of evidence, work attitudes, work pace, transparency of goals, evaluation and continuation strategies and public accountability. Creating awareness of these disconnections may result in more compatibility between researchers, policy makers and practitioners.

CONCLUSION

We provide an analysis that can be used by public health services-related researchers, practitioners and policy makers to be aware of the risk for disconnections. A synthesis of the social, practical and scientific relevance of public health problems should be the starting point for a dialogue that seeks to establish a joint approach. To overcome the above mentioned disconnections, face-to-face encounters consistently emerge as the most efficient way to transfer knowledge, achieve higher quality and acknowledge mutual dependence. We recommend practice and policy based research networks to establish strong links between researchers, policy makers and practitioners to improve public health.