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Golden RE, Sanders AM, Frayne SM. RE-AIM applied to a primary care workforce training for rural providers and nurses: the Department of Veterans Affairs' Rural Women's Health Mini-Residency. FRONTIERS IN HEALTH SERVICES 2023; 3:1205521. [PMID: 38028946 PMCID: PMC10656764 DOI: 10.3389/frhs.2023.1205521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction Application of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate workforce education and training programs targeting clinical health care staff has received relatively little attention. This paper aims to contribute to this area with RE-AIM findings from a women's health-focused workforce training program implemented by the U.S. Department of Veterans Affairs (VA). Over the past two decades, the rapid expansion of the women Veteran population in VA has necessitated a quick response to meet clinical demand. To address this health care need, the VA Offices of Rural Health (ORH) and Women's Health (OWH) partnered to deploy a primary care workforce development initiative for Rural Providers and Nurses-the Rural Women's Health Mini-Residency (Rural WH-MR)-to train VA clinicians in rural locations in skills for the care of women Veterans. Here we assess the applicability of RE-AIM as an evaluation framework in this context. Methods We evaluated the Rural WH-MR, relying on a primarily quantitative approach, rooted in RE-AIM. It included longitudinal and cross-sectional measurements from multiple quantitative and qualitative data sources to develop selected metrics. Data collection instruments consisted of pre-, post-, and follow-up training surveys, course evaluations, existing VA databases, and implementation reports. We developed metrics for and assessed each RE-AIM component by combining data from multiple instruments and then triangulating findings. Results Results from the Rural WH-MR program for fiscal years 2018-2020 indicate that RE-AIM provides an instructive evaluation framework for a rural workforce training program, particularly in eliciting clarity between measures of Reach vs. Adoption and focusing attention on both provider- and patient-level outcomes. Discussion We describe evaluation metric development and barriers to and facilitators of utilizing RE-AIM as an evaluation framework for a provider- and nurse-facing intervention such as this workforce training program. We also reflect upon RE-AIM benefits for highlighting process and outcomes indicators of a training program's success and lessons learned for evaluating rural workforce development innovations. Several of our observations have implications for training and evaluation approaches in rural areas with more limited access to health care services.
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Affiliation(s)
- Rachel E. Golden
- United States Department of Veterans Affairs, HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Veterans Health Administration, Palo Alto, CA, United States
| | - Aimee M. Sanders
- US Department of Veterans Affairs, Office of Women’s Health, Washington, DC, United States
| | - Susan M. Frayne
- United States Department of Veterans Affairs, HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Veterans Health Administration, Palo Alto, CA, United States
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, United States
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Dworatzek PDN, Mori M, Mellet S. Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study. Can J Diabetes 2023; 47:482-489. [PMID: 37060941 DOI: 10.1016/j.jcjd.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/14/2023] [Accepted: 04/08/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVES Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements. METHODS A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted. RESULTS Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs. CONCLUSIONS Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.
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Affiliation(s)
- Paula D N Dworatzek
- School of Food and Nutritional Sciences, Brescia University College at Western University, London, Ontario, Canada; Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Marilyn Mori
- School of Food and Nutritional Sciences, Brescia University College at Western University, London, Ontario, Canada
| | - Savannah Mellet
- School of Food and Nutritional Sciences, Brescia University College at Western University, London, Ontario, Canada
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Wang W, Choi D, Yu CH. Effective web-based clinical practice guidelines resources: recommendations from a mixed methods usability study. BMC PRIMARY CARE 2023; 24:29. [PMID: 36694137 PMCID: PMC9872348 DOI: 10.1186/s12875-023-01974-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPG) are an important knowledge translation resource to help clinicians stay up to date about relevant clinical knowledge. Effective communication of guidelines, including format, facilitates its implementation. Despite the digitalization of healthcare, there is little literature to guide CPG website creation for effective dissemination and implementation. Our aim was to assess the effectiveness of the content and format of the Diabetes Canada CPG website, and use our results to inform recommendations for other CPG websites. METHODS Fourteen clinicians (family physicians, nurses, pharmacists, and dieticians) in diabetes care across Canada participated in this mixed-methods study (questionnaires, usability testing and interviews). Participants "thought-aloud" while completing eight usability tasks on the CPG website. Outcomes included task success rate, completion time, click per tasks, resource used, paths, search attempts and success rate, and error types. Participants were then interviewed. RESULTS The Diabetes Canada CPG website was found to be usable. Participants had a high task success rate of 79% for all tasks and used 144 (standard deviation (SD) = 152) seconds and 4.6 (SD = 3.9) clicks per task. Interactive tools were most frequently used compared to full guidelines and static tools. Misinterpretation accounted for 48% of usability errors. Participants overall found the website intuitive, with effective content and design elements. CONCLUSION Different versions of CPG information (e.g. interactive tools, quick reference guide, static tools) can help answer clinical questions more quickly. Effective web design should be assessed during CPG website creation for effective guideline dissemination and implementation.
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Affiliation(s)
- Wei Wang
- grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada
| | - Dorothy Choi
- grid.415502.7Li Ka Shing Knowledge Institute of St. Michael’s Hospital (Unity Health Toronto), 30 Bond Street, Toronto, ON M5B 1W8 Canada
| | - Catherine H. Yu
- grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada ,grid.415502.7Li Ka Shing Knowledge Institute of St. Michael’s Hospital (Unity Health Toronto), 30 Bond Street, Toronto, ON M5B 1W8 Canada
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Milder TY, Stocker SL, Baysari M, Day RO, Greenfield JR. Prescribing of SGLT2 inhibitors in primary care: A qualitative study of General Practitioners and Endocrinologists. Diabetes Res Clin Pract 2021; 180:109036. [PMID: 34481911 DOI: 10.1016/j.diabres.2021.109036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/21/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023]
Abstract
AIMS To explore: 1) General Practitioners' (GPs') perspectives regarding initiating SGLT2 inhibitors and the resources that inform their pharmacotherapy choices; and 2) The support provided to GPs by Endocrinologists in relation to the prescription of type 2 diabetes medications. METHODS Semi-structured interviews with 15 GPs and 12 Endocrinologists working in diverse areas in New South Wales, Australia. Interviews were recorded, transcribed, and emergent themes were identified using a general inductive approach. RESULTS Under-appreciation of the cardio-renal benefits of SGLT2 inhibitors, a preference for an Endocrinologist to initiate therapy, and patients' experiences with adverse effects were identified as reasons for low rates of initiating SGLT2 inhibitors by some GPs. GPs reported that they would like to receive education about this topic from Endocrinologists, ideally via case-based discussions. A perceived challenge faced by Endocrinologists in providing GP education included potential constraints on talk content imposed by industry at sponsored events. Endocrinologists indicated that interactive sessions were most useful to GPs. CONCLUSIONS Despite the evidence for the cardio-renal benefits of SGLT2 inhibitors, there are barriers to GPs prescribing these agents. Case-based discussions between GPs and Endocrinologists about type 2 diabetes treatment including the role of SGLT2 inhibitors could overcome some of these barriers.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Diabetes and Metabolism, Garvan Institute of Medical Research, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia.
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, 2006, Australia
| | - Melissa Baysari
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, 2006, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Victoria St, Darlinghurst, Sydney 2010, Australia; Diabetes and Metabolism, Garvan Institute of Medical Research, Victoria St, Darlinghurst, Sydney 2010, Australia; St. Vincent's Clinical School, Faculty of Medicine and Health, University of NSW, Victoria St, Darlinghurst, Sydney, Australia
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Lega IC, Campitelli MA, Austin PC, Na Y, Zahedi A, Leung F, Yu C, Bronskill SE, Rochon PA, Lipscombe LL. Potential diabetes overtreatment and risk of adverse events among older adults in Ontario: a population-based study. Diabetologia 2021; 64:1093-1102. [PMID: 33491105 DOI: 10.1007/s00125-020-05370-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/05/2020] [Indexed: 01/17/2023]
Abstract
AIMS/HYPOTHESIS More than 25% of older adults (age ≥75 years) have diabetes and may be at risk of adverse events related to treatment. The aim of this study was to assess the prevalence of intensive glycaemic control in this group, potential overtreatment among older adults and the impact of overtreatment on the risk of serious events. METHODS We conducted a retrospective, population-based cohort study of community-dwelling older adults in Ontario using administrative data. Participants were ≥75 years of age with diagnosed diabetes treated with at least one anti-hyperglycaemic agent between 2014 and 2015. Individuals were categorised as having intensive or conservative glycaemic control (HbA1c <53 mmol/mol [<7%] or 54-69 mmol/mol [7.1-8.5%], respectively), and as undergoing treatment with high-risk (i.e. insulin, sulfonylureas) or low-risk (other) agents. We measured the composite risk of emergency department visits, hospitalisations, or death within 30 days of reaching intensive glycaemic control with high-risk agents. RESULTS Among 108,620 older adults with diagnosed diabetes in Ontario, the mean (± SD) age was 80.6 (±4.5) years, 49.7% were female, and mean (± SD) diabetes duration was 13.7 (±6.3) years. Overall, 61% of individuals were treated to intensive glycaemic control and 21.6% were treated to intensive control using high-risk agents. Using inverse probability treatment weighting with propensity scores, intensive control with high-risk agents was associated with nearly 50% increased risk of the composite outcome compared with conservative glycaemic control with low-risk agents (RR 1.49, 95% CI 1.08, 2.05). CONCLUSIONS/INTERPRETATION Our findings underscore the need to re-evaluate glycaemic targets in older adults and to reconsider the use of anti-hyperglycaemic medications that may lead to hypoglycaemia, especially in setting of intensive glycaemic control.
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Affiliation(s)
- Iliana C Lega
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada.
- ICES, Toronto, ON, Canada.
| | | | | | - Yingbo Na
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Afshan Zahedi
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Freda Leung
- Scarborough and Rouge Hospital, Toronto, ON, Canada
| | - Catherine Yu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Susan E Bronskill
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lorraine L Lipscombe
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
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Nichols J, Mamdani M, Gomes T, Shah BR, Casey CG, Yu CH. Impact of Clinical Practice Guidelines on Blood Glucose Test Strip Prescription Rates in Manitoba and Saskatchewan (Canada): An Interrupted Time-Series Analysis. Can J Diabetes 2020; 45:557-565.e2. [PMID: 33558147 DOI: 10.1016/j.jcjd.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/09/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Our aim in this study was to assess the impact of the Diabetes Canada Dissemination & Implementation strategy on population-level prescription rates of blood glucose test strips. METHODS We extracted all diabetes-related drugs and test strip claims in Manitoba and Saskatchewan between January 1, 2000 and September 30, 2015 from the Canadian Institute for Health Information's National Prescription Drug Utilization Information System. The primary outcome was the proportion of the cohort in each quarter who had been dispensed strips in accordance with the Diabetes Canada 2013 guidelines. We conducted an interrupted time-series analysis examining prescribing trends overall and by drug groups. RESULTS The overall average sample size per quarter was 57,576 (standard deviation [SD]=12,320) and 49,533 (SD=10,206) individuals; the average age was 62.1 (SD=0.3) and 63.8 (SD=0.3) years, and the average proportion of total beneficiaries in the sample was 12.7% (SD=1.9%) and 12.6% (SD=1.7%) for Manitoba and Saskatchewan, respectively. On average preintervention, 27.9% (SD=0.68%, Manitoba) and 31.9% (SD=0.73%, Saskatchewan) of the sampled patients used strips according to the guidelines. On average postintervention, 26.5% (SD=0.29%, Manitoba) and 30.6% (SD=0.53%, Saskatchewan) of the patients used strips according to the guidelines. None of the interrupted time-series models reached statistical significance (p values ranging from 0.44 to 0.98 for Manitoba and 0.13 to 0.81 for Saskatchewan, depending on drug group). CONCLUSIONS The guideline and its Dissemination & Implementation strategy did not change strip prescribing. Potential reasons include complexity of the recommendations, lack of penetrance to primary care physicians and/or disagreement with recommendations.
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Affiliation(s)
| | - Muhammad Mamdani
- Unity Health Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada, ICES, Toronto, Ontario, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Unity Health Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada, ICES, Toronto, Ontario, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Baiju R Shah
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Catherine H Yu
- Diabetes Canada, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
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Alharbi NS, Alanazi MA. Perceptions of health care professionals towards clinical practice guidelines: The case of Diabetes Mellitus in Saudi Arabia. Prim Care Diabetes 2020; 14:605-609. [PMID: 32057724 DOI: 10.1016/j.pcd.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/24/2020] [Accepted: 02/03/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Clinical practice guidelines are developed by healthcare policy makers and disseminated to practitioners in order to minimize practice variations and to improve the quality of care. Problems arise when there is a sole reliance on passive dissemination strategies such as mailing or publishing the guidelines, as these approaches do not usually lead to the adoption. OBJECTIVE This study aims to explore the perspectives of the health care professionals toward the Saudi National Diabetes Guidelines in terms of awareness, adherence and their preferred dissemination and implementation strategies of the guideline. METHOD A cross-sectional survey was conducted among physicians and nurses working in twenty primary health care centers in the city of Riyadh between February and March 2019. RESULTS Nearly half of the total 179 respondents reported that they were unaware of the guidelines (49.1%), and 92% of the remaining 91 participants who were aware of the guideline reported that they had first heard about it through their official mail. The mean scores ranked according to the most preferred methods for disseminating and implementing the diabetes guidelines were as follows: via reminder systems 4.35±0.74, financial incentives 4.33±0.65, and audit and feedback 4.27±0.58. On the other hand, the least favorable strategies were traditional education 3.79±0.96 and the distribution of the guideline by mail 3.13±0.95. CONCLUSION The level of awareness of the diabetes guidelines among the primary health care professionals was suboptimal. This was more likely due to the Ministry of Health's reliance on passive implementation strategies. In order to have the guidelines translated into clinical practice, active and targeted implementation strategies such as reminder systems, audit and feedback must be considered by the Saudi health policy makers.
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Affiliation(s)
- Nouf Sahal Alharbi
- Department of Health Sciences, Collage of Applied Studies and Community Service, King Saud University, Riyadh, Saudi Arabia
| | - Musaad Alnashmi Alanazi
- Department of hospital and health administration, Collage of Business Administration, King Saud University, Saudi Arabia.
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Impact of a Comprehensive Guideline Dissemination Strategy on Diabetes Diagnostic Test Rates: an Interrupted Time Series. J Gen Intern Med 2020; 35:2662-2667. [PMID: 32157647 PMCID: PMC7458977 DOI: 10.1007/s11606-020-05747-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/10/2020] [Accepted: 02/13/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Diabetes Canada launched a comprehensive Dissemination and Implementation (D&I) strategy to optimize uptake of their 2013 Clinical Practice Guidelines; the strategy involved continuing professional development courses, webinars, an interactive website, applications for mobile devices, point-of-care decision support tools, and media awareness campaigns. It included a focus on promoting HbA1c as the recommended diagnostic test for diabetes. OBJECTIVE To determine the impact of Diabetes Canada's 2013 D&I strategy on physician test-ordering behavior, specifically HbA1c testing, for the diagnosis of diabetes, using provincial healthcare administrative data. DESIGN Population-based interrupted time series. SETTING Ontario, Canada. PARTICIPANTS Ontario residents aged 40-79 not previously diagnosed with diabetes. MEASUREMENTS For each quarter between January 2005 and December 2014, we conducted an interrupted time series analysis on the first-order difference of the proportion of patients receiving HbA1c tests per quarter with an autoregressive integrated moving average model with the intervention step occurring in quarter 2 of 2013. Subgroup analyses by rurality, physician graduation year, and practice size were also conducted. RESULTS There were 32 quarters pre-intervention and 6 post-intervention; average sample size per quarter was 5,298,686 individuals. Pre-intervention, the quarter-to-quarter growth was 1.51 HbA1c tests per quarter per 1000 people. Post-intervention, the quarter-to-quarter growth increased by 8.45 tests per 1000 people (p < 0.005). Growth of HbA1c ordering differed significantly by region, years since physician graduation, and practice size. LIMITATIONS Incomplete data collection, inadequate stratification, and other unidentified confounders. CONCLUSION The D&I strategy resulted in a significant increase in the growth of HbA1c tests. The successful uptake of this recommendation may be due to its simplicity; guideline developers should consider this when drafting recommendations. Furthermore, differential uptake by user groups suggests that future strategies should include targeted barrier analysis and interventions to these groups.
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Environmental Scan on Canadian Interactive Knowledge Translation Tools to Prevent Diabetes Complications in Patients With Diabetes. Can J Diabetes 2020; 45:97-104.e2. [PMID: 33046403 DOI: 10.1016/j.jcjd.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/30/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022]
Abstract
In this study, we identify existing interactive knowledge translation tools that could help patients and health-care professionals to prevent diabetes complications in the Canadian context. We conducted an environmental scan in collaboration with researchers and 4 patient partners across Canada. We conducted searches among the research team members, their networks and Twitter, and through searches in databases and Google. To be included, interactive knowledge translation tools had to meet the following criteria: used to prevent diabetes complications; used in a real-life setting; used any instructional method or material; had relevance in the Canadian context, written in English or French; developed and/or published by experts in diabetes complications or by a recognized organization; created in 2013 or after; and accessibility online or on paper. Two reviewers independently screened each record for selection and extracted the following data: authorship, objective(s), patients' characteristics, type of diabetes complications targeted, type of knowledge users targeted and tool characteristics. We used simple descriptive statistics to summarize our results. Thirty-one of the 1,700 potentially eligible interactive knowledge translation tools were included in the scan. Tool formats included personal notebook, interactive case study, risk assessment tool, clinical pathway, decision support tool, knowledge quiz and checklist. Diabetes complications targeted by the tools included foot-related neuropathy, cardiovascular diseases, mental disorders and distress and any complications related to diabetes and kidney disease. Our results inform Canadian stakeholders interested in the prevention of diabetes complications to avoid unnecessary duplication, identify gaps in knowledge and support implementation of these tools in clinical and patients' decision-making.
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Thompson S, Johnson D, Lindgren T, Compton L, Chen JL. Clinical practice guideline for primary care providers in the management of antidepressant-induced hyperhidrosis: A quality improvement project. J Am Assoc Nurse Pract 2020; 33:1080-1086. [PMID: 32773537 DOI: 10.1097/jxx.0000000000000478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antidepressant-induced excessive sweating (ADIES) is a side effect that occurs in approximately 22% of patients taking antidepressant medications and can negatively affect patient medication adherence. LOCAL PROBLEM Primary care providers may not have adequate knowledge of ADIES management. The aims of this project were to increase primary care provider's overall perceived knowledge related to ADIES, improve confidence in the management of ADIES, and gather input on the perceived usefulness of the initial clinical practice guideline (CPG) for ADIES management. METHODS This quality improvement (QI) project consisted of two phases. Phase 1 included the development of a CPG for the pharmacologic management of ADIES based on processes recommended by the Institute of Medicine. INTERVENTIONS Phase 2 of the project consisted of a pretest-posttest design pilot of the guideline via a "Lunch and Learn" educational session at a Federally Qualified Health Care Center located in the Northern California. RESULTS The results indicated that after exposure to the CPG and participation in the educational program about the guideline, there was an overall significant improvement in provider knowledge and confidence about identification and management of ADIES in their practice. CONCLUSIONS Although small in scope, this QI project provides important avenues for further implementation and dissemination of the guideline to manage ADIES. The potential for improved patient care and medication adherence support the usefulness of the implementation of this guideline in other locations.
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Affiliation(s)
- Summer Thompson
- Department of Community Health Systems, University of California, San Francisco, California
| | - Deborah Johnson
- Department of Community Health Systems, University of California, San Francisco, California
| | - Teri Lindgren
- Department of Community Health Systems, University of California, San Francisco, California
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Kim JO, Hanumanthappa N, Chung YT, Beck J, Koul R, Bashir B, Cooke A, Dubey A, Butler J, Nashed M, Hunter W, Ong A. Does dissemination of guidelines alone increase the use of palliative single-fraction radiotherapy? Initial report of a longitudinal change management campaign at a provincial cancer program. Curr Oncol 2020; 27:190-197. [PMID: 32905177 PMCID: PMC7467795 DOI: 10.3747/co.27.6193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Despite level 1 evidence demonstrating the equivalence of single-fraction radiotherapy (sfrt) and multiple-fraction radiotherapy (mfrt) for the palliation of painful bone metastases, sfrt remains underused. In 2015, to encourage the sustainable use of palliative radiation oncology resources, CancerCare Manitoba disseminated, to each radiation oncologist in Manitoba, guidelines from Choosing Wisely Canada (cwc) that recommend sfrt. We assessed whether dissemination of the guidelines influenced sfrt use in Manitoba in 2016, and we identified factors associated with mfrt. Methods All patients treated with palliative radiotherapy for bone metastasis in Manitoba from 1 January 2016 to 31 December 2016 were identified from the provincial radiotherapy database. Patient, treatment, and disease characteristics were extracted from the electronic medical record and tabulated by fractionation schedule. Univariable and multivariable logistic regression analyses were performed to identify risk factors associated with mfrt. Results In 2016, 807 patients (mean age: 70 years; range: 35-96 years) received palliative radiotherapy for bone metastasis, with 69% of the patients having uncomplicated bone metastasis. The most common primary malignancies were prostate (27.1%), lung (20.6%), and breast cancer (15.9%). In 62% of cases, mfrt was used-a proportion that was unchanged from 2015. On multivariable analysis, a gastrointestinal [odds ratio (or): 5.3] or lung primary (or: 3.3), complicated bone metastasis (or: 4.3), and treatment at a subsidiary site (or: 4.4) increased the odds of mfrt use. Conclusions Dissemination of cwc recommendations alone did not increase sfrt use by radiation oncologists in 2016. A more comprehensive knowledge translation effort is therefore warranted and is now underway to encourage increased uptake of sfrt in Manitoba.
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Affiliation(s)
- J O Kim
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | | | - Y T Chung
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg
| | - J Beck
- Medical Physics, CancerCare Manitoba, Winnipeg
| | - R Koul
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - B Bashir
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - A Cooke
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - A Dubey
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - J Butler
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - M Nashed
- Radiation Oncology, CancerCare Manitoba, Winnipeg
| | - W Hunter
- Radiation Oncology, Western Manitoba Cancer Centre, Brandon, MB
| | - A Ong
- Radiation Oncology, CancerCare Manitoba, Winnipeg
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Greiver M, Kalia S, Moineddin R, Chen S, Duchen R, Rigobon A. Impact of the diabetes Canada guideline dissemination strategy on dispensed vascular protective medications for older patients in Ontario, Canada: a linked EMR and administrative data study. BMC Health Serv Res 2020; 20:370. [PMID: 32357891 PMCID: PMC7195730 DOI: 10.1186/s12913-020-05232-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The 2013 Diabetes Canada guidelines recommended routinely using vascular protective medications for most patients with diabetes. These medications included statins and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). Antiplatelet agents were only recommended for secondary prevention of cardiovascular disease. Using Electronic Medical Record (EMR) data, we previously found that guideline dissemination efforts were not associated with an increase in the rate of primary care prescriptions of these medications. However, this needs confirmation: patients can receive prescriptions from different sources including specialists and they may not always fill these prescriptions. Using both EMR and administrative health data, we examined whether guideline dissemination impacted the dispensing of vascular protective medications to patients. METHODS The study population included patients with diabetes aged 66 or over in Ontario, Canada. We created two cohorts using two different approaches: an Electronic Medical Record (EMR) algorithm for diabetes using linked EMR-administrative data and an administrative algorithm using population level administrative data. We examined data from January 2010 to December 2016. Patients with diabetes were deemed to be likely taking a medication (or covered) during a quarter if the daily amount for a dispensed medication would last for at least 75% of days in any given quarter. An interrupted time series analysis was used to assess the proportion of patients covered by each medication class. Proton pump inhibitors (PPIs) were used as a reference. RESULTS There was no increase in the rate of change for medication coverage following guideline release in either the EMR or the administrative diabetes cohorts. For statins, the change in trend was - 0.03, p = 0.7 (EMR) and - 0.12, p = 0.04(administrative). For ACEI/ARBs, this was 0.03, p = 0.6 (EMR) and 0, p = 1(administrative). For antiplatelets, this was 0.001, P = .97 (EMR) and - 0.03, p = 0.03 (administrative). The comparator PPI was - 0.07, p = 0.4 (EMR) and - 0.11, p = 0.002 (administrative). CONCLUSIONS Using both EMR and administrative health data, we confirmed that the Diabetes Canada 2013 guideline dissemination strategy did not lead to an increased rate of coverage for vascular protective medications. Alternative strategies are needed to effect change in practice.
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Affiliation(s)
- Michelle Greiver
- Gordon F. Cheesbrough Chair in Family and Community Medicine Research, North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
- ICES, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Sumeet Kalia
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
- ICES, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
| | - Simon Chen
- ICES, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
| | - Raquel Duchen
- ICES, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada
| | - Alanna Rigobon
- Faculty of Medicine, University of Toronto, 1 King’s College Cir, Toronto, Ontario M5S 1A8 Canada
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Levis-Peralta M, González MDR, Stalmeijer R, Dolmans D, de Nooijer J. Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review. Front Endocrinol (Lausanne) 2020; 11:352. [PMID: 32760344 PMCID: PMC7375199 DOI: 10.3389/fendo.2020.00352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/05/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Team-based care models (TBC) have demonstrated effectiveness to improve health outcomes for vulnerable diabetes patients but have proven difficult to implement in low income settings. Organizational conditions have been identified as influential on the implementation of TBC. This scoping review aims to answer the question: What is known from the scientific literature about how organizational conditions enable or inhibit TBC for diabetic patients in primary care settings, particularly settings that serve low-income patients? Methods: A scoping review study design was selected to identify key concepts and research gaps in the literature related to the impact of organizational conditions on TBC. Twenty-six articles were finally selected and included in this review. This scoping review was carried out following a directed content analysis approach. Results: While it is assumed that trained health professionals from diverse disciplines working in a common setting will sort it out and work as a team, co-location, and health professions education alone do not improve patient outcomes for diabetic patients. Health system, organization, and/or team level factors affect the way in which members of a care team, including patients and caregivers, collaborate to improve health outcomes. Organizational factors span across seven categories: governance and policies, structure and process, workplace culture, resources, team skills and knowledge, financial implications, and technology. These organizational factors are cited throughout the literature as important to TBC, however, research on the organizational conditions that enable and inhibit TBC for diabetic patients is extremely limited. Dispersed organizational factors are cited throughout the literature, but only one study specifically assesses the effect of organizational factors on TBC. Thematic analysis was used to categorize organizational factors in the literature about TBC and diabetes and a framework for analysis and definitions for key terms is presented. Conclusions: The review identified significant gaps in the literature relating to the study of organizational conditions that enable or inhibit TBC for low-income patients with diabetes. Efforts need to be carried out to establish unifying terminology and frameworks across the field to help explain the relationship between organizational conditions and TBC for diabetes. Gaps in the literature include research be based on organizational theories, research carried out in low-income settings and low and middle income countries, research explaining the difference between the organizational conditions that impact the implementation of TBC vs. maintaining or sustaining TBC and the interaction between organizational factors at the micro, meso and macro level and their impact on TBC. Few studies include information on patient outcomes, and fewer include information on low income settings. Further research is necessary on the impact of organizational conditions on TBC and diabetic patient outcomes.
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Affiliation(s)
| | | | - Renée Stalmeijer
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Jascha de Nooijer
- Department of Health Promotion, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
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14
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Process Evaluation of the Diabetes Canada Guidelines Dissemination Strategy Using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) Framework. Can J Diabetes 2019; 43:263-270.e9. [DOI: 10.1016/j.jcjd.2018.08.189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/21/2018] [Accepted: 08/07/2018] [Indexed: 12/21/2022]
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Rigobon AV, Kalia S, Nichols J, Aliarzadeh B, Greiver M, Moineddin R, Sullivan F, Yu C. Impact of the Diabetes Canada Guideline Dissemination Strategy on the Prescription of Vascular Protective Medications: A Retrospective Cohort Study, 2010-2015. Diabetes Care 2019; 42:148-156. [PMID: 30389671 DOI: 10.2337/dc18-0935] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 10/04/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The 2013 Diabetes Canada guidelines launched targeted dissemination tools and a simple assessment for vascular protection. We aimed to 1) examine changes associated with the launch of the 2013 guidelines and additional dissemination efforts in the rates of vascular protective medications prescribed in primary care for older patients with diabetes and 2) examine differences in the rates of prescriptions of vascular protective medications by patient and provider characteristics. RESEARCH DESIGN AND METHODS The study population included patients (≥40 years of age) from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) with type 2 diabetes and at least one clinic visit from April 2010 to December 2015. An interrupted time series analysis was used to assess the proportion of eligible patients prescribed a statin, ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB), or antiplatelet prescription in each quarter. Proton pump inhibitor (PPI) prescriptions were the reference control. RESULTS A dynamic cohort was used where participants were enrolled each quarter using a prespecified set of conditions (range 25,985-70,693 per quarter). There were no significant changes in statin (P = 0.43), ACEI/ARB (P = 0.42), antiplatelet (P = 0.39), or PPI (P = 0.16) prescriptions at baseline (guideline intervention). After guideline publication, there was a significant change in slope for statin (-0.52% per quarter, SE 0.15, P < 0.05), ACEI/ARB (-0.38% per quarter, SE 0.13, P < 0.05), and reference PPI (-0.18% per quarter, SE 0.05, P < 0.05) prescriptions. CONCLUSIONS There was a decrease in prescribing trends over time that was not specific to vascular protective medications. More effective knowledge translation strategies are needed to improve vascular protection in diabetes in order for patients to receive the most effective interventions.
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Affiliation(s)
- Alanna V Rigobon
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sumeet Kalia
- University of Toronto Practice-Based Research Network, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennica Nichols
- Diabetes Canada, Toronto, Ontario, Canada.,Interdisciplinary Studies, University of British Columbia, Vancouver, British Columbia, Canada
| | - Babak Aliarzadeh
- University of Toronto Practice-Based Research Network, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Greiver
- University of Toronto Practice-Based Research Network, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,North York General Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- University of Toronto Practice-Based Research Network, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Sullivan
- University of Toronto Practice-Based Research Network, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,North York General Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada.,Medical School, University of St Andrews, St Andrews, Scotland, U.K
| | - Catherine Yu
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada .,Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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