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Djandji F, Lamontagne AJ, Blais L, Bacon SL, Ernst P, Grad R, Lavoie KL, McKinney ML, Desplats E, Ducharme FM. Enablers and determinants of the provision of written action plans to patients with asthma: a stratified survey of Canadian physicians. NPJ Prim Care Respir Med 2017; 27:21. [PMID: 28364118 PMCID: PMC5434790 DOI: 10.1038/s41533-017-0012-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/12/2016] [Accepted: 01/06/2017] [Indexed: 11/09/2022] Open
Abstract
Despite national recommendations, most patients with asthma are not given a written action plan . The objectives were to ascertain physicians' endorsement of potential enablers to providing a written action plan, and the determinants and proportion, of physician-reported use of a written action plan. We surveyed 838 family physicians, paediatricians, and emergency physicians in Quebec. The mailed questionnaire comprised 102 questions on asthma management, 11 of which pertained to written action plan and promising enablers. Physicians also selected a case vignette that best corresponded to their practice and reported their management. The survey was completed by 421 (56%) physicians (250 family physicians, 115 paediatricians and 56 emergency physicians); 43 (5.2%) reported providing a written action plan to ≥70% of their asthmatic patients and 126 (30%) would have used a written action plan in the selected vignette. Most (>60%) physicians highly endorsed the following enablers: patients requesting a written action plan, adding a blank written action plan to the chart, receiving a copy of the written action plan completed by a consultant, receiving a monetary compensation for its completion, and having another healthcare professional explain the completed written action plan to patients. Four determinants were significantly associated with providing a written action plan: being a paediatrician (RR:2.1), treating a child (RR:2.0), aiming for long-term asthma control (RR:2.5), and being aware of national recommendations to provide a written action plan to asthmatic patients (RR:2.9). A small minority of Quebec physicians reported providing a written action plan to most of their patients, revealing a huge care gap. Several enablers to improve uptake, highly endorsed by physicians, should be prioritised in future implementation efforts. ASTHMA ENCOURAGING DOCTORS TO PROVIDE WRITTEN ACTION PLANS: Changes to practice organization and doctors' perceptions should encourage the provision of written action plans for all asthma patients. International guidelines state that effective long-term treatment of asthma requires educated self-management, regular reviews and provision of a written action plan (WAP). However, many patients have poor asthma control and as few as 30 per cent have a WAP. Fabienne Djandji at the Saint-Justine University Central Hospital in Montreal, Canada, and co-workers conducted a survey of 421 doctors to determine their attitudes and provision of WAPs. Only 5.2 per cent of respondents provided WAPs to patients; those treating children or aiming for long-term asthma control were more likely to do so. The doctors said that incentives to provide WAPs would include requests from patients themselves, being paid to complete WAPs and having extra support from specialists or other health care professionals such as pharmacists.
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Affiliation(s)
- Fabienne Djandji
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada.
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
| | - Alexandrine J Lamontagne
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Lucie Blais
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Simon L Bacon
- Department of Exercise Science, Concordia University, Montreal, Quebec, Canada
- Montreal Behavioural Medicine Centre, CIUSS-NIM, Hopital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada
| | - Pierre Ernst
- Department of Pulmonary Medicine, Jewish General Hospital, Montreal, Quebec, Canada
- Division of Clinical Epidemiology (MUHC) Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Kim L Lavoie
- Montreal Behavioural Medicine Centre, CIUSS-NIM, Hopital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada
- Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada
| | - Martha L McKinney
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Eve Desplats
- Applied Clinical Research Unit, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Francine M Ducharme
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada.
- Applied Clinical Research Unit, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada.
- Department of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada.
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Ducharme FM, Lamontagne AJ, Blais L, Grad R, Lavoie KL, Bacon SL, McKinney ML, Desplats E, Ernst P. Enablers of Physician Prescription of a Long-Term Asthma Controller in Patients with Persistent Asthma. Can Respir J 2016; 2016:4169010. [PMID: 27445537 PMCID: PMC4925971 DOI: 10.1155/2016/4169010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/10/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. We aimed to identify key enablers of physician prescription of a long-term controller in patients with persistent asthma. Methods. We conducted a mailed survey of randomly selected Quebec physicians. We sent a 102-item questionnaire, seeking reported management regarding one of 4 clinical vignettes of a poorly controlled adult or child and endorsement of enablers to prescribe long-term controllers. Results. With a 56% participation rate, 421 physicians participated. Most (86%) would prescribe a long-term controller (predominantly inhaled corticosteroids, ICS) to the patient in their clinical vignette. Determinants of intention were the recognition of persistent symptoms (OR 2.67), goal of achieving long-term control (OR 5.31), and high comfort level in initiating long-term ICS (OR 2.33). Decision tools, pharmacy reports, reminders, and specific training were strongly endorsed by ≥60% physicians to support optimal management. Physicians strongly endorsed asthma education, lung function testing, specialist opinion, accessible asthma clinic, and paramedical healthcare professionals to guide patients, as enablers to improve patient adherence to and physicians' comfort with long-term ICS. Interpretation. Tools and training to improve physician knowledge, skills, and perception towards long-term ICS and resources that increase patient adherence and physician comfort to facilitate long-term ICS prescription should be considered as targets for implementation.
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Affiliation(s)
- Francine M. Ducharme
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada H3T 1C5
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
- Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada H3C 3J7
| | - Alexandrine J. Lamontagne
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
| | - Lucie Blais
- Department of Pharmacology, University of Montreal, Montreal, QC, Canada H3T 1J4
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, QC, Canada H3T 1E2
| | - Kim L. Lavoie
- Montreal Behavioural Medicine Centre, Hôpital du Sacré-Cœur de Montreal, Montreal, QC, Canada H4J 1C5
- Department of Psychology, Université du Québec à Montreal, Montreal, QC, Canada H3C 3P8
| | - Simon L. Bacon
- Montreal Behavioural Medicine Centre, Hôpital du Sacré-Cœur de Montreal, Montreal, QC, Canada H4J 1C5
- Department of Exercise Science, Concordia University, Montreal, QC, Canada H4B 1R6
| | - Martha L. McKinney
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
| | - Eve Desplats
- Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
| | - Pierre Ernst
- Divisions of Clinical Epidemiology and of Pulmonary Medicine, Department of Medicine, Jewish General Hospital, Montreal, QC, Canada H3T 1E2
- Department of Medicine, McGill University, Montreal, QC, Canada H4A 3J1
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Peláez S, Lamontagne AJ, Collin J, Gauthier A, Grad RM, Blais L, Lavoie KL, Bacon SL, Ernst P, Guay H, McKinney ML, Ducharme FM. Patients' perspective of barriers and facilitators to taking long-term controller medication for asthma: a novel taxonomy. BMC Pulm Med 2015; 15:42. [PMID: 25907709 PMCID: PMC4429418 DOI: 10.1186/s12890-015-0044-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 04/20/2015] [Indexed: 11/25/2022] Open
Abstract
Background Although asthma morbidity can be prevented through long-term controller medication, most patients with persistent asthma do not take their daily inhaled corticosteroid. The objective of this study was to gather patients’ insights into barriers and facilitators to taking long-term daily inhaled corticosteroids as basis for future knowledge translation interventions. Methods We conducted a collective qualitative case study. We interviewed 24 adults, adolescents, or parents of children, with asthma who had received a prescription of long-term inhaled corticosteroids in the previous year. The one-hour face-to-face interviews revolved around patients’ perceptions of asthma, use of asthma medications, current self-management, prior changes in self-management, as well as patient-physician relationship. We sought barriers and facilitators to optimal asthma management. Interviews were transcribed verbatim and transcripts were analyzed using a thematic approach. Results Patients were aged 2–76 years old and 58% were female. Nine patients were followed by an asthma specialist (pulmonologist or allergist), 13 patients by family doctors or pediatricians, and two patients had no regular follow-up. Barriers and facilitators to long-term daily inhaled corticosteroids were classified into the following loci of responsibility and its corresponding domains: (1) patient (cognition; motivation, attitudes and preferences; practical implementation; and parental support); (2) patient-physician interaction (communication and patient-physician relationship); and (3) health care system (resources and services). Patients recognized that several barriers and facilitators fell within their own responsibility. They also underlined the crucial impact (positive or negative) on their adherence of the quality of patient-physician interaction and health care system accessibility. Conclusions We identified a close relationship between reported barriers and facilitators to adherence to long-term daily controller medication for asthma within three loci of responsibility. As such, patients’ adherence must be approached as a multi-level phenomenon; moreover, interventions targeting the patient, the patient-physician interaction, and the health care system are recommended. The present study offers a potential taxonomy of barriers and facilitators to adherence to long-term daily inhaled corticosteroids therapy that, once validated, may be used for planning a knowledge translation intervention and may be applicable to other chronic conditions. Electronic supplementary material The online version of this article (doi:10.1186/s12890-015-0044-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra Peláez
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada.
| | - Alexandrine J Lamontagne
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada.
| | - Johanne Collin
- Department of Pharmacology, University of Montreal, Montreal, Quebec, Canada.
| | - Annie Gauthier
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada.
| | - Roland M Grad
- Department of Family Medicine, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Lucie Blais
- Department of Pharmacology, University of Montreal, Montreal, Quebec, Canada.
| | - Kim L Lavoie
- Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada.
| | - Simon L Bacon
- Department of Exercise Sciences, Concordia University, Montreal, Quebec, Canada.
| | - Pierre Ernst
- Department of Pulmonary Medicine, Jewish General Hospital, Montreal, Quebec, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Hélène Guay
- Institut national d'excellence en santé et en services sociaux, Quebec, Quebec, Canada.
| | - Martha L McKinney
- Department of Paediatrics, University of Montreal, Montreal, Quebec, Canada.
| | - Francine M Ducharme
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada. .,Department of Paediatrics, University of Montreal, Montreal, Quebec, Canada. .,Department of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada. .,Departments of Pediatrics and of Social and Preventive Medicine, Associate Director of Clinical Research, Research Centre, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Room 7939, Montreal, Quebec, H3T 1C5, Canada.
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Does guideline knowledge affect treatment compliance among emergency doctors? Am J Med Sci 2015; 348:357-61. [PMID: 25118657 DOI: 10.1097/maj.0000000000000269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The insufficient adoption of internationally accepted clinical guidelines may lead to less than adequate patient care of patients with asthma. OBJECTIVE To evaluate the knowledge and treatment compliance with Global Initiative of Asthma (GINA, 2011) asthma treatment guidelines among emergency physicians (EPs) at a referral hospital in northern Malaysia. METHODS A cross-sectional study was designed in the territory-level referral hospital in northern Malaysia. Twenty-seven EPs were asked to complete an asthma guideline questionnaire to assess their knowledge regarding GINA 2011 asthma treatment guidelines. A total of 810 patients were enrolled, and 30 patients were selected per physician. The authors evaluated the physicians' compliance with GINA 2011 asthma treatment guidelines. RESULTS Of 27 EPs, 20 (74.1%) had adequate knowledge of GINA 2011 asthma treatment guidelines. A total of 615 (75.9%) patients received guideline-recommended emergency treatment. Shortness of breath (n = 436, 53.8%) was the most frequently reported chief complaint. Furthermore, there was a significant but weak association between knowledge of the guideline and treatment compliance among emergency doctors (P = 0.003, φ = 0.110). Moreover, there was no significant change in therapy for patients with comorbid conditions. The mean age of respondents was 27.3 years. CONCLUSIONS Overall, a fair level of guideline knowledge and treatment compliance was noted among EPs. Doctors with adequate guideline knowledge were more likely to comply with GINA 2011 asthma treatment guidelines.
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Facilitators and solutions for practicing optimal guided asthma self-management: the physician perspective. Can Respir J 2014; 20:285-93. [PMID: 23936888 DOI: 10.1155/2013/146839] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify key solutions that facilitate the prescription of long-term asthma controller and provision of written self-management plans by physicians. METHODS One hour individualized semistructured interviews were conducted with physicians. Interviews were transcribed verbatim and analyzed independently by two trained qualitative researchers. A taxonomy of facilitators (contemplated solutions) and experienced solutions was achieved by consensus within the research team. RESULTS Forty-two physicians (family physicians, pediatricians, emergency physicians, pulmonologists and allergists) were interviewed. The 867 facilitators and solutions, grouped in 10 categories, addressed three physician needs: support physicians in delivering optimal care (guideline dissemination, workplace culture, physician training and experience, physician attitudes toward optimal practice, tools and resources supporting physicians' decision making); assist patients with following recommendations (patient characteristics, experiences and attitudes; physician behaviour; and tools and resources supporting patient self-management); and offer efficient services (reorganization of care; interprofessional patient management). Suggestions pertaining to the latter two categories were most frequently cited to optimize asthma management and use of self-management plans (e.g., access to self-management plans; education by allied health care professionals). The most cited suggestions to support prescribing long-term controller pertained to physician behaviour (e.g., involvement in patient education, personalization of prescriptions, feedback to patients of the benefits of long-term controller). The distribution of facilitators and solutions varied across specialties. CONCLUSIONS Physicians proposed multiple facilitators and solutions to support optimal practice, leading to the development of a novel taxonomy. Key suggestions varied across physician specialties and behaviours sought, emphasizing the need to carefully select the most promising knowledge translation interventions.
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Jabbour M, Curran J, Scott SD, Guttman A, Rotter T, Ducharme FM, Lougheed MD, McNaughton-Filion ML, Newton A, Shafir M, Paprica A, Klassen T, Taljaard M, Grimshaw J, Johnson DW. Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial. Implement Sci 2013; 8:55. [PMID: 23692634 PMCID: PMC3674906 DOI: 10.1186/1748-5908-8-55] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 05/15/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. DESIGN/METHODS We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. DISCUSSION This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. TRIAL REGISTRATION ClinicalTrials.gov: NCT01815710.
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Affiliation(s)
- Mona Jabbour
- Division of Emergency Medicine, Children’s Hospital of Eastern Ontario, Ottawa, Canada
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Janet Curran
- IWK Health Centre, Halifax, Canada, School of Nursing, Dalhousie University, Halifax, Canada
| | | | - Astrid Guttman
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Thomas Rotter
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Francine M Ducharme
- Departments of Pediatrics and of Social and Preventive Medicine, University of Montreal, Montreal, Canada
- Research Centre, CHU Sainte-Justine, Montreal, Canada
| | - M Diane Lougheed
- Departments of Medicine (Respirology), Biomedical and Molecular Sciences (Physiology) and Community Health and Epidemiology, Queen’s University, Kingston, Canada
- ICES-Queen’s University, Kingston, Canada
| | - M Louise McNaughton-Filion
- University of Ottawa, Ottawa, Canada
- Montfort Hospital, Ottawa, Canada
- Champlain Local Health Integrated Network, Ottawa, Canada
| | - Amanda Newton
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Mark Shafir
- Department of Emergency Medicine, Cambridge Memorial Hospital, Cambridge, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Alison Paprica
- Ontario Ministry of Health and Long-Term Care, Toronto, Canada
| | - Terry Klassen
- Faculty of Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba Institute of Child Health, Winnipeg, Canada
| | - Monica Taljaard
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - David W Johnson
- Division of Emergency Medicine, Alberta Children’s Hospital, Calgary, Canada
- Alberta Children’s Hospital Research Institute, Calgary, Canada
- Department of Pediatrics, Physiology and Pharmacology, University of Calgary, Calgary, Canada
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Newhouse RP, Himmelfarb CD, Liang Y. Psychometric Testing of the Smoking Cessation Counseling Scale. J Nurs Scholarsh 2011; 43:405-11. [DOI: 10.1111/j.1547-5069.2011.01420.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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