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Thériault G, Limburg H, Klarenbach S, Reynolds DL, Riva JJ, Thombs BD, Tessier LA, Grad R, Wilson BJ. Recommendations on screening for primary prevention of fragility fractures. CMAJ 2023; 195:E639-E649. [PMID: 37156553 PMCID: PMC10166624 DOI: 10.1503/cmaj.221219] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Fragility fractures are a major health concern for older adults and can result in disability, admission to hospital and long-term care, and reduced quality of life. This Canadian Task Force on Preventive Health Care (task force) guideline provides evidence-based recommendations on screening to prevent fragility fractures in community-dwelling individuals aged 40 years and older who are not currently on preventive pharmacotherapy. METHODS We commissioned systematic reviews on benefits and harms of screening, predictive accuracy of risk assessment tools, patient acceptability and benefits of treatment. We analyzed treatment harms via a rapid overview of reviews. We further examined patient values and preferences via focus groups and engaged stakeholders at key points throughout the project. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence for each outcome and strength of recommendations, and adhered to Appraisal of Guidelines for Research and Evaluation (AGREE), Guidelines International Network and Guidance for Reporting Involvement of Patients and the Public (GRIPP-2) reporting guidance. RECOMMENDATIONS We recommend "risk assessment-first" screening for prevention of fragility fractures in females aged 65 years and older, with initial application of the Canadian clinical Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD). The FRAX result should be used to facilitate shared decision-making about the possible benefits and harms of preventive pharmacotherapy. After this discussion, if preventive pharmacotherapy is being considered, clinicians should request BMD measurement using dual-energy x-ray absorptiometry (DXA) of the femoral neck, and re-estimate fracture risk by adding the BMD T-score into FRAX (conditional recommendation, low-certainty evidence). We recommend against screening females aged 40-64 years and males aged 40 years and older (strong recommendation, very low-certainty evidence). These recommendations apply to community-dwelling individuals who are not currently on pharmacotherapy to prevent fragility fractures. INTERPRETATION Risk assessment-first screening for females aged 65 years and older facilitates shared decision-making and allows patients to consider preventive pharmacotherapy within their individual risk context (before BMD). Recommendations against screening males and younger females emphasize the importance of good clinical practice, where clinicians are alert to changes in health that may indicate the patient has experienced or is at higher risk of fragility fracture.
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Affiliation(s)
- Guylène Thériault
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Heather Limburg
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Scott Klarenbach
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Donna L Reynolds
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - John J Riva
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Brett D Thombs
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Laure A Tessier
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Roland Grad
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Brenda J Wilson
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
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2
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Sibley KM, Gardner P, Bentley DC, Khan M, McGlynn M, Shing P, Shaffer J, O'Hoski S, Salbach NM. Exploring factors influencing physiotherapists' perceptions of measuring reactive balance following a theory-based multi-component intervention: a qualitative descriptive study. Disabil Rehabil 2021; 44:4709-4716. [PMID: 34148468 DOI: 10.1080/09638288.2021.1916840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Reactive balance is a critical consideration for mobility and fall avoidance, but is under-assessed among physiotherapists. The objective of this study was to explore factors influencing physiotherapist perceptions about measuring reactive balance upon completion of a 12-month theory-based, multi-component intervention to increase use of a measure of reactive balance.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 28 physiotherapists treating adults with balance impairment in three urban Canadian rehabilitation hospitals that participated in the intervention. Interviews explored perceptions of reactive balance measurement and perceived changes in clinical behavior. Thematic analysis involved multiple rounds of coding, review and discussion, theme generation, and interpretation of findings through individual analysis and team meetings.Findings: Participants expressed contrasting views about integrating reactive balance measurement in their practice, despite consistent acknowledgement of the importance of reactive balance for function. Three themes were identified highlighting factors that mediated perceptions about measuring reactive balance: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Conclusions: The findings highlight that decision making for measuring reactive balance in rehabilitation settings is complex. There is a need for additional work to facilitate long-term implementation of clinical reactive balance measurement, such as refining patient criteria for administration, ensuring sufficient time to establish a trusting relationship, and developing and testing strategies to address physiotherapist fear.IMPLICATIONS FOR REHABILITATIONReactive balance is important for falls prevention and mobility, but is under-assessed among physiotherapists.This study identified three factors that influenced uptake of reactive balance measurement among physiotherapists in rehabilitation settings: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Knowledge of the identified factors may assist with design and use of reactive and other balance measurements.Strategies aimed at developing trusting relationships between physiotherapist and patient along with addressing physiotherapist fear could facilitate the uptake of clinical reactive balance measurement.
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Affiliation(s)
- K M Sibley
- Department ofCommunity Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Canada.,Toronto Rehabilitation Institute- University Health Network, Toronto, Canada
| | - P Gardner
- Department of Health Sciences, Brock University, St. Catharines, Canada.,Bridgepoint Active Healthcare - Sinai Health System, Toronto, Canada
| | - D C Bentley
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada.,Division of Anatomy, University of Toronto, Toronto, Canada
| | - M Khan
- Department ofCommunity Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - M McGlynn
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - P Shing
- Bridgepoint Active Healthcare - Sinai Health System, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - J Shaffer
- Department of Physical Therapy, University of Toronto, Toronto, Canada.,Sunnybrook Health Sciences Centre - St. John's Rehab, Toronto, Canada
| | - S O'Hoski
- West Park Healthcare Centre, Toronto, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - N M Salbach
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
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Lam JH, Pickles K, Stanaway FF, Bell KJL. Why clinicians overtest: development of a thematic framework. BMC Health Serv Res 2020; 20:1011. [PMID: 33148242 PMCID: PMC7643462 DOI: 10.1186/s12913-020-05844-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests. METHODS Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development. RESULTS The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.
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Affiliation(s)
- Justin H Lam
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia.
| | - Kristen Pickles
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Fiona F Stanaway
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
| | - Katy J L Bell
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Edward Ford Building, A27 Fisher Rd, University of Sydney, Sydney, NSW, 2066, Australia
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Kueper JK, Alsabbagh MW, Peterson S, Wong ST. Achieving cross provincial comparisons of osteoporosis screening performance from administrative health data. Int J Popul Data Sci 2019; 4:1116. [PMID: 34095537 PMCID: PMC8144816 DOI: 10.23889/ijpds.v4i1.1116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Administrative databases can be used to measure healthcare performance. This can lead to identification of high-performing practice characteristics and inform innovations. However, a key challenge is that administrative data cannot be easily combined across provinces. Comparable measures must be defined across provinces but operationalized within each province. The purpose of this work is to provide an example of defining a population health concept, osteoporosis screening, and creating measures to examine it across British Columbia, Ontario, and Nova Scotia, Canada. TRANSFORMATION is a study that seeks to improve the science and reporting of Primary Health Care performance. We used administrative data from the above three provinces to examine osteoporosis screening in those aged 65 years and older. Challenges of databases with different data elements and levels of methods development (e.g. macros) can be overcome for purposes of cross-provincial comparisons. Flexibility of analytic methods and frequent communication is needed.
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Affiliation(s)
- J K Kueper
- Department of Epidemiology and Biostatistics, The University of Western Ontario, Kresge Building, 1151 Richmond Street, London, Ontario, Canada, N6A 5C1
| | - M W Alsabbagh
- School of Pharmacy, University of Waterloo, 10A Victoria St S, Kitchener, Ontario, Canada, N2G 1C5
| | - S Peterson
- Centre for Health Services and Policy Research, University of British Columbia, 201-2206 East Mall, Vancouver, British Columbia, Canada, V6T 1Z3
| | - S T Wong
- School of Nursing and Centre for Health Services and Policy Research, University of British Columbia, 201-2206 East Mall, Vancouver, British Columbia, Canada, V6T 1Z3
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Sibley KM, Roche PL, Bell CP, Temple B, Wittmeier KDM. A descriptive qualitative examination of knowledge translation practice among health researchers in Manitoba, Canada. BMC Health Serv Res 2017; 17:627. [PMID: 28874152 PMCID: PMC5585925 DOI: 10.1186/s12913-017-2573-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The importance of effective translation of health research findings into action has been well recognized, but there is evidence to suggest that the practice of knowledge translation (KT) among health researchers is still evolving. Compared to research user stakeholders, researchers (knowledge producers) have been under-studied in this context. The goals of this study were to understand the experiences of health researchers in practicing KT in Manitoba, Canada, and identify their support needs to sustain and increase their participation in KT. METHODS Qualitative semi-structured interviews were conducted with 26 researchers studying in biomedical; clinical; health systems and services; and social, cultural, environmental and population health research. Interview questions were open-ended and probed participants' understanding of KT, their experiences in practicing KT, barriers and facilitators to practicing KT, and their needs for KT practice support. RESULTS KT was broadly conceptualized across participants. Participants described a range of KT practice experiences, most of which related to dissemination. Participants also expressed a number of negative emotions associated with the practice of KT. Many individual, logistical, and systemic or organizational barriers to practicing KT were identified, which included a lack of institutional support for KT in both academic and non-academic systems. Participants described the presence of good relationships with stakeholders as a critical facilitator for practicing KT. The most commonly identified needs for supporting KT practice were access to education and training, and access to resources to increase awareness and promotion of KT. While there were few major variations in response trends across most areas of health research, the responses of biomedical researchers suggested a unique KT context, reflected by distinct conceptualizations of KT (such as commercialization as a core component), experiences (including frustration and lack of support), and barriers to practicing KT (for example, intellectual property concerns). CONCLUSIONS The major findings of this study were the continued variations in conceptualization of KT, and persisting support needs that span basic individual to comprehensive systemic change. Expanding the study to additional regions of Canada will present opportunities to compare and contrast the state of KT practice and its influencing factors.
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Affiliation(s)
- Kathryn M Sibley
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada. .,George and Fay Yee Centre for Healthcare Innovation, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada.
| | - Patricia L Roche
- George and Fay Yee Centre for Healthcare Innovation, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada
| | - Courtney P Bell
- George and Fay Yee Centre for Healthcare Innovation, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada
| | - Beverley Temple
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, 483 Helen Glass Centre for Nursing, 89 Curry Place, Winnipeg, MB, R3T 2N2, Canada
| | - Kristy D M Wittmeier
- George and Fay Yee Centre for Healthcare Innovation, 379 - 753 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada.,Department of Physiotherapy, Winnipeg Health Sciences Centre, 183A-800 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada.,Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, 183A-800 Sherbrook Street, Winnipeg, MB, R3A 1S1, Canada
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6
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Munce SEP, Butt DA, Anantharajah R(S, Huang S, Allin S, Bereket T, Jaglal SB. Acceptability and Feasibility of an Evidence-Based Requisition for Bone Mineral Density Testing in Clinical Practice. J Osteoporos 2016; 2016:6967232. [PMID: 28050306 PMCID: PMC5168451 DOI: 10.1155/2016/6967232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/08/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction. The purpose of this study is to understand the experience of primary care providers (PCPs) using an evidence-based requisition for bone mineral density (BMD) testing. Methods. A qualitative descriptive approach was adopted. Participants were given 3 BMD Recommended Use Requisitions (RUR) to use over a 2-month period. Twenty-six PCPs were interviewed before using the RUR. Those who had received at least one BMD report resulting from RUR use were then interviewed again. An inductive thematic analysis was performed. Results. We identified four themes in interview data: (1) positive and negative characteristics of the RUR, (2) facilitators and barriers for implementation, (3) impact of the RUR, and (4) requisition preference. Positive characteristics of the RUR related to both its content and format. Negative characteristics related to the increased amount of time needed to complete the form. Facilitators to implementation included electronic availability and organizational endorsement. Time constraints were identified as a barrier to implementation. Participants perceived that the RUR would promote appropriate referrals and the majority of participants preferred the RUR to their current requisition. Conclusions. Findings from this study provide support for the RUR as an acceptable point-of-care tool for PCPs to promote appropriate BMD testing.
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Affiliation(s)
- Sarah E. P. Munce
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Debra A. Butt
- Department of Family and Community Medicine, University of Toronto, Research Department, Toronto, ON, Canada
- Family and Community Medicine, The Scarborough Hospital, Scarborough, ON, Canada
| | | | - Susana Huang
- Family and Community Medicine, The Scarborough Hospital, Scarborough, ON, Canada
| | - Sonya Allin
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Tarik Bereket
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Susan B. Jaglal
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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