Patient-mediated knowledge translation (PKT) interventions for clinical encounters: a systematic review

Making Informed Choices On Incorporating Chemoprevention into carE (MiCHOICE, SWOG 1904): Design and methods of a cluster randomized controlled trial

INTRODUCTION

Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy.

METHODS/DESIGN

We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation.

RESULTS/DISCUSSION

With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S.

CLINICAL SETTINGS

TRIAL REGISTRATION

NCT04496739.

Implementation of Pelvic Floor Rehabilitation after rectal cancer surgery: A qualitative study guided by the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

Pelvic Floor Rehabilitation (PFR) is effective in a selection of patients with low anterior resection syndrome (LARS) after rectal cancer surgery. This study aimed to identify barriers and enablers to prepare for successful implementation into clinical practice.

METHODS

A qualitative study was performed, guided by the Consolidated Framework for Implementation Research (CFIR). Individual interviews (n = 27) and two focus groups were conducted to synthesize the perspectives of rectal cancer patients, pelvic floor (PF) physiotherapists, and medical experts.

RESULTS

Barriers were found to be the absence of guidelines about LARS treatment, underdeveloped network care, suboptimal patient information, and expectation management upfront to PFR. Financial status is frequently a barrier because insurance companies do not always reimburse PFR. Enablers were the current level of evidence for PFR, the positive relationship between patients and PF physiotherapists, and the level of self-motivation by patients.

CONCLUSION

The factors identified in our study play a crucial role in ensuring a successful implementation of PFR after rectal cancer surgery.

Using implementation science to promote the use of the fascia iliaca blocks in hip fracture care

PURPOSE

There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake.

METHODS

We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied.

RESULTS

The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days).

CONCLUSION

Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

We're here too: child health information-seeking experiences and preferences of Red River Métis families - a qualitative study

BACKGROUND

Red River Métis families need access to meaningful and appropriate resources when their children are sick. At the invitation of the Manitoba Métis Federation (MMF) to partner in this research, our aim was to understand Red River Métis parents' experiences and preferences for seeking child health information when their child is acutely ill, to inform the adaptation of existing parent resources.

METHODS

A qualitative descriptive approach underpinned by a participatory paradigm guided this study. Semi-structured interviews were conducted with 19 Red River Métis parents and Elders via Zoom or telephone. An inductive thematic analysis approach was used to explore patterns and themes across the data.

RESULTS

Analysis generated four themes: (1) We're here too; (2) We are not all the same; (3) Finding trustworthy information; and (4) Information needs to be widely available. Red River Métis pride was prominent in the results. Parents provided tangible ways to modify existing parent resources, including adding information on how to access Elders, healers and/or traditional medicines and showing different family structures, transport, living situations, Métis names, and incorporating Métis languages. While most parents reported looking for child health information online, they also stressed the need to provide multiple options, including information sheets, recognizing that parents seek information in different contexts. Parents also emphasized the importance of accessible, safe spaces to find child health information, including local schools, community centres, healthcare organizations and the MMF.

CONCLUSION

There is a lack of child health information created specifically for Red River Métis families. The development of this information can support their information needs and preferences and the ongoing efforts to revitalize Red River Métis culture and language. Study findings will inform the adaptation and dissemination of existing child health resources to ensure they reflect Red River Métis parents' information needs and preferences. This research is a critical step in addressing an identified need for Red River Métis families to have culturally relevant and meaningful child health resources, and in the pursuit of equitable care for all children in Canada.

TRIAL REGISTRATION

N/A.

Improving communication and patient information recall via a question prompt list: randomized clinical trial

BACKGROUND

Patient-surgeon communication is an important component of the success of a consultation and is known to impact patient outcomes. The aim of this study was to investigate whether a document called a question prompt list, containing suggested questions that a patient may like to ask their doctor, improved communication.

METHODS

A prospective RCT was conducted from October 2021 to October 2022 at The Queen Elizabeth Hospital, Adelaide, Australia. Patients 16 years or older, seeing a general surgeon for a pre-surgical consultation, not requiring a translator, were randomized to receive a question prompt list (intervention) or standard care without a question prompt list (control). The primary outcomes were number of questions asked, talk time, and mutual eye gaze. Secondary outcomes were patient recall of information, anxiety, and consultation duration. Randomization was achieved using a computer program, with allocation concealment by opaque sequentially numbered envelopes. Patients were blinded to study group; surgeons were aware of study group, but blinded to outcomes.

RESULTS

Patients (59) were randomly allocated to receive the question prompt list (31) or to the control group (28). A patient from the intervention group withdrew before consultation, resulting in 58 patients being included in the analysis. In the question prompt list consultations, 24 per cent more questions were asked (incidence rate ratio = 1.25, 95 per cent c.i. 1.10 to 1.42; P = 0.001). The intervention group recalled 9 per cent more items than the control group (incidence rate ratio = 1.09, 95 per cent c.i. 1.02 to 1.17; P = 0.012). The control group were 26 per cent less likely to correctly recall information about surgical treatment (OR = 0.26, 95 per cent c.i. 0.10 to 0.68; P = 0.006). No statistically significant differences between study arms for talk time, mutual eye gaze, anxiety, or consultation duration were demonstrated.

CONCLUSION

The question prompt list was associated with increased question asking and greater patient recall of medical information. It did not increase patient anxiety or consultation duration.

REGISTRATION NUMBER

ACTRN12623000089639 (http://www.ANZCTR.org.au).

Seeing the person before the numbers: Personas for understanding patients' life stories when using patient-reported outcome measures in practice settings

AIMS

While patient-reported outcome measures (PROMs) are increasingly being integrated into health information technologies, one challenge has been to assist clinicians in understanding how the responses to PROMs relate to patient stories for identifying and addressing the care needs of individual patients. Personas, hypothetical representations of patients, can be used as an innovative strategy to support clinicians' use of PROMs in their practice. These personas embody patients' life stories, making them a valuable tool for understanding the person when using PROMs. The aim of this project focused on cancer-related experiences to develop personas as a knowledge translation strategy to support clinicians' use of PROMs for person-centred cancer care.

METHODS

Eight older adults participated in online workshops (n = 2-3 participants/workshop; 1.5-hour sessions) to co-develop personas that reflected their collective experiences at a particular stage of their cancer journeys. Participants were asked to identify themes that focused on what the personas were thinking and feeling, what influenced how the personas acted, and the personas' overall goals. Participants subsequently completed an emotional well-being PROM from the perspective of the persona. Personas were further refined based on key themes identified during the workshop discussions.

RESULTS

Four personas representing the cumulative experiences of the workshop participants were developed to help clinicians link PROM responses to patient stories. These personas became the basis of four practice scenarios, which were examples of interactions between a clinician and each persona, to demonstrate the use of PROMs in practice.

CONCLUSION

Personas can be used to illustrate patients' life stories and contextualize PROMs data. As a knowledge translation strategy, personas can foster clinician awareness of how responses to PROMs can be used to initiate conversations to better understand patients' unique life situations.

Can youth-engaged research facilitate equitable access to contraception in Canada? The qualitative study protocol for the Ask Us project

INTRODUCTION

There is little to no evidence in Canada on the barriers that youth face when accessing contraception. We seek to identify the contraception access, experiences, beliefs, attitudes, knowledge, and needs of youth in Canada, from the perspectives of youth and youth service providers.

METHODS AND ANALYSIS

This prospective, mixed-methods, integrated knowledge mobilisation study, the Ask Us project, will involve a national sample of youth, healthcare and social service providers, and policy makers recruited via a novel relational mapping and outreach approach led by youth. Phase I will centre the voices of youth and their service providers through in-depth one-on-one interviews. We will explore the factors influencing youth access to contraception, theoretically guided by Levesque's Access to Care framework. Phase II will focus on the cocreation and evaluation of knowledge translation products (youth stories) with youth, service providers, and policy makers.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia's Research Ethics Board (H21-01091). Full open-access publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to youth and service providers through social media, newsletters, and communities of practice, and to policy makers through invited evidence briefs and face-to-face presentations.

Study protocol for a factorial-randomized controlled trial evaluating the implementation, costs, effectiveness, and sustainment of digital therapeutics for substance use disorder in primary care (DIGITS Trial)

BACKGROUND

Experts recommend that treatment for substance use disorder (SUD) be integrated into primary care. The Digital Therapeutics for Opioids and Other SUD (DIGITS) Trial tests strategies for implementing reSET® and reSET-O®, which are prescription digital therapeutics for SUD and opioid use disorder, respectively, that include the community reinforcement approach, contingency management, and fluency training to reinforce concept mastery. This purpose of this trial is to test whether two implementation strategies improve implementation success (Aim 1) and achieve better population-level cost effectiveness (Aim 2) over a standard implementation approach.

METHODS/DESIGN

The DIGITS Trial is a hybrid type III cluster-randomized trial. It examines outcomes of implementation strategies, rather than studying clinical outcomes of a digital therapeutic. It includes 22 primary care clinics from a healthcare system in Washington State and patients with unhealthy substance use who visit clinics during an active implementation period (up to one year). Primary care clinics implemented reSET and reSET-O using a multifaceted implementation strategy previously used by clinical leaders to roll-out smartphone apps ("standard implementation" including discrete strategies such as clinician training, electronic health record tools). Clinics were randomized as 21 sites in a 2x2 factorial design to receive up to two added implementation strategies: (1) practice facilitation, and/or (2) health coaching. Outcome data are derived from electronic health records and logs of digital therapeutic usage. Aim 1's primary outcomes include reach of the digital therapeutics to patients and fidelity of patients' use of the digital therapeutics to clinical recommendations. Substance use and engagement in SUD care are additional outcomes. In Aim 2, population-level cost effectiveness analysis will inform the economic benefit of the implementation strategies compared to standard implementation. Implementation is monitored using formative evaluation, and sustainment will be studied for up to one year using qualitative and quantitative research methods.

DISCUSSION

The DIGITS Trial uses an experimental design to test whether implementation strategies increase and improve the delivery of digital therapeutics for SUDs when embedded in a large healthcare system. It will provide data on the potential benefits and cost-effectiveness of alternative implementation strategies.

CLINICALTRIALS

gov Identifier: NCT05160233 (Submitted 12/3/2021). https://clinicaltrials.gov/ct2/show/NCT05160233.

A Parent Guidebook for Occupational Therapy Using Ayres Sensory Integration®

IMPORTANCE

Occupational therapy using Ayres Sensory Integration® (ASI) is an evidence-based intervention that includes parent education and participation to support outcomes. However, guidelines for this parent component have not been published.

OBJECTIVE

To obtain input from stakeholders on a revised guidebook for parent education during ASI intervention.

DESIGN

Cross-sectional survey design.

SETTING

Online surveys.

PARTICIPANTS

Experts in ASI, occupational therapy practitioners who use this approach, and parents of children with autism who received occupational therapy using this intervention.

OUTCOMES AND MEASURES

Surveys designed and vetted to obtain input on content and usability.

RESULTS

Experts rated the guidebook as consistent with ASI principles, practitioners rated it as clinically useful, and parents rated it as useful and clear.

CONCLUSIONS AND RELEVANCE

The parent guidebook for ASI is ready for further testing and use. What This Article Adds: This report adds knowledge translation and best practice strategies in parent education to the parent guidebook for ASI and provides evidence that it is acceptable by experts, parents, and clinicians.

Effectiveness of a guideline implementation tool for supporting management of mental health complications after mild traumatic brain injury in primary care: protocol for a randomised controlled trial

INTRODUCTION

Mental health problems frequently interfere with recovery from mild traumatic brain injury (mTBI) but are under-recognised and undertreated. Consistent implementation of clinical practice guidelines for proactive detection and treatment of mental health complications after mTBI will require evidence-based knowledge translation strategies. This study aims to determine if a guideline implementation tool can reduce the risk of mental health complications following mTBI. If effective, our guideline implementation tool could be readily scaled up and/or adapted to other healthcare settings.

METHODS AND ANALYSIS

We will conduct a triple-blind cluster randomised trial to evaluate a clinical practice guideline implementation tool designed to support proactive management of mental health complications after mTBI in primary care. We will recruit 535 adults (aged 18-69 years) with mTBI from six emergency departments and two urgent care centres in the Greater Vancouver Area, Canada. Upon enrolment at 2 weeks post-injury, they will complete mental health symptom screening tools and designate a general practitioner (GP) or primary care clinic where they plan to seek follow-up care. Primary care clinics will be randomised into one of two arms. In the guideline implementation tool arm, GPs will receive actionable mental health screening test results tailored to their patient and their patients will receive written education about mental health problems after mTBI and treatment options. In the usual care control arm, GPs and their patients will receive generic information about mTBI. Patient participants will complete outcome measures remotely at 2, 12 and 26 weeks post-injury. The primary outcome is rate of new or worsened mood, anxiety or trauma-related disorder on the Mini International Neuropsychiatric Interview at 26 weeks.

ETHICS AND DISSEMINATION

Study procedures were approved by the University of British Columbia's research ethics board (H20-00562). The primary report for the trial results will be published in a peer-reviewed journal. Our knowledge user team members (patients, GPs, policymakers) will co-create a plan for public dissemination.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04704037).

A Research Protocol for Implementation and Evaluation of a Patient-Focused eHealth Intervention for Chronic Kidney Disease

Self-management in chronic kidney disease (CKD) can slow disease progression; however, there are few tools available to support patients with early CKD. My Kidneys My Health is a patient-focused electronic health (eHealth) self-management tool developed by patients and caregivers. This study will investigate the implementation of My Kidneys My Health across primary care and general nephrology clinics. The study aims to: (1) identify and address barriers and facilitators that may impact implementation and sustainability of the website into routine clinical care; (2) evaluate implementation quality to inform spread and scale-up. We will conduct a multi-stage approach using qualitative methods, guided by the Quality Implementation Framework and using a qualitative content analysis approach. First, we will identify perceived barriers and facilitators to implementation and considerations for sustainability through interviews with clinicians, based on the Readiness Thinking Tool and the Long Term Success Tool. Analysis will be guided by the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Appropriate implementation strategies will be identified using the Expert Recommendations for Implementing Change compilation, and implementation plans will be developed based on Proctor's recommendations and the Action, Actor, Context, Target, Time framework. Finally, we will explore implementation quality guided by the RE-AIM framework. There is limited literature describing systematic approaches to implementing and sustaining patient-focused self-management tools into clinical care, in addition to employing tailored implementation strategies to promote adoption and sustainability. We aim to generate insights on how My Kidneys My Health can be integrated into clinical care and how to sustain use of patient-centric eHealth tools in clinical settings on a larger scale.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00038-3.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework

BACKGROUND

Although guidelines have long recommended objective pulmonary function testing to diagnose asthma and chronic obstructive lung disease (COPD), many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side-effects, and delays actual diagnosis.

RESEARCH QUESTION

What are the barriers and enablers to lung function testing for asthma and/or COPD in primary care?

STUDY DESIGN AND METHODS

We searched the literature for qualitative and quantitative studies reporting barriers and/or enablers to in-office or out-of-office lung function testing for diagnosing asthma and/or COPD, in primary care. Two reviewers independently screened abstracts and full texts; assessed methodological quality using the Mixed Methods Appraisal Tool; and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual.

RESULTS

We identified 7988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, 3 were qualitative, and 3 used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in- and out-of-office settings. We identified more reported barriers (e.g. lack of knowledge of the usefulness of spirometry) than enablers (e.g. skills for performing reliable spirometry). Barriers mapped to 9 (of a possible 14) TDF domains (for both in- and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing.

INTERPRETATION

Barriers to objective testing for airways disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behaviour change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD should now be developed and tested.

Evaluation of two strategies to implement physical cancer rehabilitation guidelines for survivors of abdominopelvic cavity tumors: a controlled before-and-after study

Purpose

This study evaluates the effectiveness and feasibility of two strategies to implement physical cancer rehabilitation (PCR) guidelines for patients who have survived abdominopelvic cavity malignancies.

Methods

We tested and compared two tailored strategies to implement PCR guidelines for survivors of gastrointestinal, female organ and urogenital organ malignancies, in a clustered controlled before-and-after study. A patient-directed (PD) strategy was tested in five cancer centers, aiming to empower survivors. A multifaceted (MF) strategy was tested in four cancer centers, aiming additionally to influence healthcare professionals and the healthcare organization. Data were collected from existing registration systems, patient questionnaires and professional questionnaires. We measured both implementation- and client outcomes. For insight into the effectiveness we measured indicators related to PCR guidelines: (1) screening with the Distress Thermometer (DT) (=primary outcome measure), (2) information provision concerning physical activity (PA) and physical cancer rehabilitation programs (PCRPs), (3) advice to take part in PA and PCRPs, (4) referral to PCRPs, (5) participation in PCRPs, (6) PA uptake (PAU); and patient reported outcomes (PROs) such as (7) quality of life, (8) fatigue, and (9) empowerment. Furthermore, survivor and center determinants were assessed as possible confounders. Multilevel analyses were performed to compare the scores of the indicators of the PD and MF strategies, as well as the differences between the characteristics of these groups. The use of and experiences with both strategies were measured using questionnaires and Google Analytics to assess feasibility.

Results

In total, 1326 survivors participated in the study, 673 in the before- and 653 in the after-measurement. Regarding our primary outcome measure, we found a significant improvement of screening with the DT between the before- and after-measurement for both strategies, respectively from 34.2 to 43.1% (delta=8.9%; odds ratio (OR)=1.6706; p=0.0072) for the PD strategy and from 41.5 to 56.1% (delta=14.6%; OR=1.7098; p=0.0028) for the MF strategy. For both the primary and secondary outcomes, no statistically significant effect of the MF strategy compared to the PD strategy was observed. We found good use of and positive experiences with both strategies.

Conclusion

Implementation strategies containing tools enhancing patient empowerment seem to be effective in increasing the systematic screening with the DT for survivors of abdominopelvic cavity malignancies. Further research is needed to assess the additional effectiveness of strategies that stimulate compliance among healthcare professionals and healthcare organizations.

Implications for Cancer Survivors

Using implementation strategies containing tools enhancing patient empowerment seem to be effective in increasing the systematic screening with the DT and might improve the quality of care of patients who have survived abdominopelvic cavity malignancies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01045-3.

Integration as a Tool for Interprofessional Work: A Synthesis of the Literature Regarding How to Use Integrative Strategies to Address Complex Public Health Problems

Background and Purpose

There has been limited success addressing complex public health problems using "siloed" approaches. A next important step in addressing persistent public health problems is adopting an "integrative" approach-intentional collaboration across the domains of research, clinical practice, community, and policy. This synthesis of the literature aggregates and synthesizes the diffuse and multi-disciplinary integration literature base to describe key concepts, aspects of praxis, and challenges and successes to help guide interprofessional practice.

Methods

A three-step approach was used: 1) a wide-ranging search for articles on integration theory/praxis; 2) a more focused search in the health literature bases; 3) a snowball strategy to identify additional studies.

Discussion/Conclusions

Identified themes included elements of successful integration; characteristics of an effective integrator; and dynamics between stakeholders in integration praxis. Results of this synthesis of the integration literature provide a deeper understanding of integration and points to clear and exciting next steps for integration praxis and inquiry.

Age of Diagnosis, Fidelity and Acceptability of an Early Diagnosis Clinic for Cerebral Palsy: A Single Site Implementation Study

Cerebral palsy (CP) diagnosis is historically late, at between 12 and 24 months. We aimed to determine diagnosis age, fidelity to recommended tests and acceptability to parents and referrers of an early diagnosis clinic to implement a recent evidence-based clinical guideline for the early diagnosis of CP. A prospective observational case series of infants <12 months with detectable risks for CP attending our clinic was completed with data analysed cross-sectionally. Infants had a high risk of CP diagnosis at a mean age of 4.4 (standard deviation [SD] 2.3) months and CP diagnosis at 8.5 [4.1] months. Of the 109 infants seen, 57% had a diagnosis of CP or high risk of CP, showing high specificity to our inclusion criteria. Parent and referrer acceptability of the clinic was high. Paediatricians had the highest rate of referral (39%) followed by allied health (31%), primary carer (14%) and other health workers (16%). Fidelity to the guideline was also high. All infants referred <5 mths had the General Movements Assessment (GMA) and all except one had the Hammersmith Infant Neurological Examination (HINE) administered. N = 92 (84%) of infants seen had neuroimaging, including n = 53 (49%) who had magnetic resonance imaging (MRI), showing recommended tests are feasible. Referral to CP-specific interventions was at 4.7 [3.0] months, sometimes before referral to clinic. Clinicians can be confident CP can be diagnosed well under 12 months using recommended tools. This clinic model is acceptable to parents and referrers and supports access to CP-specific early interventions when they are likely to be most effective.

Knowledge translation of the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: a collaborative movement guideline knowledge translation process

Establishing a step-by-step process that provides practitioners with a blueprint for translating movement guidelines into action stands to optimize the investment in guideline development, improve guideline promotion and uptake, and ultimately enhance population health. The purpose of this paper is to describe how the Knowledge-to-Action framework and integrated knowledge translation were operationalized to systematically inform our knowledge translation (KT) efforts for the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older. In October 2018, the need for a KT Process, operating in tandem with the Guideline Development Process, led to the establishment of a KT team with a specific structure and terms of reference. The KT team collaboratively agreed on decision-making principles prior to selecting target audiences to focus their efforts. We undertook formative research to assess the local context and determinants of guideline dissemination and implementation efforts among target audiences. Plans for the subsequent steps and research are outlined. We highlight recommendations and lessons learned for applying the process in other settings. Novelty We outline a collaborative and systematic process and research program for the knowledge translation of movement guidelines. This paper provides an innovative and replicable blueprint to optimize future movement guideline knowledge translation efforts.

Lessons Learned from Developing Plain Language Summaries of Research Studies

Background:

Plain language translation may facilitate the public's ability to understand and use results of scientific research.

Brief description of activity:

This article describes the Patient-Centered Outcomes Research Institute's (PCORI) approach to and lessons learned from developing plain language summaries of PCORI-funded research for the lay public.

Implementation:

We developed and tested a standard template for the summaries, incorporating feedback in the template design from focus groups with members of the public. Between February 2017 and March 2020, we completed translation of 272 plain language summaries of PCORI-funded studies, covering topics including cardiovascular disease, obesity, cancer, mental health, asthma, HIV/AIDS, and comparative effectiveness research methods.

Results:

Templates use a question-and-answer format, with sections on the rationale, methods, results, limitations, and how the research will help inform decisions. In addition to feedback on template heading wording and order, focus group participants stressed the importance of establishing relevance and conveying credibility and limitations.

Lessons learned:

Lessons learned relate to supporting consistency across individual summaries, carefully prioritizing content to include in the summaries, and balancing plain language and reading level with precision. These lessons learned from template development and implementation may be useful to other organizations or publishers contemplating similar efforts to make scientific research results more accessible. [HLRP: Health Literacy Research and Practice. 2021;5(2):e155–e161.]

Plain Language Summary:

The Patient-Centered Outcomes Research Institute (PCORI) funds comparative effectiveness research. This research compares the benefits and harms of two or more health care choices. In this article, we describe lessons learned from PCORI's efforts to develop plain language summaries of results from the research it funds. These lessons may help other organizations that want to share research results in plain language.

The psychological burden of waiting for procedures and patient-centred strategies that could support the mental health of wait-listed patients and caregivers during the COVID-19 pandemic: A scoping review

BACKGROUND

Waiting for procedures delayed by COVID-19 may cause anxiety and related adverse consequences.

OBJECTIVE

To synthesize research on the mental health impact of waiting and patient-centred mitigation strategies that could be applied in the COVID-19 context.

METHODS

Using a scoping review approach, we searched 9 databases for studies on waiting lists and mental health and reported study characteristics, impacts and intervention attributes and outcomes.

RESULTS

We included 51 studies that focussed on organ transplant (60.8%), surgery (21.6%) or cancer management (13.7%). Most patients and caregivers reported anxiety, depression and poor quality of life, which deteriorated with increasing wait time. The impact of waiting on mental health was greater among women and new immigrants, and those of younger age, lower socio-economic status, or with less-positive coping ability. Six studies evaluated educational strategies to develop coping skills: 2 reduced depression (2 did not), 1 reduced anxiety (2 did not) and 2 improved quality of life (2 did not). In contrast, patients desired acknowledgement of concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date.

CONCLUSIONS

Findings revealed patient-centred strategies to alleviate the mental health impact of waiting for procedures. Ongoing research should explore how to optimize the impact of those strategies for diverse patients and caregivers, particularly in the COVID-19 context.

PATIENT OR PUBLIC CONTRIBUTION

Six patients and four caregivers waiting for COVID-19-delayed procedures helped to establish eligibility criteria, plan data extraction and review a draft and final report.

Effect of question prompt lists for cancer patients on communication and mental health outcomes-A systematic review

OBJECTIVE

To provide a systematic review on the effects of question prompt lists (QPL) in oncological settings.

METHODS

A systematic literature search was conducted in Medline, PsycINFO and the Cochrane Collaboration. Randomized controlled studies (RCTs) that evaluated QPL-only interventions were included. Risk of bias of included studies was evaluated using the Cochrane RoB 2 tool. Data concerning effects on communicative processes in patient-physician relationship and psychological outcomes were analyzed.

RESULTS

10 RCTs met the inclusion criteria. Results suggest that QPLs lead to a shift of topics discussed. There were weak indications that QPL interventions increase anxiety shortly before and after consultations, but may decline anxiety during follow-up. Patients consistently perceive QPLs as more helpful than usual information sheets. QPL-only interventions show limited impact on communicative processes and psychological outcomes. They help not to forget or discuss important questions.

CONCLUSION

With a better integration in patient-physician communication QPLs may become a useful tool for patients and physicians. Future research is needed to investigate if there is greater benefit from QPL interventions in specific settings.

PRACTICE IMPLICATIONS

QPLs are an inexpensive tool to influence communicative processes positively in oncological consultations.

Factors associated with parents' experiences using a knowledge translation tool for vaccination pain management: a qualitative study

Background

Vaccination is a common painful procedure for children. Parents’ concern regarding vaccination pain is a significant driver of vaccine hesitancy. Despite the wealth of evidence-based practices available for managing vaccination pain, parents lack knowledge of, and access to, these strategies. Knowledge translation (KT) tools can communicate evidence-based information to parents, however little is known about what factors influence parents’ use of these tools. A two-page, electronic KT tool on psychological, physical, and pharmacological vaccination pain management strategies for children, was shared with parents as part of a larger mixed methods study, using explanatory sequential design, exploring factors related to uptake of this KT tool. The aim of this qualitative study was to understand what influenced parents’ perceptions of the relevance of the KT tool, as well as their decision as to whether to use the tool.

Methods

A qualitative descriptive design was used. A total of 20 parents of children aged 0–17 years (n = 19 mothers) reviewed the KT tool ahead of their child’s upcoming vaccination and participated in a semi-structured interview at follow-up. Interviews were recorded, transcribed verbatim, and analyzed with reflexive thematic analysis using an inductive approach.

Results

The analysis generated three interrelated themes which described factors related to parents’ use of the KT tool: (1) Relevance to parents’ needs and circumstances surrounding their child’s vaccination; (2) Alignment with parents’ personal values around, and experiences with, vaccination pain management (e.g., the importance of managing pain); and (3) Support from the clinical environment for implementing evidence-based strategies (e.g., physical clinical environment and quality of interactions with the health care provider).

Conclusions

Several factors were identified as central to parents’ use of the KT tool, including the information itself and the clinical environment. When the tool was perceived as relevant, aligned with parents’ values, and was supported by health care providers, parents were more inclined to use the KT tool to manage their children’s vaccination pain. Future research could explore other factors related to promoting engagement and uptake when creating parent-directed KT tools for a range of health-related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06326-2.

Understanding parents' use of a knowledge translation tool to manage children's vaccination pain

Supplemental Digital Content is Available in the Text.

The relevance of KT tools, and parents' confidence in using them, was related to uptake of vaccination pain management strategies for children.

Introduction:

Although several evidence-based strategies for managing children's vaccination pain exist, many parents report being unaware of them. Knowledge translation (KT) tools present evidence-based information in plain language.

Objectives:

This two-phase study assessed parents/caregivers' uptake of evidence-based pain management strategies via a KT tool and considered factors related to parents' planned, actual, and future use of these strategies.

Methods:

In phase 1, parents were exposed to an online KT tool on physical, psychological, and pharmacological vaccination pain management strategies, and their impressions were assessed by questionnaires including the Information Assessment Method for Parents. In phase 2, after vaccination, parents completed a follow-up survey on their uptake and experiences using the information.

Results:

A total of 312 participants reported their plans for KT tool use. Parents who found the KT tool relevant were more likely to plan to use it at their child's upcoming vaccination. A total of 128 parents (93% mothers) completed both surveys. Nearly all parents who planned to use the information did so during their child's subsequent vaccination (90%). When the KT tool was relevant to their needs, parents were more likely to use the information during their child's vaccination. Parents who felt confident using the tool were significantly more likely to report plans for future tool use.

Discussion:

This study demonstrates the effectiveness of a KT tool that was relevant to parents' needs and built confidence to increase parent-reported uptake of evidence-based strategies. Proper pain management could positively impact parents' uptake of vaccinations for children.

Patients, family members and providers perceive family-administered delirium detection tools in the adult ICU as feasible and of value to patient care and family member coping: a qualitative focus group study

PURPOSE

While studies report on perceptions of family participation in delirium prevention, little is known about the use of family-administered delirium detection tools in the care of critically ill patients. This study sought the perspectives of patients, their family members, and healthcare providers on the use of family-administered delirium detection tools to detect delirium in critically ill patients and barriers and facilitators to using family-administered delirium detection tools in patient care.

METHODS

In this qualitative study, critical care providers (five physicians, six registered nurses) and participants from the Family ICU Delirium Detection Study (seven past patients and family members) took part in four focus groups at one hospital in Calgary, Alberta.

RESULTS

Key themes identified following thematic analysis from 18 participants included: 1) perceptions of acceptability of family-administered delirium detection (e.g., family feels valued, intensive care unit (ICU) care team may not use a family member's results, intensification of work load), 2) considerations regarding feasibility (e.g., insufficient knowledge, healthcare team buy-in), and 3) overarching strategies to support implementation into routine patient care (e.g., value of family-administered delirium detection for patients and families is well understood in the clinical context, regular communication between the family and ICU providers, an electronic version of the tool).

CONCLUSIONS

Patients, family members and healthcare providers who participated in the focus groups perceived family participation in delirium detection and the use of family-administered delirium detection tools at the bedside as feasible and of value to patient care and family member coping.

TRIAL REGISTRATION

www.ClinicalTrials.gov (NCT03379129); registered 15 December 2017.

Identifying Barriers to and Facilitators of Health Service Access Encountered by Individuals with Multiple Sclerosis

Background

The symptoms of multiple sclerosis (MS) can be diverse, complex, and progressive, creating a need for frequent and long-standing health care services. The purpose of this scoping review was to identify the barriers people with MS encounter when attempting to access multidisciplinary health services and the reported facilitators for better access to health services.

Methods

The MEDLINE, Embase, and CINAHL databases were searched, without date or geographic restrictions, using the following terms: multiple sclerosis, health services accessibility, health care access, health care delivery, and delivery of health care. After screening based on exclusion criteria, 23 articles were included in the final review.

Results

Five main themes were identified as barriers and facilitators to accessing health services: 1) information (information available to people with MS, health care provider knowledge of and familiarity with MS), 2) interactions (interactions between health care providers and people with MS, social networks and support of people with MS, collaboration among health care providers), 3) beliefs and skills (personal values and beliefs, perceived time to travel to and attend appointments, and self-assessment of symptoms and needs of people with MS), 4) practical considerations (wait times, physical barriers, affordability of services), and 5) nature of MS (complexity and unpredictability of disease symptoms).

Conclusions

People with MS and their health care providers may benefit from structured and comprehensive MS-specific education to address barriers to accessing health care services. The education can ultimately facilitate the process of addressing unmet health care needs and contribute to a greater quality of life for people with MS.

Even High-Quality CPGs Seldom Include Implementation Strategies

Background: Implementation is a key step in ensuring that high-quality clinical practice guideline (CPG) recommendations are followed and have a positive impact. This step must be planned during CPG development. This study aims to inform professionals tasked with developing and implementing CPGs regarding implementation strategies and tools reported in high-quality CPGs for chronic non-communicable diseases (NCDs).

Methods: NCD guidelines were selected based on Appraisal of Guideline Research and Evaluation (AGREE) II assessment. CPGs with a score of ≥60% in AGREE II domains 3 (rigor of development), 5 (applicability), and 6 (editorial independence), were considered high quality. The content related to implementation was extracted from CPG full texts and complementary materials. Implementation strategies and tools were assessed and classified using Mazza taxonomy.

Results: Twenty high-quality CPGs were selected, most of which were developed by government institutions (16; 80%) with public funding (16; 80%); almost half (9; 45%) addressed the treatment of cardiovascular diseases. The countries with the most high-quality CPGs were the UK (6; 30%) and Colombia (5; 25%). These countries also had the highest average number of strategies, Colombia with 28 (SD = 1) distributed in all levels, and the UK with 15 (SD = 7), concentrating on professional and organizational levels. Although the content of the Colombian CPGs was similar regardless the disease, the CPGs from the UK were specific and contained data-based feedback reports and information on CPG compliance. Implementation strategies most frequently identified were at the professional level, such as distributing reference material (18; 80%) and educating groups of healthcare professionals (18; 80%). At the organizational level, the most frequent strategies involve changes in structure (15; 75%) and service delivery method (13; 65%).

Conclusion: Countries with established CPG programs, such as the UK and Colombia, where identified as having the highest number of high-quality CPGs, although CPG implementation content had significant differences. Among high-quality CPGs, the most common implementation strategies were at the professional and organizational levels. There is still room for improvement regarding the implementation strategies report, even among high-quality CPGs, especially concerning monitoring of implementation outcomes and selection of strategies based on relevant implementation barriers.

Opportunities, Enablers, and Barriers to the Use of Recorded Recovery Narratives in Clinical Settings

Background: Recorded Recovery Narratives (RRNs) describing first-person lived experience accounts of recovery from mental health problems are becoming more available. Little is known about how RRNs can be used in clinical practice and clinical education. Aims: The aim of this paper is to enable implementation planning for RRN interventions by identifying determinants of uptake. The objective was to identify opportunities, barriers, and enablers to the uptake of RRN interventions in clinical practice and education. Method: Three phases of focus groups were conducted with multi-professional mental health clinicians. Phase 1 (4 groups, n = 25) investigated current and possible uses of RRNs, Phase 2 (2 groups, n = 15) investigated a specific intervention delivering recovery narratives. Phase 3 (2 groups, n = 12) investigated clinical education uses. Thematic analysis was conducted. Results: RRNs can reinforce the effectiveness of existing clinical practices, by reducing communication barriers and normalizing mental health problems. They can also extend clinical practice (increase hope and connection, help when stuck). Clinical considerations are the relationship with care pathways, choice of staff and stage of recovery. In educational use there were opportunities to access lived experience perspectives, train non-clinical staff and facilitate attitudinal change. Barriers and enablers related to design (ability to use online resources, accessibility of language, ability to individualize choice of narrative), risk (triggering content, staff skills to respond to negative effects), trust in online resource (evidence base, maintenance), and technology (cost of use, technology requirements). Conclusions: RRNs can both improve and extend existing clinical practice and be an important educational resource. RRNs can improve engagement and hope, and address internalized stigma. Beneficially incorporating RRNs into clinical practice and education may require new staff skills and improved technological resources in healthcare settings. Future work could focus on the use of peer support workers views on RRN use and how to avoid unnecessary and unhelpful distress. Trial Registration Number: Work in this paper has informed three clinical trials: ISRCTN11152837; ISRCTN63197153; ISRCTN76355273.

Promoting early treatment for mild traumatic brain injury in primary care with a guideline implementation tool: a pilot cluster randomised trial

OBJECTIVES

New clinical practice guidelines for the management of mild traumatic brain injury (mTBI) emphasise that family physicians should proactively screen and initiate treatment for depression/anxiety, insomnia and headaches. This study aimed to evaluate the feasibility of delivering an implementation intervention to family physicians.

DESIGN

Pilot cluster randomised controlled trial.

SETTING

Specialty outpatient clinic (recruitment) and primary care (implementation).

PARTICIPANTS

114 primary care clinics were randomised. These clinics were associated with 137 unique family physicians caring for 148 adult patients who sustained an mTBI within the previous 3 months and were seeking care for persistent symptoms.

INTERVENTIONS

Patients completed self-report screening measures for depression/anxiety, insomnia and headaches. A tailored letter that incorporates the patient's screening test results and associated treatment algorithms was sent to their family physician (or walk-in clinic). Physicians at clinics assigned to the control condition received a generic letter, without the screening test results.

PRIMARY OUTCOME MEASURES

Feasibility outcomes included the frequency of primary care follow-up, retention rates and reliability of patient recall of their physicians' actions (primary mechanistic outcome). The primary efficacy outcome was the Rivermead Post-Concussion Symptom Questionnaire (RPQ).

RESULTS

Most patients (97.8%; 128 of 131) followed up at the primary care clinic they planned to. Retention rates were 88% (131 of 148) and 78% (116 of 148) at the 1-month and 3-month assessments, respectively. Agreement between patient recall of their physicians' actions and medical chart audits was moderate (intraclass correlation coefficient=0.48-0.65). Patients in the experimental group reported fewer symptoms on the RPQ compared with those in the control group, whose physician received a general letter (B=-4.0, 95% CI: -7.3 to -0.7).

CONCLUSIONS

A larger trial will need to address minor feasibility challenges to evaluate the effectiveness of this guideline implementation tool for improving mTBI clinical outcomes and confirm the mechanism(s) of intervention benefit.

TRIAL REGISTRATION NUMBER

NCT03221218.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol

INTRODUCTION

Discharge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the ED with minimal opportunity to ask questions or to ensure comprehension of important information. Strategies for improving discharge communication have primarily targeted patients and/or parents, although neither group has been engaged in intervention design or implementation. Furthermore, ED healthcare providers (HCPs), important actors in discharge communication practice, are rarely consulted regarding intervention design decisions. We will generate evidence to enhance discharge communication by engaging youth, parents and HCPs in the codesign of ED discharge communication strategies (EDUCATE) for asthma and minor head injury.

METHODS AND ANALYSIS

This mixed methods study will take place at two academic paediatric EDs in Canada. The study will occur in two phases: (A) codesign and refinement of the intervention prototypes; and (B) usability testing of the prototypes. During the first phase, two codesign teams (one for each condition) will follow a series of structured design meetings based on the Behavior Change Wheel to develop the EDUCATE interventions. Each codesign team (composed of youth, parents, HCPs and study researchers) will collaborate to identify priority target behaviours and acceptable components to include in the interventions. During the second phase, we will conduct usability testing in two EDs with a group of youth, parents and HCPs to refine the interventions. Two cycles of usability testing will be conducted with intervention refinement occurring at the end of each cycle.

ETHICS AND DISSEMINATION

Informed consent will be obtained from all participants. Ethics approval for this study has been obtained from the Research Ethics Board, IWK Health Centre. Results from this study will form the basis of a future effectiveness implementation trial. Key findings will be presented at national and international conferences and published within peer-reviewed journals.

Engaging patients in de-implementation interventions to reduce low-value clinical care: a systematic review and meta-analysis

BACKGROUND

Many decisions regarding health resource utilization flow through the patient-clinician interaction. Thus, it represents a place where de-implementation interventions may have considerable effect on reducing the use of clinical interventions that lack efficacy, have risks that outweigh benefits, or are not cost-effective (i.e., low-value care). The objective of this systematic review with meta-analysis was to determine the effect of de-implementation interventions that engage patients within the patient-clinician interaction on use of low-value care.

METHODS

MEDLINE, EMBASE, and CINAHL were searched from inception to November 2019. Gray literature was searched using the CADTH tool. Studies were screened independently by two reviewers and were included if they (1) described an intervention that engaged patients in an initiative to reduce low-value care, (2) reported the use of low-value care with and without the intervention, and (3) were randomized clinical trials (RCTs) or quasi-experimental designs. Studies describing interventions solely focused on clinicians or published in a language other than English were excluded. Data was extracted independently in duplicate and pertained to the low-value clinical intervention of interest, components of the strategy for patient engagement, and study outcomes. Quality of included studies was assessed using the Cochrane Risk of Bias tool for RCTs and a modified Downs and Black checklist for quasi-experimental studies. Random effects meta-analysis (reported as risk ratio, RR) was used to examine the effect of de-implementation interventions on the use of low-value care.

RESULTS

From 6736 unique citations, 9 RCTs and 13 quasi-experimental studies were included in the systematic review. Studies mostly originated from the USA (n = 13, 59%), targeted treatments (n = 17, 77%), and took place in primary care (n = 10, 45%). The most common intervention was patient-oriented educational material (n = 18, 82%), followed by tools for shared decision-making (n = 5, 23%). Random effects meta-analysis demonstrated that de-implementation interventions that engage patients within the patient-clinician interaction led to a significant reduction in low-value care in both RCTs (RR 0.74; 95% CI 0.66-0.84) and quasi-experimental studies (RR 0.61; 95% CI 0.43-0.87). There was significant inter-study heterogeneity; however, intervention effects were consistent across subgroups defined by low-value practice and patient-engagement strategy.

CONCLUSIONS

De-implementation interventions that engage patients within the patient-clinician interaction through patient-targeted educational materials or shared decision-making tools are effective in decreasing the use of low-value care. Clinicians and policymakers should consider engaging patients within initiatives that seek to reduce low-value care.

REGISTRATION

Open Science Framework (https://osf.io/6fsxm).

A system uptake analysis and GUIDES checklist evaluation of the Electronic Asthma Management System: A point-of-care computerized clinical decision support system

OBJECTIVE

Computerized clinical decision support systems (CCDSSs) promise improvements in care quality; however, uptake is often suboptimal. We sought to characterize system use, its predictors, and user feedback for the Electronic Asthma Management System (eAMS)-an electronic medical record system-integrated, point-of-care CCDSS for asthma-and applied the GUIDES checklist as a framework to identify areas for improvement.

MATERIALS AND METHODS

The eAMS was tested in a 1-year prospective cohort study across 3 Ontario primary care sites. We recorded system usage by clinicians and patient characteristics through system logs and chart reviews. We created multivariable models to identify predictors of (1) CCDSS opening and (2) creation of a self-management asthma action plan (AAP) (final CCDSS step). Electronic questionnaires captured user feedback.

RESULTS

Over 1 year, 490 asthma patients saw 121 clinicians. The CCDSS was opened in 205 of 1033 (19.8%) visits and an AAP created in 121 of 1033 (11.7%) visits. Multivariable predictors of opening the CCDSS and producing an AAP included clinic site, having physician-diagnosed asthma, and presenting with an asthma- or respiratory-related complaint. The system usability scale score was 66.3 ± 16.5 (maximum 100). Reported usage barriers included time and system accessibility.

DISCUSSION

The eAMS was used in a minority of asthma patient visits. Varying workflows and cultures across clinics, physician beliefs regarding asthma diagnosis, and relevance of the clinical complaint influenced uptake.

CONCLUSIONS

Considering our findings in the context of the GUIDES checklist helped to identify improvements to drive uptake and provides lessons relevant to CCDSS design across diseases.

Advanced informatics understanding of clinician-patient communication: A mixed-method approach to oral health literacy talk in interpreter-mediated pediatric dentistry

Background

In the clinical dental consultation, multi-party configurations predominate with the presence of parents/ primary caregivers in pediatric dentistry adding another layer of complexity. In managing child oral healthcare, parents/ primary caregivers are critical, especially in dental caries prevention. This study aimed (1) to identify the structure of oral health literacy (OHL) talk in interpreter-mediated pediatric dentistry and (2) to analyze interpreter contributions to the communication strategies: patient-centered direct interpreting (PC-DI), patient-centered mediated interpreting (PC-MI), clinician-centered direct interpreting (CC-DI), and clinician-centered mediated interpreting (CC-MI).

Methods

Visual text analysis (VTA) of video recorded pediatric clinical consultations in Hong Kong utilized Discursis^™ software to illustrate temporal and topical structures and their distribution across turns-at-talk. Conversation analysis (CA) was applied to analyze turn-taking of the identified OHL talk qualitatively. The mixed-method approach of combining VTA and CA was applied to analyze the patterns and features of the recorded OHL talk.

Results

The conceptual recurrences of the 77 transcribed video recordings were plotted visually. CC- and PC-OHL talk were identified by the recurrence patterns of monochromatic and multi-colored triangular clusters formed by off-diagonal boxes, respectively. CA of interpreter-mediated turns supported earlier findings regarding patterns of MI in multilingual adult dental consultations; however, the role of the interpreter in parent/ primary caregiver education and patient management was more distinctive in the pediatric dentistry.

Conclusions

The mixed-method approach assisted in unpacking the complexities of the multi-party interactions, supported identification of effective communication strategies, and illustrated the roles of the dental professionals in initiating CC- and PC-OHL talk in pediatric dentistry. The intervention showed the implication of the professional education of evidence-based practices for clinicians in balancing agenda management and the communicative dimension of OHL with the help of VTA and CA in multilingual consultations.

Implementation Effectiveness of a Parent-Directed YouTube Video ("It Doesn't Have To Hurt") on Evidence-Based Strategies to Manage Needle Pain: Descriptive Survey Study

BACKGROUND

Despite the availability of high-quality evidence and clinical practice guidelines for the effective management of pediatric pain, this evidence is rarely used in practice for managing children's pain from needle procedures such as vaccinations. Parents are generally unaware of pain management strategies they can use with their children.

OBJECTIVE

This study aimed to develop, implement, and evaluate the implementation effectiveness of a parent-directed YouTube video on evidence-based strategies to manage needle pain in children.

METHODS

This was a descriptive study. Analytics were extracted from YouTube to describe video reach. A Web-based survey was used to seek parent and health care professional (HCP) feedback about the video. The 2-minute 18-second video was launched on YouTube on November 4, 2013. In the video, a 4-year-old girl tells parents what they should and should not do to help needles hurt less. The key evidence-based messages shared in the video were distraction, deep breathing, and topical anesthetic creams. A group of parents (n=163) and HCPs (n=278) completed the Web-based survey. Measures of reach included number of unique views, country where the video was viewed, sex of the viewer, and length of watch time. The Web-based survey assessed implementation outcomes of the video, such as acceptability, appropriateness, penetration, and adoption.

RESULTS

As of November 4, 2018 (5 years after launch), the video had 237,132 unique views from 182 countries, with most viewers watching an average of 55.1% (76/138 seconds) of the video. Overall, both parents and HCPs reported strong acceptance of the video (ie, they liked the video, found it helpful, and felt more confident) and reported significant improvements in plans to use distraction, deep breathing, and topical anesthetic creams.

CONCLUSIONS

This parent-directed YouTube video was an acceptable and appropriate way to disseminate evidence about the procedure of pain management to a large number of parents.

Knowledge translation strategies for dissemination with a focus on healthcare recipients: an overview of systematic reviews

BACKGROUND

While there is an ample literature on the evaluation of knowledge translation interventions aimed at healthcare providers, managers, and policy-makers, there has been less focus on patients and their informal caregivers. Further, no overview of the literature on dissemination strategies aimed at healthcare users and their caregivers has been conducted. The overview has two specific research questions: (1) to determine the most effective strategies that have been used to disseminate knowledge to healthcare recipients, and (2) to determine the barriers (and facilitators) to dissemination of knowledge to this group.

METHODS

This overview used systematic review methods and was conducted according to a pre-defined protocol. A comprehensive search of ten databases and five websites was conducted. Both published and unpublished reviews in English, Spanish, or Portuguese were included. A methodological quality assessment was conducted; low-quality reviews were excluded. A narrative synthesis was undertaken, informed by a matrix of strategy by outcome measure. The Health System Evidence taxonomy for "consumer targeted strategies" was used to separate strategies into one of six categories.

RESULTS

We identified 44 systematic reviews that describe the effective strategies to disseminate health knowledge to the public, patients, and caregivers. Some of these reviews also describe the most important barriers to the uptake of these effective strategies. When analyzing those strategies with the greatest potential to achieve behavioral changes, the majority of strategies with sufficient evidence of effectiveness were combined, frequent, and/or intense over time. Further, strategies focused on the patient, with tailored interventions, and those that seek to acquire skills and competencies were more effective in achieving these changes. In relation to barriers and facilitators, while the lack of health literacy or e-literacy could increase inequities, the benefits of social media were also emphasized, for example by widening access to health information for ethnic minorities and lower socioeconomic groups.

CONCLUSIONS

Those interventions that have been shown to be effective in improving knowledge uptake or health behaviors should be implemented in practice, programs, and policies-if not already implemented. When implementing strategies, decision-makers should consider the barriers and facilitators identified by this overview to ensure maximum effectiveness.

PROTOCOL REGISTRATION

PROSPERO: CRD42018093245.

Parental Perspectives about Research and Knowledge Translation in Juvenile Idiopathic Arthritis

Objective

To identify barriers and facilitators to the uptake of information from research by parents of children with juvenile idiopathic arthritis (JIA).

Methods

Parents of children with JIA participated in focus group and telephone interviews at four Canadian pediatric rheumatology centers. The semistructured interviews focused on perceptions about JIA research, how new information about JIA was obtained and used, and what information was of most interest. Transcripts were analyzed using a general inductive approach.

Results

Twenty‐eight parents participated in the study. Parents were very interested in research that addresses the outcomes of JIA and side effects of medications. Parents communicated an expectation that information from research be communicated to them by their child's pediatric rheumatologist as part of clinical care. Parents felt that it would be helpful to have information available to them in a variety of formats including written, video, and online. The timing of information delivery is an important factor, with parents being most interested and engaged in learning about new information about JIA at diagnosis and disease flares. We found that parents were overall unaware of new findings from JIA research and therefore may not be optimally utilizing this potentially helpful information in the care of their children.

Conclusion

This study has led to an understanding of Canadian parents’ perceptions about research and existing gaps in the translation of research knowledge. This information will facilitate the development, implementation, and evaluation of future knowledge translation interventions aimed at improving the uptake of research information in the care of children with JIA.

Patients' and Clinicians' Preferences on Outcomes and Medication Attributes for Type 2 Diabetes: a Mixed-Methods Study

BACKGROUND

Patients' views on the relative importance of treatment outcomes and medication attributes for type 2 diabetes may differ from clinicians' perceptions.

OBJECTIVE

To assess which treatment outcomes and medication attributes are considered important by patients and clinicians for therapeutic decisions in type 2 diabetes.

DESIGN

Exploratory, sequential, mixed-methods design comprising a qualitative (focus groups) and a quantitative (survey) phase.

PARTICIPANTS

Patients in the focus groups (n = 33) and the survey study (n = 656) were recruited from 4 and 9 diabetes clinics across Greece, respectively. Clinicians in the survey study (n = 363) were identified from Greek registries for healthcare professionals.

MEASUREMENTS

We conducted 6 focus groups to obtain patients' views regarding the impact of type 2 diabetes on their lives. Identified themes informed the development of a survey, which aimed to assess which outcomes and medication attributes are considered most important by patients and clinicians. We calculated odds ratios to compare patients' and clinicians' responses.

RESULTS

The focus groups identified 6 main themes and 15 subthemes. In the survey study, patients were more likely than clinicians to rate prevention of amputation (odds ratio, 9.32; 95% CI, 6.51 to 13.35), diabetic eye disease (6.16; 4.63 to 8.21), sexual dysfunction, and stroke as important, while clinicians were more likely than patients to choose risk for hypoglycemia, and reduction of all-cause mortality, HbA1c, and body weight. Compared with clinicians, patients were less concerned about drug cost (0.16; 0.11 to 0.23), but more concerned about route of administration and need for less frequent glucose self-monitoring.

CONCLUSIONS

Patients and clinicians differ in the perception of the relative importance of treatment outcomes and drug characteristics. Individual patient preferences should be explored and implemented in the therapeutic decision-making for type 2 diabetes.

Promoting the use of self-management in patients with spine pain managed by chiropractors and chiropractic interns: barriers and design of a theory-based knowledge translation intervention

Background

The literature supports the effectiveness of self-management support (SMS) to improve health outcomes of patients with chronic spine pain. However, patient engagement in SMS programs is suboptimal. The objectives of this study were to: 1) assess participation in self-care (i.e. activation) among patients with spine pain, 2) identify patients’ barriers and enablers to using SMS, and 3) map behaviour change techniques (BCTs) to key barriers to inform the design of a knowledge translation (KT) intervention aimed to increase the use of SMS.

Methods

In summer 2016, we invited 250 patients with spine pain seeking care at the Canadian Memorial Chiropractic College in Ontario, Canada to complete the Patient Activation Measure (PAM) survey to assess the level of participation in self-care. We subsequently conducted individual interviews, in summer 2017, based on the Theoretical Domains Framework (TDF) in a subset of patients to identify potential challenges to using SMS. The interview guide included 20 open-ended questions and accompanying probes. Findings were deductively analysed guided by the TDF. A panel of 7 experts mapped key barriers to BCTs, designed a KT intervention, and selected the modes of delivery.

Results

Two hundred and twenty-three patients completed the PAM. Approximately 24% of respondents were not actively involved in their care. Interview findings from 13 spine pain patients suggested that the potential barriers to using SMS corresponded to four TDF domains: Environmental Context and Resources; Emotion; Memory, Attention & Decision-Making; and Behavioural Regulation. The proposed theory-based KT intervention includes paper-based educational materials, webinars and videos, summarising and demonstrating the therapeutic recommendations including exercises and other lifestyle changes. In addition, the KT intervention includes Brief Action Planning, a SMS strategy based on motivational interviewing, along with a SMART plan and reminders.

Conclusions

Almost one quarter of study participants were not actively engaged in their spine care. Key barriers likely to influence uptake of SMS among patients were identified and used to inform the design of a theory-based KT intervention to increase their participation level. The proposed multi-component KT intervention may be an effective strategy to optimize the quality of spine pain care and improve patients’ health-outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0267-6) contains supplementary material, which is available to authorized users.

A survey of Canadian healthcare professionals' practices regarding reactive balance training

Background: Perturbation-based balance training (PBT) is a relatively new type of balance training that aims to improve control of reactions to a loss of balance. This study aimed to determine the prevalence of use of PBT in clinical practice, and the most significant barriers and facilitators to implementing PBT in practice.Methods: Health-care professionals across Canada (primarily physiotherapists and kinesiologists) who provide balance training to individuals with balance impairments and/or increased fall risk completed a questionnaire that asked about knowledge and use of PBT in practice.Results: Overall, 76.3% of participants (299/392) reported that they had used PBT in their practices, with 22.4% (88/392) reporting regular PBT use. Lack of knowledge of PBT appeared to be the most significant barrier for those not currently using PBT in their practices, whereas individuals who were familiar with PBT and open to using it in practice experienced barriers related to training, knowledge, human resources, client characteristics, and the practice setting. More than 90% of respondents were interested in learning more about almost all aspects of PBT.Conclusions: These findings could be used to inform development of future educational strategies to increase uptake of PBT in rehabilitation practice.

Building patient capacity to participate in care during hospitalisation: a scoping review

OBJECTIVES

To map the existing literature and describe interventions aimed at building the capacity of patients to participate in care during hospitalisation by: (1) describing and categorising the aspects of care targeted by these interventions and (2) identifying the behaviour change techniques (BCTs) used in these interventions. A patient representative participated in all aspects of this project.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, Embase and CINAHL (Inception -2017).

STUDY SELECTION

Studies reporting primary research studies on building the capacity of hospitalised adult patients to participate in care which described or included one or more structured or systematic interventions and described the outcomes for at least the key stakeholder group were included.

DATA EXTRACTION

Title and abstract screening and full text screening were conducted by pairs of trained reviewers. One reviewer extracted data, which were verified by a second reviewer. Interventions were classified according to seven aspects of care relevant to hospital settings. BCTs identified in the articles were assigned through consensus of three reviewers.

RESULTS

Database searches yielded a total 9899 articles, resulting in 87 articles that met the inclusion criteria. Interventions directed at building patient capacity to participate in care while hospitalised were categorised as those related to improving: patient safety (20.9%); care coordination (5.7%); effective treatment (5.7%) and/or patient-centred care using: bedside nursing handovers (5.7%); communication (29.1%); care planning (14%) or the care environment (19.8%). The majority of studies reported one or more positive outcomes from the defined intervention. Adding new elements (objects) to the environment and restructuring the social and/or physical environment were the most frequently identified BCTs.

CONCLUSIONS

The majority of studies to build capacity for participation in care report one or more positive outcomes, although a more comprehensive analysis is warranted.

Quality of DCIS information on the internet: a content analysis

PURPOSE

Women with ductal carcinoma in situ (DCIS) experience lingering confusion and anxiety, and may use the Internet for supplemental information. This study assessed the content and quality of DCIS information on the Internet.

METHODS

We searched Google for English-language, publicly available DCIS information tools published from 2010 to current by non-profit organizations. We summarized tool characteristics, DCIS labels, and information important to women with DCIS corresponding to domains of a patient-centred care (PCC) framework. Tool quality was appraised with the DISCERN instrument.

RESULTS

Of 39 tools included, most were plain language summaries published since 2016. Tools employed a median of 2.0 labels (range 1.0 to 5.0) for DCIS, most frequently non-invasive breast cancer (29, 74.4%), abnormal cells (14, 35.9%), pre-cancer (14, 35.9%), and early form of breast cancer (13, 33.3%). Tools addressed a median of 4.0 (range 2.0 to 5.0) PCC domains. Few tools contained content in the domains of fostering the relationship (30.8%), addressing emotions (41.0%), or follow-up (41.0%); 74.4% noted the risk of progression or recurrence but provided vague details. Tools were assessed as high (25.6%), moderate (48.7%), and low (25.6%) quality.

CONCLUSIONS

Few DCIS information tools available to women on the Internet meet quality criteria for consumer health information or address concerns of importance to women with DCIS. By identifying a range of poorly defined terms used to label DCIS, and specific content domains that were lacking, this study identified how existing tools could be improved, and identified higher-quality tools that clinicians can use when discussing DCIS with patients.

Patient-mediated interventions to improve professional practice: A summary of a Cochrane systematic review

OBJECTIVE

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance.

METHODS

We conducted a systematic Cochrane review according to established guidelines. We searched predefined databases in 2016 and 2017. Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, performed meta-analyses, and assessed the certainty of the evidence (GRADE).

RESULTS

We included 25 randomised studies with a total of 12 268 patients. We found that patient-reported health information interventions and patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate certainty evidence). We also found that patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).

CONCLUSION

Our findings strengthen the belief that patient-mediated interventions have the potential to improve professional practice, especially patient-reported health information interventions and patient education interventions.

PRACTICE IMPLICATIONS

Our findings show that patient-reported health information interventions and patient education interventions are relevant approaches to improve professional practice. Thus, it seems reasonable to conclude that these types of patient-mediated interventions can contribute to improving the quality of healthcare services.

Treat-to-target in rheumatoid arthritis: Evaluating the patient perspective using the Patient Opinion Real-Time Anonymous Liaison system: The RA T2T PORTAL study

OBJECTIVES

To determine the level of agreement among patients with rheumatoid arthritis (RA) with the principles and recommendations of the treat-to-target (T2T) initiative in New Zealand (NZ) and to further explore specific patient opinions via online iterative surveys.

METHODS

Participants with RA were recruited from rheumatology clinics in NZ and invited to receive and reply to surveys administered via the Patient Opinion Real-Time Anonymous Liaison (PORTAL) system. An enrolment survey recorded demographics, disease duration and treatment and then RA T2T surveys were administered weekly. A Likert scale 1-5 measured agreement with the principles and recommendations and further surveys explored responses of interest identified by investigators from each prior survey.

RESULTS

One hundred and ninety patients consented to participate in PORTAL and 132 in the RA T2T surveys. Level of agreement with RA T2T principles was: 93.3% to 99.3% and to the recommendations: 77.3%-100%. The lowest level of agreement 77.3% was with recommendation 8, 3 monthly treatment adjustment, and the highest was 100% agreement with recommendation 10, shared decision-making. Patients agreed less with low disease activity as the target compared with remission (91.4% and 98%). Despite high-level agreement for the use of a disease activity score (95.7%), 23% did not feel the individual components reflected their disease control. Patients rated difficulty coping, erosions on imaging, health-related quality of life and pain all significantly higher than C-reactive protein as indicators of worsening arthritis.

CONCLUSIONS

Despite a high level of patient agreement with RA T2T this study highlights the importance of patient engagement in the RA T2T process to individualize therapy adjustments, make shared decisions and decide on targets that accurately reflect disease control according to patients.

Development process and patient usability preferences for a touch screen tablet-based questionnaire

We sought to design a touch tablet asthma questionnaire while identifying patient preferences for usability features of such questionnaires. We created an evidence-based prototype and employed rapid-cycle design (semi-structured focus group testing, analysis, corresponding modifications, re-testing) with asthma patients aged ⩾16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-type-scale responses, the System Usability Scale, and questionnaire completion times. There were 20 participants across five focus groups (15/20 female, age 49.1 ± 15.6 years). Usability-related themes included (1) "Touch Technology" (hygiene, touch technology familiarity, ease of use) and (2) "Questionnaire Design" (visual characteristics, navigation). Completion time was 11.7 ± 5.9 min. Summative Likert-type scale responses suggested high system usability, as did a System Usability Scale score of 84.2 ± 14.7. In summary, Attention to specific technology- and design-related preferences can result in a highly usable patient-facing touch tablet questionnaire. Our findings can inform touch questionnaire design across other diseases.

Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda

The field of implementation science was developed to better understand the factors that facilitate or impede implementation and generate evidence for implementation strategies. In this article, we briefly review progress in implementation science, and suggest five priorities for enhancing the impact of implementation strategies. Specifically, we suggest the need to: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; (4) increase economic evaluations of implementation strategies; and (5) improve the tracking and reporting of implementation strategies. We believe that pursuing these priorities will advance implementation science by helping us to understand when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

Defining barriers and enablers for clinical pathway implementation in complex clinical settings

BACKGROUND

While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings.

METHODS

This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel.

RESULTS

Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model.

CONCLUSIONS

Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01815710 .

Patient preferences for a touch screen tablet-based asthma questionnaire

OBJECTIVE

Assessment of asthma control and provision of asthma action plans are seldom performed in practice, partly due to limited time for physicians to ascertain required information. A patient-facing electronic asthma questionnaire could facilitate information collection. We sought to design a touch-tablet asthma questionnaire for use in the clinic waiting room and to describe patient preferences for the content of such a questionnaire.

METHODS

We created a questionnaire prototype based on best evidence and employed rapid-cycle design (semi-structured focus group testing; analysis; corresponding modifications and re-testing) with asthma patients aged ≥16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-scale questions and questionnaire completion times.

RESULTS

There were 20 participants across five focus groups (15/20 (75%) female, age 49.1 ± 15.6 years). Content-related themes included: 1) comprehensibility (language) (how questionnaire language affected ease and accuracy of comprehension) and b) information collection (issues arising during information collection in the following identified subthemes: personal asthma symptoms and triggers; asthma control; asthma medications and contact information). Average questionnaire completion time was 11.7 ± 5.9 min. Summative Likert scale responses suggested high levels of question comprehension and confidence with responses.

CONCLUSIONS

Our analysis provides novel insight about how best to formulate and present asthma-related content in an electronic questionnaire. Such questionnaires might facilitate quality improvement by improving efficiency of data collection, enabling better assessment of asthma control and medication adherence, and personalization of asthma action plans. Future studies should measure real-world uptake of such a questionnaire and impact on care.

Patient-mediated interventions to improve professional practice

BACKGROUND

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

OBJECTIVES

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

SEARCH METHODS

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

SELECTION CRITERIA

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

MAIN RESULTS

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

AUTHORS' CONCLUSIONS

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.