Knowledge creation: synthesis, tools and products

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Patient and clinician perspectives on implant dentistry decision aid content: Results from an enhanced Delphi study

PURPOSE

To investigate patient and clinician perspectives on what is considered important to include in a decision aid for replacement of a missing tooth with an implant.

METHODS

An online modified Delphi method with pair comparisons technique was used to survey participants (66 patients, 48 prosthodontists, 46 periodontists, and 31 oral surgeons) in Ontario, Canada from November 2020 to April 2021 regarding the importance of information provided during an implant consultation. Round one included 19 items derived from the literature and informed consent protocols. The decision to retain an item was based on group consensus, defined as at least 75% of participants identifying the item as "important" or "highly important." After analysis of round one results, a second-round survey was sent to all participants to rank the relative importance of the consensus items. Statistical testing was completed using the Kruskal-Wallis one-way analysis of variance test and post hoc Mann-Whitney U tests with a significance level set at p ≤ 0.05.

RESULTS

The first and second surveys had response rates of 77.0% and 45.6%, respectively. In round one, all items except purpose of steps reached group consensus. In round two, the highest group ranked items were patient responsibilities for treatment success and follow-ups after treatment. The lowest group ranked items were cost factors and restorative steps. Significant differences between the stakeholder groups were found on several items, including diagnosis (p ≤ 0.00), non-implant options (p ≤ 0.00), and cost (p ≤ 0.01). In general, patients' opinions were significantly different than clinicians' opinions on the relative importance of items.

CONCLUSIONS

Clinicians and patients feel that multiple items are important to include in a decision aid for implant therapy; however, differences exist between patients and clinicians on the relative importance of items.

Advancing the Actionability of Mental Health Information: Identifying Online, Evidence-Based Mental Health Resources

To improve the dissemination and actionability of mental health research, many mental health professionals have developed online informational resources to increase the general public's awareness of mental health difficulties and available treatments. Yet, limited information exists on the quality and scope of these resources. This study aimed to explore the scope and quantity of online, free, evidence-based mental health resources. Fifty-two mental health professionals nominated 178 resources, which predominantly consisted of homepages and links to more information. When reviewing the original nominations, our team identified an additional 290 resources (e.g., fact sheets linked from a nominated homepage). Of the 468 total nominated resources, 72 were screened out due to not meeting the inclusion criteria of being free (inter-screener reliability = 95%), evidence-based (inter-screener reliability = 94%), and online (inter-screener reliability = 96%). Nominated resources most commonly covered anxiety and obsessive-compulsive disorder (n = 67) and suicide (n = 60). Resources providing information about the mental health problem were most common (n = 210) and resources providing information about immediate help (e.g., hotline) were least common (n = 57). Our findings indicate many free, online, evidence-based resources are available and raise questions of whether efforts to disseminate mental health research are recreating the issue of information overload. Other considerations and future directions for improving the utilization and synthesizing of available resources are discussed.

Developing an Educational and Decision Support Tool for Stage I Lung Cancer Using Decision Science

BACKGROUND

Guidelines recommend shared decision-making about treatment options for high-risk, operable stage I lung cancer. Patient decision aids can facilitate shared decision-making; however, their development, implementation, and evaluation in routine clinical practice presents numerous challenges and opportunities.

METHODS

The purpose of this review is to reflect on the process of tool development; identify the challenges associated with meeting the needs of patients, clinicians from multiple disciplines, and institutional workflow during implementation; and propose recommendations for future clinicians who wish to develop, refine, or implement similar tools into routine care.

RESULTS

In this review, we: (1) discuss guidelines for decision aid development; (2) describe how we applied those to create an education and decision support tool for patients with clinical stage I lung cancer deciding between radiation therapy and surgical resection; and (3) highlight challenges in implementing and evaluating the tool.

CONCLUSIONS

We provide recommendations for those seeking to develop, refine, or implement similar tools into routine care.

User Experience of a Computer-Based Decision Aid for Prenatal Trisomy Screening: Mixed Methods Explanatory Study

BACKGROUND

Mobile health tools can support shared decision-making. We developed a computer-based decision aid (DA) to help pregnant women and their partners make informed, value-congruent decisions regarding prenatal screening for trisomy.

OBJECTIVE

This study aims to assess the usability and usefulness of computer-based DA among pregnant women, clinicians, and policy makers.

METHODS

For this mixed methods sequential explanatory study, we planned to recruit a convenience sample of 45 pregnant women, 45 clinicians from 3 clinical sites, and 15 policy makers. Eligible women were aged >18 years and >16 weeks pregnant or had recently given birth. Eligible clinicians and policy makers were involved in prenatal care. We asked the participants to navigate a computer-based DA. We asked the women about the usefulness of the DA and their self-confidence in decision-making. We asked all participants about usability, quality, acceptability, satisfaction with the content of the DA, and collected sociodemographic data. We explored participants' reactions to the computer-based DA and solicited suggestions. Our interview guide was based on the Mobile App Rating Scale. We performed descriptive analyses of the quantitative data and thematic deductive and inductive analyses of the qualitative data for each participant category.

RESULTS

A total of 45 pregnant women, 14 clinicians, and 8 policy makers participated. Most pregnant women were aged between 25 and 34 years (34/45, 75%) and White (42/45, 94%). Most clinicians were aged between 35 and 44 years (5/14, 36%) and women (11/14, 79%), and all were White (14/14, 100%); the largest proportion of policy makers was aged between 45 and 54 years (4/8, 50%), women (5/8, 62%), and White (8/8, 100%). The mean usefulness score for preparing for decision-making for women was 80/100 (SD 13), and the mean self-efficacy score was 88/100 (SD 11). The mean usability score was 84/100 (SD 14) for pregnant women, 77/100 (SD 14) for clinicians, and 79/100 (SD 23) for policy makers. The mean global score for quality was 80/100 (SD 9) for pregnant women, 72/100 (SD 12) for clinicians, and 80/100 (SD 9) for policy makers. Regarding acceptability, participants found the amount of information just right (52/66, 79%), balanced (58/66, 88%), useful (38/66, 58%), and sufficient (50/66, 76%). The mean satisfaction score with the content was 84/100 (SD 13) for pregnant women, 73/100 (SD 16) for clinicians, and 73/100 (SD 20) for policy makers. Participants thought the DA could be more engaging (eg, more customizable) and suggested strategies for implementation, such as incorporating it into clinical guidelines.

CONCLUSIONS

Pregnant women, clinicians, and policy makers found the DA usable and useful. The next steps are to incorporate user suggestions for improving engagement and implementing the computer-based DA in clinical practice.

Improving providers' survival estimates and selection of prognosis- and guidelines-appropriate treatment for patients with symptomatic bone metastases: Development of the Bone Metastases Ensemble Trees for Survival Decision Support Platform

RATIONALE, AIMS AND OBJECTIVES

In the management of symptomatic bone metastases, current practice guidelines do not provide clear methodology for selecting palliative radiotherapy (RT) regimens based on specific patient and disease features. Decision support aids may offer an effective means for translating the complex data needed to render individualised treatment decisions, yet no such tools are available for use in this setting. Thus, we describe the development of the Bone Metastases Ensemble Trees for Survival-Decision Support Platform (BMETS-DSP), which aims to optimise selection of evidence-based, individualised palliative RT regimens.

METHOD

The Ottawa Decision Support Framework was used as the theoretical basis for development of BMETS-DSP. First, we utilised stakeholder input and review of the literature to assess determinants underlying the provider decision. Based on this assessment and iterative stakeholder feedback, we developed the web-based, provider-facing BMETS-DSP. Consistent with the underlying theoretical framework, our design also included assessment of decision quality using the International Patient Decision Aids Standards (IPDAS) certification checklist.

RESULTS

Stakeholder input and review of 54 evidence-based publications identified the following determinants of the provider decision: estimated prognosis, characteristics of the target symptomatic lesion and the primary cancer type, consideration of alternative interventions, access to patient-specific recommendations, and patient preferences. Based on these determinants, we developed the BMETS-DSP that (1) collects patient-specific data, (2) displays an individualised predicted survival curve, and (3) provides case-specific, evidence-based recommendations regarding RT, open surgery, systemic therapy, and hospice referral to aid in the decision-making process. The finalised tool met IPDAS quality requirements. Preliminary results of a pilot assessment suggest impact of clinical outcomes.

CONCLUSIONS

We describe the successful development of a provider-facing decision support platform to aid in the provision of palliative RT in better alignment with patient and disease features. Impact of the BMETS-DSP on decision outcomes will be further assessed in a randomised, controlled study.

A knowledge implementation model in health system management based on the PARIHS model

BACKGROUND

The gap between knowledge and practice, along with postponing or not implementing research findings in practice and policy-making, is one of the reasons for low-quality services. Hence, this study aimed at presenting a model of knowledge implementation in health system management in Iran.

METHODS

The present two-phase study was first performed qualitatively using a directive content analysis approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model. The researchers extracted the barriers and facilitators by conducting semi-structured individual interviews. Then, in a three-stage Delphi study, 25 health experts determined the barrier removal strategies. Data were analysed using MAXQDA10 software.

RESULTS

 The content analysis of the interviews led to the emergence of 1212 codes under three categories of evidence, context and facilitation. The findings indicate that health managers make fewer decisions based on research findings. Instead, they make decisions regarding the experiences of service providers and organization data. In addition to the subcategories in the PARIHS model, the researchers extracted political, social and administrative factors under the context category. The relationships between the features of evidence, context, facilitation, barriers and strategies were presented in the final model.

CONCLUSION

 The presented model comprehensively emphasizes the evidence resources, context preparation, and facilitation of the knowledge implementation process.

Clinician perspectives on a culturally adapted patient decision aid concerning maintenance therapy for asthma

BACKGROUND AND OBJECTIVE

Patients with persistent asthma often show poor adherence to inhaled corticosteroids (ICS). Shared decision-making can improve adherence rates in this population. Patient decision aids (PDAs) are tools to facilitate shared decision-making. To date, only one PDA, developed in a Canadian French-speaking population, exists for patients considering ICS maintenance therapy. This PDA has been culturally adapted in this study to contextualize to the needs of multi-ethnic Asian patients in Singapore. This study explored the views of local clinicians on the content, design and implementation of this newly-adapted PDA.

METHODS

24 clinicians, who were purposively sampled from polyclinics and a tertiary institution, were interviewed on the content, design and implementation of the PDA. The interviews were audio-recorded, transcribed and analyzed via thematic analysis.

RESULTS

Clinicians generally accepted the design of the PDA. They suggested for the target users to be patients on Step 2 of GINA guidelines and the number of options to be reduced from four to two (do nothing or start inhaled corticosteroids). Moreover, they supported including a list of values for patients to select from given that Asian patients often do not articulate their values readily. The addition of more visual aids, the production of multilingual Asian editions and the involvement of nurses to administer the PDA was also suggested.

CONCLUSION

The PDA was culturally-adapted with local clinicians' perspectives to target multi-ethnic Asian patients with persistent asthma (Step 2 GINA guidelines). The main changes include a list of values and addition of visual aids.

A strategic initiative to facilitate knowledge translation research in rehabilitation

BACKGROUND

While there is a growing body of literature supporting clinical decision-making for rehabilitation professionals, suboptimal use of evidence-based practices in that field persists. A strategic initiative that ensures the relevance of the research and its implementation in the context of rehabilitation could 1) help improve the coordination of knowledge translation (KT) research and 2) enhance the delivery of evidence-based rehabilitation services offered to patients with physical disabilities. This paper describes the process and methods used to develop a KT strategic initiative aimed at building capacity and coordinating KT research in physical rehabilitation and its strategic plan; it also reports the initial applications of the strategic plan implementation.

METHODS

We used a 3-phase process consisting of an online environmental scan to identify the extent of KT research activities in physical rehabilitation in Quebec, Canada. Data from the environmental scan was used to develop a strategic plan that structures KT research in physical rehabilitation. Seven external KT experts in health science reviewed the strategic plan for consistency and applicability.

RESULTS

Sixty-four KT researchers were identified and classified according to the extent of their level of involvement in KT. Ninety-six research projects meeting eligibility criteria were funded by eight of the fourteen agencies and organizations searched. To address the identified gaps, a 5-year strategic plan was developed, containing a mission, a vision, four main goals, nine strategies and forty-two actions.

CONCLUSION

Such initiatives can help guide researchers and relevant key stakeholders, to structure, organize and advance KT research in the field of rehabilitation. The strategies are being implemented progressively to meet the strategic initiative's mission and ultimately enhance users' rehabilitation services.

Usability of the Participation and Quality of Life (PAR-QoL) Outcomes Toolkit Website for Spinal Cord Injury

Background: Quality of life (QoL) is an important parameter to monitor during rehabilitation; however, accurate assessment is challenging. Among individuals with spinal cord injury (SCI), assessing QoL is further challenged due to complex sequelae, such as secondary health conditions and factors related to community integration. A Participation and Quality of Life (PAR-QoL) toolkit was created to aid clinicians and researchers in the selection of QoL outcomes tools specific to SCI. Objectives: The aim of this study was to evaluate the use and usability of the PAR-QoL toolkit. Methods: A cross-sectional study was conducted using an online survey from December 2013 to November 2016. Google Analytics were collected from April 2012 to April 2018. Survey sections addressed "use" (behavioral practices and actual use) and "usability" (perceived ease of use and perceived usefulness). Any person who visited the PAR-QoL website was invited to complete the survey. Summary statistics and percent concordances were calculated to describe results from the survey and Google Analytics. Results: The PAR-QoL website had 188,577 users. The five most visited webpages were outcome tools, with bounce rates ranging from 77% to 90%. Of the 46 survey respondents, 67% were not current users of the PAR-QoL website, and 87% intended to use the resources in the future. Conclusion: Uptake of the PAR-QoL website is currently limited. Usability of the PAR-QoL website may be improved by modifying navigation, removing the "less useful" components, ensuring regular updates of content and resources, and promoting the website.

Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource

Study design

Knowledge translation (KT) study.

Objectives

To demonstrate how to use systematic, community-engaged methods to (1) translate the international scientific spinal cord injury (SCI) exercise guidelines into community and clinical practice guidelines, and (2) develop supporting resources.

Setting

Canada.

Methods

An expert panel of SCI researchers and stakeholders translated the guidelines and developed a supporting resource, using a KT process guided by an adapted version of the Appraisal of Guidelines, Research and Evaluation (AGREE) II Instrument. Pilot tests with end-users were conducted throughout.

Results

The panel recommended (1) the two scientific exercise guidelines be combined and presented in a single message titled “The Canadian SCI physical activity guidelines”; (2) development of an online supporting resource, with educational and motivational information presented in “layers” to address the needs and preferences of diverse end-users. The top layer presents and explains the Canadian SCI physical activity guidelines. The deeper layers include information on benefits, overcoming barriers, activity examples, safety tips, and links to existing resources. Interviews with adults with SCI (n = 8) and survey-data from end-users (n = 90) showed that the guidelines and supporting resource were perceived as clear, useful, and appropriate.

Conclusion

Using community-engaged methods, the two scientific SCI exercise guidelines were combined into one single physical activity guideline message. This KT process provides a template for groups in other countries to translate the scientific SCI exercise guidelines to their local settings using a similar systematic, community-engaged approach.

Sponsorship

Rick Hansen Institute; Social Sciences and Humanities Research Council of Canada.

A conceptual framework for patient-directed knowledge tools to support patient-centred care: Results from an evidence-informed consensus meeting

OBJECTIVE

Patient-directed knowledge tools are designed to engage patients in dialogue or deliberation, to support patient decision-making or self-care of chronic conditions. However, an abundance of these exists. The tools themselves and their purposes are not always clearly defined; creating challenges for developers and users (professionals, patients). The study's aim was to develop a conceptual framework of patient-directed knowledge tool types.

METHODS

A face-to-face evidence-informed consensus meeting with 15 international experts. After the meeting, the framework went through two rounds of feedback before informal consensus was reached.

RESULTS

A conceptual framework containing five patient-directed knowledge tool types was developed. The first part of the framework describes the tools' purposes and the second focuses on the tools' core elements.

CONCLUSION

The framework provides clarity on which types of patient-directed tools exist, the purposes they serve, and which core elements they prototypically include. It is a working framework and will require further refinement as the area develops, alongside validation with a broader group of stakeholders.

PRACTICE IMPLICATIONS

The framework assists developers and users to know which type a tool belongs, its purpose and core elements, helping them to develop and use the right tool for the right job.

Practice, complexity and evidence-based practice

In this opinion piece, I explore practice and complexity, the latter a term often used in relation to the field of special care dentistry. As research is usually concerned with generating new knowledge of some sort, I explore how knowledge is viewed from a practice perspective, as shared, transitory and situated in interactions, rather than being a thing possessed. This leads into a discussion of how the word complexity has been viewed in complexity science, contrasting it with the linear models generated in the evidence-based practice realm from research and research-informed guidelines. Finally, I address the inherent paradox of attempting to align linear models generated from research with the complexity of practice. I suggest that to evaluate and improve practices we should use narrative and exploratory methods that allow its complexity to be made sense of, made transparent and made available for interpretation.

Developing quality criteria for patient-directed knowledge tools related to clinical practice guidelines. A development and consensus study

BACKGROUND

Patient-directed knowledge tools such as patient versions of guidelines and patient decision aids are increasingly developed to facilitate shared decision making. In this paper, we report how consensus was reached within the Netherlands on quality criteria for development, content and governance of these tools.

METHOD

A 12-month development and consensus study. The consortium worked on four work packages: (a) reviewing existing criteria; (b) drafting the quality criteria; (c) safe-guarding the acceptability and feasibility of the draft criteria by participatory research in on-going tool development projects; and (d) gaining formal support from national stakeholders on the quality criteria.

RESULTS

We reached consensus on a 8-step guidance; describing minimal quality criteria for (a) the team composition; (b) setting the scope; (c) identifying needs; (d) the content and format; (e) testing the draft; (f) finalizing and approval; (g) dissemination and application, and (h) ownership and revision. The participants of the on-going tool development projects were positive about the quality criteria in general, but divided as to the degree of detail. Whereas some expressed a clear desire for procedural standards, others felt that it would be sufficient to provide only general directions. Despite the different views as to the degree of detail, consensus was reached in three stakeholder meetings.

DISCUSSION

We successfully collaborated with all stakeholders and achieved formal support from national stakeholders on a set of minimum criteria for the development process, content and governance of patient-directed knowledge tools.

From Science to Policy and Practice: A Critical Assessment of Knowledge Management before, during, and after Environmental Public Health Disasters

Canada regularly faces environmental public health (EPH) disasters. Given the importance of evidence-based, risk-informed decision-making, we aimed to critically assess the integration of EPH expertise and research into each phase of disaster management. In-depth interviews were conducted with 23 leaders in disaster management from Canada, the United States, the United Kingdom, and Australia, and were complemented by other qualitative methods. Three topics were examined: governance, knowledge creation/translation, and related barriers/needs. Data were analyzed through a four-step content analysis. Six critical success factors emerged from the analysis: blending the best of traditional and modern approaches; fostering community engagement; cultivating relationships; investing in preparedness and recovery; putting knowledge into practice; and ensuring sufficient human and financial resources. Several promising knowledge-to-action strategies were also identified, including mentorship programs, communities of practice, advisory groups, systematized learning, and comprehensive repositories of tools and resources. There is no single roadmap to incorporate EPH expertise and research into disaster management. Our findings suggest that preparation for and management of EPH disaster risks requires effective long-term collaboration between science, policy, and EPH practitioners at all levels in order to facilitate coordinated and timely deployment of multi-sectoral/jurisdictional resources when and where they are most needed.

Factors influencing the use by radiation therapists of cancer symptom guides: a mixed-methods study

Background

Radiation therapists play an important role in helping patients to safely manage and triage potentially life-threatening symptoms. The purpose of the present study was to assess factors influencing the use by radiation therapists of evidence-informed symptom practice guides for patients experiencing cancer treatment-related symptoms.

Methods

In a mixed-methods descriptive study guided by the Knowledge-to-Action framework, interviews and a barriers survey were conducted. Two independent reviewers conducted a content analysis of interview transcripts. Barriers survey data were analyzed using frequency distributions and univariate descriptive statistics. Open-ended data from the surveys underwent content analysis and were triangulated with interview findings.

Results

Of 90 radiation therapists approached, 58 completed the survey (64%), and 14 were interviewed. Of the 98% who reported providing symptom management to patients undergoing radiation treatment, 53% used evidence-informed practice guidelines. Radiation therapists had moderate moral norms (4.6 of 7) and beliefs about the consequences of using costars (pan-Canadian Oncology Symptom Triage and Remote Support) practice guides (4.8), but neutral intention (3.4) and beliefs about their own capabilities (3.9). Environmental barriers included lack of time (2.0), lack of access (2.5), and neutral organizational support (3.0). Radiation therapists identified a need for training (5.5). Common unique barriers to practice guide use were lack of time during radiation treatments, unclear fit with scope of practice, disparate focus on site-specific symptoms, and lack of medication knowledge.

Conclusions

The symptom practice guides were perceived by the radiation therapists to benefit patients, enhance their own knowledge of symptom management, and promote consistent practice. Additional work is required to identify the scope of practice of radiation therapists within the interprofessional team.

Implementing Practice Guides to Improve Cancer Symptom Management in Homecare: A Comparative Case Study

Symptoms experienced by clients with cancer often occur at home and can become life-threatening, posing serious safety concerns. This study evaluated implementation of evidence-informed symptom practice guides to enhance quality of cancer symptom support by homecare nurses. A comparative case study was conducted using the Knowledge to Action Framework. Case were created for each of six agencies providing nursing care within a regional homecare authority. A team of researchers and knowledge users (e.g., managers, educators, family member): (1) assessed factors influencing practice guide use (survey, interviews) at six agencies, (2) adapted 15 practice guides for local use, (3) implemented with interventions to address barriers, and (4) monitored use. Analysis was within and across cases. Of six nursing agencies, one withdrew and five participated. In the baseline survey, 51% of nurses reported using guidelines but nurses did not describe using them in their current practice during the interviews. To overcome barriers, 489 nurses in five agencies were trained in how to use the practice guides, principles were established for documenting cancer symptom management, and practice guides were made available in various formats. Success with implementation varied across the participating cases. Chart audits conducted in three agencies revealed evidence of practice guide use for 16%, 22%, and 70% client visits, respectively. Implementation of evidence-informed practice guides in nursing required an approach tailored for each agency. Training, integration in documentation, and easy access to practice guides increased use for some nurses but ongoing support and reinforcement from nurse leaders is required.

Interventions for increasing the use of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review.

OBJECTIVES

To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs.

AUTHORS' CONCLUSIONS

It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Mentoring as a Knowledge Translation Intervention for Implementing Nursing Practice Guidelines: A Qualitative Study

An interpretive descriptive qualitative study was conducted to explore the characteristics and outcomes of mentoring used for implementing nursing practice guidelines. We interviewed six mentees, eight mentors, and four program leaders who were involved in the Registered Nurses' Association of Ontario fellowship program in Ontario, Canada. Inductive content analysis was used and study rigor was verified using triangulation of findings and member checking. Mentors were described as accessible, dedicated, and having expertise; mentees were described as enthusiastic, self-directed, and having mixed levels of expertise. The mentoring process included building relationships, developing learning plans, and using teaching and learning activities guided by learning plans to support development of mentees. Mentoring was described as positively impacting mentoring relationships, mentees, mentors, and organizations. A central feature of this fellowship program was the learning plan used to identify mentees' needs, guide mentoring activities, and monitor measureable outcomes.

Effects of exercise on fitness and health of adults with spinal cord injury: A systematic review

OBJECTIVE

To synthesize and appraise research testing the effects of exercise interventions on fitness, cardiometabolic health, and bone health among adults with spinal cord injury (SCI).

METHODS

Electronic databases were searched (1980-2016). Included studies employed exercise interventions for a period ≥2 weeks, involved adults with acute or chronic SCI, and measured fitness (cardiorespiratory fitness, power output, or muscle strength), cardiometabolic health (body composition or cardiovascular risk factors), or bone health outcomes. Evidence was synthesized and appraised using Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

RESULTS

A total of 211 studies met the inclusion criteria (22 acute, 189 chronic). For chronic SCI, GRADE confidence ratings were moderate to high for evidence showing exercise can improve all of the reviewed outcomes except bone health. For acute SCI, GRADE ratings were very low for all outcomes. For chronic SCI, there was low to moderate confidence in the evidence showing that 2-3 sessions/week of upper body aerobic exercise at a moderate to vigorous intensity for 20-40 minutes, plus upper body strength exercise (3 sets of 10 repetitions at 50%-80% 1-repetition maximum for all large muscle groups), can improve cardiorespiratory fitness, power output, and muscle strength. For chronic SCI, there was low to moderate confidence in the evidence showing that 3-5 sessions per week of upper body aerobic exercise at a moderate to vigorous intensity for 20-44 minutes can improve cardiorespiratory fitness, muscle strength, body composition, and cardiovascular risk.

CONCLUSIONS

Exercise improves fitness and cardiometabolic health of adults with chronic SCI. The evidence on effective exercise types, frequencies, intensities, and durations should be used to formulate exercise guidelines for adults with SCI.

Managing Symptoms During Cancer Treatments: Barriers and Facilitators to Home Care Nurses Using Symptom Practice Guides

Nurses are instrumental in helping clients safely manage at home and triage potentially life-threatening symptoms from cancer. The purpose of this study was to assess factors influencing home care nurses’ use of 15 evidence-informed symptom practice guides for providing telephone or in-home nursing services to clients with cancer. A mixed-methods descriptive study was guided by the Knowledge-to-Action Framework. All six nursing agencies within a regional home care authority participated. Data collection included retrospective audit of symptom management in 50 patient records, 14 interviews, and barriers survey from 150 of 243 (61.7%) registered nurses and registered practical nurses providing cancer symptom support in home care. Chart audit revealed more than 80% of clients were on chemotherapy and common symptoms were nausea/vomiting (44%), constipation (32%), fatigue (32%), loss of appetite (32%), and pain (20%). Nurses had positive intentions ( M = 5.4 out of 7; SD = 1.3) and felt capable of using the symptom practice guides ( M = 5.4; SD = 1.0), held strong beliefs about the consequences ( M = 5.8; SD = 1.1) and moral norms of using them ( M = 5.7; SD = 1.1), and identified neutral to low social influence ( M = 3.0; SD = 1.6). Common barriers were inadequate time in practice, learning curve, need to integrate into documentation, and competing system changes. Common facilitators were being comprehensive, an evidence-based resource for use in practice, and having consistent symptom management guides across settings. Overall, the symptom guides were well received by the nurses. Interventions nurses identified to overcome barriers were education, clear organizational mandate for implementation, and integration with documentation.

Implementation of asthma clinical practice guidelines in primary care: A cross-sectional study based on the Knowledge-to-Action Cycle

OBJECTIVE

Based on the Knowledge-to-Action Cycle, we assessed the self-reported implementation and perception of asthma clinical practice guideline (CPG) recommendations in primary care physicians (PCPs), along with the barriers and facilitators to CPG use in primary care.

METHODS

We conducted a cross-sectional study. Using the extended Asthma Physicians' Practice Assessment Questionnaire^©, PCPs self-reported the following: their knowledge of 15 key asthma CPG recommendations, the perceived usefulness of each of these recommendations, their motivation to apply these recommendations, and their agreement with the content of these recommendations. Participants also reported the barriers and facilitators to CPG use in primary care.

RESULTS

Out of the 46 potential participants, 43 physicians completed the questionnaire (response rate: 93%). Results underlined care gaps regarding the provision of asthma education and written action plans, inhaler technique demonstrations, and assessment of patients' concerns. Results showed that the majority of physicians knew the key asthma CPG recommendations, but their motivation to implement them and the perceived usefulness of these recommendations varied from one proposal to another. Main barriers to the implementation of these recommendations were related to time and resources. PCPs stressed the importance of teamwork for enhancing the use of asthma CPGs in primary care.

CONCLUSIONS

Our results suggest that the implementation of asthma CPGs remains suboptimal in primary care. Interventions addressing the identified barriers and providing facilitators to asthma CPG implementation, such as continuing education, could be implemented and evaluated to sustain asthma CPG use in primary care settings.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.

OBJECTIVES

To assess the effects of decision aids in people facing treatment or screening decisions.

SEARCH METHODS

Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.

SELECTION CRITERIA

We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.

MAIN RESULTS

We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.

AUTHORS' CONCLUSIONS

Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

Use of a patient decision aid for prenatal screening for Down syndrome: what do pregnant women say?

BACKGROUND

Patient decision aids (PtDAs) help people make difficult, values-sensitive decisions. Prenatal screening for assessing the risk of genetic conditions in the fetus is one such decision and patient decision aids are rarely used in this clinical context. We sought to identify factors influencing pregnant women's use of a patient decision aid for deciding about prenatal screening for Down syndrome (DS).

METHODS

This qualitative study was embedded in a sequential mixed-methods research program whose main aim is to implement shared decision-making (SDM) in the context of prenatal screening for DS in the province of Quebec, Canada. We planned to recruit a purposive sample of 45 pregnant women with low-risk pregnancy consulting for prenatal care at three clinical sites. Participating women watched a video depicting a prenatal care follow-up during which a pregnant woman, her partner and a health professional used a PtDA to decide about prenatal screening for DS. The women were then interviewed about factors that would influence the use of this PtDA using questions based on the Theoretical Domains Framework (TDF). We performed content analysis of transcribed verbatim interviews.

RESULTS

Out of 216 eligible women, 100 agreed to participate (46% response rate) and 46 were interviewed. Regarding the type of health professional responsible for their prenatal care, 19 participants (41%) reported having made a decision about prenatal screening for DS with an obstetrician-gynecologist, 13 (28%) with a midwife, 12 (26%) with a family physician, and two (4%) decided on their own. We identified 54 factors that were mapped onto nine of the 12 TDF domains. The three most frequently-mentioned were: opinion of the pregnant woman's partner (n = 33, 72%), presentation of the PtDA by health professional and a discussion (n = 27, 72%), and not having encountered a PtDA (n = 26, 57%).

CONCLUSION

This study allowed us to identify factors influencing pregnant women's use of a PtDA for prenatal screening for DS. Use of a PtDA by health professionals and patients is one step in providing the needed decision support and our study results will allow us to design an effective implementation strategy for PtDAs for prenatal screening for DS.

Assessment of implementability of an adapted clinical practice guideline for surgical antimicrobial prophylaxis at a tertiary care university hospital

RATIONALE, AIMS AND OBJECTIVES

Surgical site infections are the most common healthcare-associated infections. Appropriate surgical antimicrobial prophylaxis (SAP), which is an integral part of surgical site infection SSI prevention, is one of the major preventable risks to surgical patient safety. Several clinical practice guidelines (CPGs) for SAP have been published. The aim of this study was to adapt a CPG for SAP and to assess its implementability.

METHODS

The methodology was based on two validated tools for CPGs, namely, the ADAPTE and the Guideline Implementability Appraisal (GLIA).

RESULTS

The ADAPTE CPG adaptation process methodology was utilized to produce an adapted CPG for SAP based on the American Society of Health System Pharmacists 2013 CPG. The finalized CPG was then assessed to identify any possible intrinsic barriers for implementation.

CONCLUSIONS

In conclusion, the ADAPTE tool is a practical and successful tool for production of CPGs. The GLIA tool is useful for assessing and preparing the finalized adapted CPG for the transition from the production stage to the implementation stage. GLIA could be added to the ADAPTE process either as a final step or to check the draft of the CPG before finalization.

Implementation of Symptom Protocols for Nurses Providing Telephone-Based Cancer Symptom Management: A Comparative Case Study

Background

The pan‐Canadian Oncology Symptom Triage and Remote Support (COSTaRS) team developed 13 evidence‐informed protocols for symptom management.

Aim

To build an effective and sustainable approach for implementing the COSTaRS protocols for nurses providing telephone‐based symptom support to cancer patients.

Methods

A comparative case study was guided by the Knowledge to Action Framework. Three cases were created for three Canadian oncology programs that have nurses providing telephone support. Teams of researchers and knowledge users: (a) assessed barriers and facilitators influencing protocol use, (b) adapted protocols for local use, (c) intervened to address barriers, (d) monitored use, and (e) assessed barriers and facilitators influencing sustained use. Analysis was within and across cases.

Results

At baseline, >85% nurses rated protocols positively but barriers were identified (64‐80% needed training). Patients and families identified similar barriers and thought protocols would enhance consistency among nurses teaching self‐management. Twenty‐two COSTaRS workshops reached 85% to 97% of targeted nurses (N = 119). Nurses felt more confident with symptom management and using the COSTaRS protocols (p < .01). Protocol adaptations addressed barriers (e.g., health records approval, creating pocket versions, distributing with telephone messages). Chart audits revealed that protocols used were documented for 11% to 47% of patient calls. Sustained use requires organizational alignment and ongoing leadership support.

Linking Evidence to Action

Protocol uptake was similar to trials that have evaluated tailored interventions to improve professional practice by overcoming identified barriers. Collaborating with knowledge users facilitated interpretation of findings, aided protocol adaptation, and supported implementation. Protocol implementation in nursing requires a tailored approach. A multifaceted intervention approach increased nurses’ use of evidence‐informed protocols during telephone calls with patients about symptoms. Training and other interventions improved nurses’ confidence with using COSTaRS protocols and their uptake was evident in some documented telephone calls. Protocols could be adapted for use by patients and nurses globally.

Patient and family experiences with accessing telephone cancer treatment symptom support: a descriptive study

PURPOSE

Assess patient and family member experiences with telephone cancer treatment symptom support.

METHODS

Descriptive study guided by the Knowledge-to-Action Framework. Patients and family members who received telephone support for a cancer treatment symptom within the last month at one of three ambulatory cancer programs (Nova Scotia, Ontario, Quebec) were eligible. An adapted Short Questionnaire for Out-of-hours Care instrument was analyzed with univariate statistics.

RESULTS

Of 105 participants, 83 % telephoned about themselves and 17 % for a family member. Participants received advice over the telephone (90 %) and were advised to go to emergency (13 %) and/or the clinic (9 %). Two left a message and were not called back. Participants were "very satisfied" with the manner of nurse or doctor (58 %), explanation about problem (56 %), treatment/advice given (54 %), way call was handled (48 %), getting through (40 %), and wait time to speak to a nurse or doctor (38 %). The proportion "dissatisfied" or "very dissatisfied" for the above items was 4, 5, 9, 11, 10, and 14 %, respectively. Suggestions were shorter call back time, weekend access to telephone support, more knowledgeable advice on self-care strategies, more education at discharge, and shared documentation on calls to avoid repetition and improve continuity.

CONCLUSIONS

Most patients and family members who responded to the survey were satisfied with telephone-based cancer treatment symptom support. Programs could improve telephone support services by providing an estimated time for callback, ensuring that nurses have access to and use previous call documentation, and enhancing patient education on self-care strategies for managing and triaging treatment-related symptoms.

Adherence to and uptake of clinical practice guidelines: lessons learned from a clinical practice guideline on chemotherapy concomitant with radiotherapy in head-and-neck cancer

BACKGROUND

Clinical practice guidelines (cpgs) are systematically developed statements designed to assist practitioners and patients in making decisions about appropriate heath care interventions. Clinical practice guidelines are expensive and time-consuming to create. A cpg on concurrent chemotherapy with radiation therapy (ccrt) was developed in Ontario at a time when treatment approaches for head-and-neck cancer were changing significantly.

METHODS

An assessment of treatments and outcomes based on electronic and chart data obtained from a population-based study of 571 patients with oropharynx cancer treated in Ontario (2003-2004) was combined with a review of relevant knowledge transfer (publications and presentations at major meetings) to understand variation in adherence to a cpg.

RESULTS

In 9 Ontario cancer treatment centres, ccrt was used for 55% of all patients with oropharyngeal cancer; however, at the centres individually, that proportion ranged from 82% to 39%. Furthermore, there was no agreement on the chemotherapy regimen: 2-4 years later (a period during which newer regimens were emerging), only 4 of 9 centres were following the guideline for most patients. When outcomes of treated patients were compared for centres with "higher" and "lower" use of ccrt, no difference in survival was observed (p = 0.64).

CONCLUSIONS

At a time of treatment evolution, the new guideline was controversial, and there are many reasons for the mixed adherence. An estimation of adherence should be included during both development and review of guidelines.

Middle-aged women's decisions about body weight management: needs assessment and testing of a knowledge translation tool

OBJECTIVE

This study aims to assess middle-aged women's needs when making body weight management decisions and to evaluate a knowledge translation tool for addressing their needs.

METHODS

A mixed-methods study used an interview-guided theory-based survey of professional women aged 40 to 65 years. The tool summarized evidence to address their needs and enabled women to monitor actions taken. Acceptability and usability were reported descriptively.

RESULTS

Sixty female participants had a mean body mass index of 28.0 kg/m(2) (range, 17.0-44.9 kg/m(2)), and half were premenopausal. Common options for losing (82%) or maintaining (18%) weight included increasing physical activity (60%), eating healthier (57%), and getting support (40%). Decision-making involved getting information on options (52%), soliciting others' decisions/advice (20%), and being self-motivated (20%). Preferred information sources included written information (97%), counseling (90%), and social networking websites (43%). Five professionals (dietitian, personal trainer, occupational therapist, and two physicians) had similar responses. Of 53 women sent the tool, 27 provided acceptability feedback. They rated it as good to excellent for information on menopause (96%), body weight changes (85%), and managing body weight (85%). Most would tell others about it (81%). After 4 weeks of use, 25 women reported that the wording made sense (96%) and that the tool had clear instructions (92%) and was easy to use across time (88%). The amount of information was rated as just right (64%), but the tool had limited space for responding (72%).

CONCLUSIONS

When making decisions about body weight management, women's needs were "getting information" and "getting support." The knowledge translation tool was acceptable and usable, but further evaluation is required.

Implementation of a cystic fibrosis lung transplant referral patient decision aid in routine clinical practice: an observational study

Background

The decision to have lung transplantation as treatment for end-stage lung disease from cystic fibrosis (CF) has benefits and serious risks. Although patient decision aids are effective interventions for helping patients reach a quality decision, little is known about implementing them in clinical practice. Our study evaluated a sustainable approach for implementing a patient decision aid for adults with CF considering referral for lung transplantation.

Methods

A prospective pragmatic observational study was guided by the Knowledge-to-Action Framework. Healthcare professionals in all 23 Canadian CF clinics were eligible. We surveyed participants regarding perceived barriers and facilitators to patient decision aid use. Interventions tailored to address modifiable identified barriers included training, access to decision aids, and conference calls. The primary outcome was >80% use of the decision aid in year 2.

Results

Of 23 adult CF clinics, 18 participated (78.2%) and 13 had healthcare professionals attend training. Baseline barriers were healthcare professionals’ inadequate knowledge for supporting patients making decisions (55%), clarifying patients’ values for outcomes of options (58%), and helping patients handle conflicting views of others (71%). Other barriers were lack of time (52%) and needing to change how transplantation is discussed (42%). Baseline facilitators were healthcare professionals feeling comfortable discussing bad transplantation outcomes (74%), agreeing the decision aid would be easy to experiment with (71%) and use in the CF clinic (87%), and agreeing that using the decision aid would not require reorganization of the CF clinic (90%). After implementing the decision aid with interventions tailored to the barriers, decision aid use increased from 29% at baseline to 85% during year 1 and 92% in year 2 (p < 0.001). Compared to baseline, more healthcare professionals at the end of the study were confident in supporting decision-making (p = 0.03) but continued to feel inadequate ability with supporting patients to handle conflicting views (p = 0.01).

Conclusion

Most Canadian CF clinics agreed to participate in the study. Interventions were used to target identified modifiable barriers to using the patient decision aid in routine CF clinical practice. CF clinics reported using it with almost all patients in the second year.

Impact of an online medical internet site on knowledge and practice of health care providers: a mixed methods study of the Spinal Cord Injury Rehabilitation Evidence project

Background

It is not known whether ongoing access to a broad-based Internet knowledge resource can influence the practice of health care providers. We undertook a study to evaluate the impact of a Web-based knowledge resource on increasing access to evidence and facilitating best practice of health care providers.

Objective

The objective of this study was to evaluate (1) the impact of the Spinal Cord Injury Rehabilitation Evidence (SCIRE) project on access to information for health care providers and researchers and (2) how SCIRE influenced health care providers' management of clients.

Methods

A 4-part mixed methods evaluation was undertaken: (1) monitoring website traffic and utilization using Google Analytics, (2) online survey of users who accessed the SCIRE website, (3) online survey of targeted end-users, that is, rehabilitation health care providers known to work with spinal cord injury (SCI) clients, as well as researchers, and (4) focus groups with health care providers who had previously accessed SCIRE.

Results

The online format allowed the content for a relatively specialized field to have far reach (eg, 26 countries and over 6500 users per month). The website survey and targeted end-user survey confirmed that health care providers, as well as researchers perceived that the website increased their access to SCI evidence. Access to SCIRE not only improved knowledge of SCI evidence but helped inform changes to the health providers’ clinical practice and improved their confidence in treating SCI clients. The SCIRE information directly influenced the health providers’ clinical decision making, in terms of choice of intervention, equipment needs, or assessment tool.

Conclusions

A Web-based knowledge resource may be a relatively inexpensive method to increase access to evidence-based information, increase knowledge of the evidence, inform changes to the health providers’ practice, and influence their clinical decision making.

Interventions for improving the adoption of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) can reduce overuse of options not associated with benefits for all and respects patient rights, but has not yet been widely adopted in practice.

OBJECTIVES

To determine the effectiveness of interventions to improve healthcare professionals' adoption of SDM.

SEARCH METHODS

For this update we searched for primary studies in The Cochrane Library, MEDLINE, EMBASE, CINAHL, the Cochrane Effective Practice and Organisation of Care (EPOC) Specialsied Register and PsycINFO for the period March 2009 to August 2012. We searched the Clinical Trials.gov registry and the proceedings of the International Shared Decision Making Conference. We scanned the bibliographies of relevant papers and studies. We contacted experts in the field to identify papers published after August 2012.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies evaluating interventions to improve healthcare professionals' adoption of SDM where the primary outcomes were evaluated using observer-based outcome measures (OBOM) or patient-reported outcome measures (PROM).

DATA COLLECTION AND ANALYSIS

The three overall categories of intervention were: interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Studies in each category were compared to studies in the same category, to studies in the other two categories, and to usual care, resulting in nine comparison groups. Statistical analysis considered categorical and continuous primary outcomes separately. We calculated the median of the standardized mean difference (SMD), or risk difference, and range of effect across studies and categories of intervention. We assessed risk of bias.

MAIN RESULTS

Thirty-nine studies were included, 38 randomised and one non-randomised controlled trial. Categorical measures did not show any effect for any of the interventions. In OBOM studies, interventions targeting both patients and healthcare professionals had a positive effect compared to usual care (SMD of 2.83) and compared to interventions targeting patients alone (SMD of 1.42). Studies comparing interventions targeting patients with other interventions targeting patients had a positive effect, as did studies comparing interventions targeting healthcare professionals with usual care (SDM of 1.13 and 1.08 respectively). In PROM studies, only three comparisons showed any effect, patient compared to usual care (SMD of 0.21), patient compared to another patient (SDM of 0.29) and healthcare professional compared to another healthcare professional (SDM of 0.20). For all comparisons, interpretation of the results needs to consider the small number of studies, the heterogeneity, and some methodological issues. Overall quality of the evidence for the outcomes, assessed with the GRADE tool, ranged from low to very low.

AUTHORS' CONCLUSIONS

It is uncertain whether interventions to improve adoption of SDM are effective given the low quality of the evidence. However, any intervention that actively targets patients, healthcare professionals, or both, is better than none. Also, interventions targeting patients and healthcare professionals together show more promise than those targeting only one or the other.

Orthopaedic Surgical Content Associated with Resources for Clinical Evidence

Introduction: As evidence-based medicine is increasingly being adopted in medical and surgical practice, effective processing and interpretation of medical literature is imperative. Databases presenting the contents of medical literature have been developed; however, their efficacy merits investigation. The objective of this study was to quantify surgical and orthopaedic content within five evidence-based medicine resources: DynaMed, Clinical Evidence, UpToDate, PIER, and First Consult. Methods: We abstracted surgical and orthopaedic content from UpToDate, DynaMed, PIER, First Consult, and Clinical Evidence. We defined surgical content as that which involved surgical interventions. We classified surgical content by specialty and, for orthopaedics, by subspecialty. The amount of surgical content, as measured by the number of relevant reviews, was compared with the total number of reviews in each database. Likewise, the amount of orthopaedic content, as measured by the number of relevant reviews, was compared with the total number of reviews and the total number of surgical reviews in each database. Results: Across all databases containing a total of 13268 reviews, we identified an average of 18% surgical content. Specifically, First Consult and PIER contained 28% surgical content as a percentage of the total database content. DynaMed contained 14% and Clinical Evidence 11%, whereas UpToDate contained only 9.5% surgical content. Overall, general surgery, pediatrics, and oncology were the most common specialty areas in all databases. Discussion: Our findings suggest that the limited surgical content within these large scope resources poses difficulties for physicians and surgeons seeking answers to complex clinical questions, specifically within the field of orthopaedics. This study therefore demonstrates the potential need for, and benefit of, surgery-specific or even specialty-specific tools.

A mixed methods approach to understand variation in lung cancer practice and the role of guidelines

INTRODUCTION

Practice pattern data demonstrate regional variation and lower than expected rates of adherence to practice guideline (PG) recommendations for the treatment of stage II/IIIA resected and stage IIIA/IIIB unresected non-small cell lung cancer (NSCLC) patients in Ontario, Canada. This study sought to understand how clinical decisions are made for the treatment of these patients and the role of PGs.

METHODS

Surveys and key informant interviews were undertaken with clinicians and administrators.

RESULTS

Participants reported favorable ratings for PGs and the evidentiary bases underpinning them. The majority of participants agreed more patients should have received treatment and that regional variation is problematic. Participants estimated that up to 30% of patients are not good candidates for treatment and up to 20% of patients refuse treatment. The most common barrier to implementing PGs was the lack of organizational support by clinical administrative leadership. There was concern that the trial results underpinning the PG recommendations were not generalizable to the typical patients seen in clinic. The qualitative analysis yielded five themes related to physicians' decision making: the unique patient, the unique physician, the family, the clinical team, and the clinical evidence. A dynamic interplay between these factors exists.

CONCLUSION

Our study demonstrates the challenges inherent in (i) the complexity of clinical decision making; (ii) how quality of care problems are perceived and operationalized; and (iii) the clinical appropriateness and utility of PG recommendations. We argue that systematic and rigorous methodologies to help decision makers mitigate or negotiate these challenges are warranted.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.

OBJECTIVES

To assess the effects of decision aids for people facing treatment or screening decisions.

SEARCH METHODS

For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).

SELECTION CRITERIA

We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.

MAIN RESULTS

This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

AUTHORS' CONCLUSIONS

There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

Knowledge flow and exchange in interdisciplinary primary health care teams (PHCTs): an exploratory study

OBJECTIVE

Improving the process of evidence-based practice in primary health care requires an understanding of information exchange among colleagues. This study explored how clinically oriented research knowledge flows through multidisciplinary primary health care teams (PHCTs) and influences clinical decisions.

METHODS

This was an exploratory mixed-methods study with members of six PHCTs in Ontario, Canada. Quantitative data were collected using a questionnaire and analyzed with social network analysis (SNA) using UCINet. Qualitative data were collected using semi-structured interviews and analyzed with content analysis procedures using NVivo8.

RESULTS

It was found that obtaining research knowledge was perceived to be a shared responsibility among team members, whereas its application in patient care was seen as the responsibility of the team leader, usually the senior physician. PHCT members acknowledged the need for resources for information access, synthesis, interpretation, or management.

CONCLUSION

Information sharing in interdisciplinary teams is a complex and multifaceted process. Specific interventions need to be improved such as formalizing modes of communication, better organizing knowledge-sharing activities, and improving the active use of allied health professionals. Despite movement toward team-based models, senior physicians are often gatekeepers of uptake of new evidence and changes in practice.

Update of strategies to translate evidence from cochrane musculoskeletal group systematic reviews for use by various audiences

For rheumatology research to have a real influence on health and well-being, evidence must be tailored to inform the decisions of various audiences. The Cochrane Musculoskeletal Group (CMSG), one of 53 groups of the not-for-profit international Cochrane Collaboration, prepares, maintains, and disseminates systematic reviews of treatments for musculoskeletal diseases. While systematic reviews provided by the CMSG fill a major gap in meeting the need for high-quality evidence syntheses, our work does not end at the completion of a review. The term "knowledge translation" (KT) refers to the activities involved in bringing research evidence to various audiences in a useful form so it can be used to support decision making and improve practices. Systematic reviews give careful consideration to research methods and analysis. Because the review is often long and detailed, the clinically relevant results may not be apparent or in the optimal form for use by patients and their healthcare practitioners. This paper describes 10 formats, many of them new, for ways that evidence from Cochrane Reviews can be translated with the intention of meeting the needs of various audiences, including patients and their families, practitioners, policy makers, the press, and members of the public (the "5 Ps"). Current and future knowledge tools include summary of findings tables, patient decision aids, plain language summaries, press releases, clinical scenarios in general medical journals, frequently asked questions (Cochrane Clinical Answers), podcasts, Twitter messages, Journal Club materials, and the use of storytelling and narratives to support continuing medical education. Future plans are outlined to explore ways of improving the influence and usefulness of systematic reviews by providing results in formats suitable to our varied audiences.

It is premature to test older drivers with the SIMARD-MD

BACKGROUND

A new tool, the SIMARD-MD, has been proposed to help physicians identify cognitively impaired drivers who may be unfit to drive, but little empirical evidence is available to justify its use. We analyzed data from a cohort of older Canadian drivers who had undergone cognitive testing to: (1) correlate the SIMARD-MD with other tools that measure cognition (e.g., trail-making test), (2) identify how many drivers, using published cut-offs on the SIMARD-MD, would be recommended to lose their license, or be considered fit to drive, or be required to undergo further driving assessment, and (3) determine if the SIMARD-MD is biased by level of education as many cognitive tools are.

METHODS

Cross-sectional data from 841 drivers aged 70 and over from seven Canadian sites who are enrolled in a 5-year cohort study were used for the analyses. Scores on the SIMARD-MD were correlated with scores on the other cognitive measures. The recommendations that would be made based on the SIMARD-MD scores were based on published cut-off values suggested by the authors of the tool. The impact of education status was examined using linear regression controlling for age.

RESULTS

Correlations between the SIMARD-MD and other cognitive measures ranged from .15 to .86. Using published cut-off scores, 21 participants (2.5%) would have been recommended to relinquish their licenses, 428 (50.9%) would have been deemed fit to drive, and 392 (46.6%) would have been required to undergo further testing. We found a difference of 8.19 points (95% CI=4.99, 11.40, p<.001) in favor of drivers with post-secondary education versus those without, representing over 11% of the mean score.

DISCUSSION

The SIMARD-MD is unlikely to be valuable to clinicians because it lacks sufficient precision to provide clear recommendations about fitness-to-drive. Recommendations based solely on the SIMARD-MD may place many seniors at risk of losing their transportation mobility or incurring unnecessary stress and costs to prove they are safe to drive. Furthermore, the education bias may create an unwanted structural inequity. Hence, adoption of the SIMARD-MD as a tool to determine fitness-to-drive appears premature.

Development and evaluation of evidence-informed clinical nursing protocols for remote assessment, triage and support of cancer treatment-induced symptoms

The study objective was to develop and evaluate a template for evidence-informed symptom protocols for use by nurses over the telephone for the assessment, triage, and management of patients experiencing cancer treatment-related symptoms. Guided by the CAN-IMPLEMENT© methodology, symptom protocols were developed by, conducting a systematic review of the literature to identify clinical practice guidelines and systematic reviews, appraising their quality, reaching consensus on the protocol template, and evaluating the two symptom protocols for acceptability and usability. After excluding one guideline due to poor overall quality, the symptom protocols were developed using 12 clinical practice guidelines (8 for diarrhea and 4 for fever). AGREE Instrument (Appraisal of Guidelines for Research and Evaluation) rigour domain subscale ratings ranged from 8% to 86% (median 60.1 diarrhea; 40.5 fever). Included guidelines were used to inform the protocols along with the Edmonton Symptom Assessment System questionnaire to assess symptom severity. Acceptability and usability testing of the symptom populated template with 12 practicing oncology nurses revealed high readability (n = 12), just the right amount of information (n = 10), appropriate terms (n = 10), fit with clinical work flow (n = 8), and being self-evident for how to complete (n = 5). Five nurses made suggestions and 11 rated patient self-management strategies the highest for usefulness. This new template for symptom protocols can be populated with symptom-specific evidence that nurses can use when assessing, triaging, documenting, and guiding patients to manage their-cancer treatment-related symptoms.

Managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols

BACKGROUND

Management of cancer treatment-related symptoms is an important safety issue given that symptoms can become life-threatening and often occur when patients are at home. With funding from the Canadian Partnership Against Cancer, a pan-Canadian steering committee was established with representation from eight provinces to develop symptom protocols using a rigorous methodology (CAN-IMPLEMENT©). Each protocol is based on a systematic review of the literature to identify relevant clinical practice guidelines. Protocols were validated by cancer nurses from across Canada. The aim of this study is to build an effective and sustainable approach for implementing evidence-informed protocols for nurses to use when providing remote symptom assessment, triage, and guidance in self-management for patients experiencing symptoms while undergoing cancer treatments.

METHODS

A prospective mixed-methods study design will be used. Guided by the Knowledge to Action Framework, the study will involve (a) establishing an advisory knowledge user team in each of three targeted settings; (b) assessing factors influencing nurses' use of protocols using interviews/focus groups and a standardized survey instrument; (c) adapting protocols for local use, ensuring fidelity of the content; (d) selecting intervention strategies to overcome known barriers and implementing the protocols; (e) conducting think-aloud usability testing; (f) evaluating protocol use and outcomes by conducting an audit of 100 randomly selected charts at each of the three settings; and (g) assessing satisfaction with remote support using symptom protocols and change in nurses' barriers to use using survey instruments. The primary outcome is sustained use of the protocols, defined as use in 75% of the calls. Descriptive analysis will be conducted for the barriers, use of protocols, and chart audit outcomes. Content analysis will be conducted on interviews/focus groups and usability testing with comparisons across settings.

DISCUSSION

Given the importance of patient safety, patient-centered care, and delivery of quality services, learning how to effectively implement evidence-informed symptom protocols in oncology healthcare services is essential for ensuring safe, consistent, and effective care for individuals with cancer. This study is likely to have a significant contribution to the delivery of remote oncology services, as well as influence symptom management by patients at home.

Implementation of national comprehensive cancer network evidence-based guidelines to prevent and treat cancer-related infections

Clinical practice guidelines are an important result of evidence-based research. However, current clinical practice remains out of step with the rapid pace of research advancements. Often, decades pass before research is translated into clinical practice. The National Comprehensive Cancer Network (NCCN) has created evidence-based clinical guidelines to promote effective clinical practice. Formerly, the NCCN established guidelines to reduce cancer-related infections only for neutropenic patients; however, they have expanded their guidelines beyond neutropenia to prevent and treat cancer-related infections. Implementing scientific evidence into clinical practice is challenging and complex, and healthcare professionals should understand barriers to implementing clinical practice guidelines to ensure successful translation into practice. This article provides a brief review of NCCN guidelines and describes common barriers encountered during implementation. In addition, a conceptual framework is offered to help identify and address potential concerns before and after adoption of guidelines.

Guidelines for psychosocial interventions in dementia care: a European survey and comparison

OBJECTIVE

The effectiveness of psychosocial interventions in treating people with dementia and their carers is increasingly emphasised in the literature. Dementia guidelines should summarise the scientific evidence and best practice that is currently available, therefore, it should include recommendations for psychosocial interventions. The aims of our study were (1) to collate dementia guidelines from countries across Europe and to check whether they included sections about psychosocial interventions, and (2) to compare the methodological quality and the recommendations for specific psychosocial interventions in these guidelines.

METHODS

The European dementia guidelines were inventoried. The methodological quality of the guideline sections for psychosocial interventions was assessed with the (AGREE) Appraisal of Guidelines Research and Evaluation instrument. The recommendations for specific psychosocial interventions were extracted from each of these guidelines and compared.

RESULTS

Guidelines for psychosocial interventions were found in five of 12 countries. Guideline developers, methodological quality and appreciation of available evidence influenced the inclusion of psychosocial interventions in dementia guidelines from Germany, Italy, the Netherlands, Spain and the UK. The UK NICE SCIE guideline had the best methodological quality and included the most recommendations for psychosocial interventions. Physical activity and carer interventions were recommended the most across all guidelines.

CONCLUSION

The inclusion of psychosocial interventions in dementia guidelines is limited across Europe. High-quality guidelines that include psychosocial interventions and are kept up to date with the emerging evidence are needed. Throughout Europe, special attention to the implementation of evidence-based psychosocial care is needed in the next few years.