Awareness and knowledge of the Canadian 24-Hour Movement Guidelines for Adults among adults living in Canada

Awareness and knowledge of national movement behaviour guidelines are needed to influence individual behaviour and public health policies. This study assessed the awareness and knowledge of the Canadian 24-Hour Movement Guidelines for Adults Aged 18-64 Years and Adults Aged 65 Years or Older (24HMG) recommendations among adults living in Canada across three timepoints. Online surveys were distributed to representative samples of adults living in Canada over a 6-month period. Findings suggest that short-term dissemination efforts were successful in increasing awareness of the 24HMG following guideline release. However, other strategies, such as education, may be needed to influence knowledge of guideline recommendations.

Development of a ParticipACTION App-Based Intervention for Improving Postsecondary Students' 24-Hour Movement Guideline Behaviors: Protocol for the Application of Intervention Mapping

BACKGROUND

The Canadian 24-Hour Movement Guidelines for adults provide specific recommendations for levels of physical activity, sedentary behavior, and sleep (ie, the movement behaviors) required for optimal health. Performance of the movement behaviors is associated with improved mental well-being. However, most postsecondary students do not meet the movement behavior recommendations within the Canadian 24-Hour Movement Guidelines and experience increased stress and declining well-being, suggesting the need for an intervention targeting students' movement behaviors.

OBJECTIVE

We aimed to develop and implement a theory-informed intervention intended to improve the movement behaviors and mental well-being of first-year postsecondary students.

METHODS

The Intervention Mapping protocol was applied in the development and implementation of the intervention. Intervention Mapping entailed performing a needs assessment, determining the intervention outcomes, selecting theory- and evidence-based change methods and applications, preparing and producing intervention plans and materials, developing the implementation plan, and finally developing an evaluation plan. The Theoretical Domains Framework and the Behavior Change Wheel were also used in conjunction with the Intervention Mapping protocol to ensure a solid theoretical basis for the intervention. This protocol led to the development and implementation of a 6-week, theory-informed ParticipACTION app-based intervention aimed at helping first-year postsecondary students improve their movement behaviors and mental well-being. The developed app content provided students with information on each of the movement behaviors and behavioral strategies (ie, goal setting, action planning, monitoring, and coping planning). The use of Intervention Mapping allowed for the continuous involvement of various multidisciplinary partners and end users, ensuring that the intervention design and implementation was appropriate for the target audience. The feasibility, acceptability, and potential impact of the intervention will be examined in a subsequent proof-of-concept study at 2 Canadian university campuses.

RESULTS

Participant recruitment occurred during September 2021, and the intervention was conducted from October to December 2021. The deadline for completion of the postintervention questionnaire by participants was mid-December 2021. The analysis of data examining the feasibility, acceptability, and potential impact of the intervention began in January 2022, with the publication of the proof-of-concept evaluation expected in 2023.

CONCLUSIONS

Intervention Mapping with the Theoretical Domains Framework and Behavior Change Wheel was a useful approach to combine evidence and theoretical concepts to guide the design and implementation of a ParticipACTION app-based intervention targeting postsecondary students' movement behaviors and mental well-being. This process may serve as an example for other researchers developing multiple behavior change app-based interventions. Should the forthcoming evaluation demonstrate the intervention's acceptability, feasibility, and potential impact, the intervention may provide a scalable method of improving postsecondary students' movement behaviors and mental well-being.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/39977.

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

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

The PROVIEW+ tool: Developing and validating a tool to predict risk of poor performance status and severe symptoms in cancer patients over time

12095

Background: There are numerous predictive cancer tools that focus on survival. However, no tools predict risk of low performance status or severe symptoms, which are important for patient decision-making and early integration of palliative care. The aim of this study was to develop and validate a model for all cancer types that predicts the risk for having low performance status and severe symptoms. Methods: A retrospective, population-based, predictive study using linked administrative data from cancer patients from 2008-2015 in Ontario, Canada. Patients were randomly selected for model derivation (60%) and validation (40%). The derivation cohort was used to develop a multivariable logistic regression model to predict the risk of having the reported outcomes in the subsequent 6 months. Model performance was assessed using discrimination and calibration plots. The main outcome was low performance status using the Palliative Performance Scale. Secondary outcomes included severe pain, dyspnea, well-being, and depression using the Edmonton Symptom Assessment System. Outcomes were recalculated after each of 4 annual survivor marks. Results: We identified 255,494 cancer patients (57% female; median age of 64; common cancers were breast (24%) and lung (13%)). At diagnosis, the risk of having low performance status, severe pain, well-being, dyspnea, and depression in 6-months is 1%, 3%, 6%, 13% and 4%, respectively for the reference case (i.e. male, lung cancer, stage I, no symptoms). Generally these covariates increased the outcome risk by > 10% across all models: obstructive lung disease, dementia, diabetes; radiation treatment; hospital admission; high pain; depression; Palliative Performance Scale score of 60-10; issues with appetite; or homecare. Model discrimination was high across all models. Conclusions: The model accurately predicted changing cancer risk for low performance status and severe symptoms over time. Providing accurate predictions of future performance status and symptom severity can support decision-making and earlier initiation of palliative care, even alongside disease modifying therapies.

Code status communication training in postgraduate oncology programs: a needs assessment

Background

Discussions with patients with cancer about cardiopulmonary resuscitation directives (code status) are often led by residents. This study was carried out in Canada to identify current educational practices and gaps in training for this communication skill.

Methods

Canadian medical and radiation oncology residents and program directors (pds) were surveyed about teaching practices, satisfaction with current education, and barriers to teaching code status discussion skills. Relative frequencies of categorical and ordinal responses were calculated.

Results

Between November 2016 and February 2017, 95 (58.6%) of 162 residents and 17 (63%) of 27 pds completed surveys. Only 54.1% and 48.3% of medical and radiation oncology residents, respectively, had received any code status communication training before entering an oncology program. While 41% of residents expected to receive formal teaching on this topic during residency, 47.1% of pds endorsed inclusion of this topic in curricula. Only 20% of residents reported receiving formal evaluation of this skill while 41.2% of pds indicated that evaluations are provided. The importance of this communication skill in oncology was strongly supported. Among residents, 88% desired more training, and 82.3% of pds identified the need for new educational resources. Lack of time, resources, and evaluation tools were among the most commonly identified barriers to teaching.

Conclusions

Oncology residency pds and trainees feel that code status communication is important, but teaching and evaluation of this skill are limited. Barriers to teaching and skill-building have been identified. Further work is underway to develop novel educational resources for code status communication training.

Optimal messaging of the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years and older

The Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years and older (“Guidelines”) integrate recommendations for physical activity, sedentary, and sleep behaviours. Given the novelty of these integrated Guidelines, it was important to consider messaging strategies that would be most effective in reaching Canadian adults. The purpose of this study was to examine optimal messaging of the Guidelines as it pertains to communication channels and messages. Representative samples of Guideline end-users (N = 1017) and stakeholders (N = 877) each completed a cross-sectional survey. Descriptive statistics were calculated along with tests of statistical significance. Inductive content analysis was used to code stakeholders’ comments (i.e., suggestions, concerns) on a draft version of the Guidelines. Most end-users had recently referred to online medical resources; family, friends, and co-workers; and physicians as communication channels for information regarding the movement behaviours. End-users and stakeholders felt that generic messages would foster self-efficacy to meet the Guidelines. Stakeholders highlighted a variety of considerations to ensure the Guidelines are inclusive towards diverse groups within the Canadian population. Findings will inform Guideline messaging.

Novelty Most end-users referred to online medical resources; family, friends, and co-workers; and physicians as communication channels. End-users and stakeholders indicated that generic messages would foster self-efficacy to meet the Guidelines. Stakeholders expressed concerns about the inclusivity of the Guidelines for diverse socioeconomic groups.

Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement

Objective

To assess the quality of recommendations from 161 clinical practice guidelines (CPGs) using AGREE-REX-D (Appraisal of Guidelines REsearch and Evaluation-Recommendations Excellence Draft).

Design

Cross-sectional study

Setting

International CPG community.

Participants

Three hundred twenty-two international CPG developers, users, and researchers.

Intervention

Participants were assigned to appraise one of 161 CPGs selected for the study using the AGREE-REX-D tool

Main outcome measures

AGREE-REX-D scores of 161 CPGs (7-point scale, maximum 7).

Results

Recommendations from 161 CPGs were appraised by 322 participants using the AGREE-REX-D. CPGs were developed by 67 different organizations. The total overall average score of the CPG recommendations was 4.23 (standard deviation (SD) = 1.14). AGREE-REX-D items that scored the highest were (mean; SD): evidence (5.51; 1.14), clinical relevance (5.95; SD 0.8), and patients/population relevance (4.87; SD 1.33), while the lowest scores were observed for the policy values (3.44; SD 1.53), local applicability (3,56; SD 1.47), and resources, tools, and capacity (3.49; SD 1.44) items. CPGs developed by government-supported organizations and developed in the UK and Canada had significantly higher recommendation quality scores with the AGREE-REX-D tool (p < 0.05) than their comparators.

Conclusions

We found that there is significant room for improvement of some CPGs such as the considerations of patient/population values, policy values, local applicability and resources, tools, and capacity. These findings may be considered a baseline upon which to measure future improvements in the quality of CPGs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and validation of a risk prediction model for poor performance status and severe symptoms among cancer patients

12097

Background: Existing cancer predictive tools focus on survival, but few incorporate patient-reported outcomes to predict quality-of-life domains, such as symptoms and performance status. The objective was to develop and validate a predictive cancer model (called PROVIEW) for poor performance status and severe symptoms over time. Methods: We used a retrospective, population-based, cohort study of patients, with a cancer diagnosis, in Ontario, Canada between 2008-2015. We randomly selected 60% of patients for model derivation and 40% for validation. Using the derivation cohort, we developed multivariable logistic regression models with baseline characteristics, using a backward stepwise variable selection process. The primary outcome was odds of having poor performance status six months from index date, as measured by a score < = 30 out of 100 on the Palliative Performance Scale. The index date for each model was diagnosis (Year 0), which was then re-calculated at each of 4 annual survivor marks after diagnosis (up to Year 4). Secondary outcomes included having severe pain, dyspnea, well-being, or depression, as measured by a score of > = 7 out of 10 on the Edmonton Symptom Assessment System. Covariates included demographics, clinical information, current symptoms and performance status, and healthcare utilization. Model performance was assessed by AUC statistics and calibration plots. Results: Our population-based cohort identified 125,479 cancer patients for the performance status model in Year 0. The median diagnosis age was 64 years, 57% were female, and the most common cancers were breast (24%), lung (13%), and prostate (9%). 32% had Stage 3 or 4 disease. In Year 0 after backwards selection, the odds of having a poor performance status in 6 months was increased by more than 10% when the patient had: COPD, dementia, diabetes; radiation treatment; a hospital admission in the prior 3 months; high pain or depression; a current performance status < = 30; any issues with appetite; or received end-of-life homecare. Generally, these variables were also associated with a > 10% increased odds in other years and for the secondary outcomes. The average AUC across all 25 models is 0.7676 which indicates high model discrimination. Conclusions: The PROVIEW model accurately predicts risk of having a poor performance status or severe symptoms over time among cancer patients. It has the potential to be a useful online tool for patients to integrate earlier supportive and palliative care.

Development and Validation of a Tool to Assess the Quality of Clinical Practice Guideline Recommendations

IMPORTANCE

Clinical practice guidelines (CPGs) may lack rigor and suitability to the setting in which they are to be applied. Methods to yield clinical practice guideline recommendations that are credible and implementable remain to be determined.

OBJECTIVE

To describe the development of AGREE-REX (Appraisal of Guidelines Research and Evaluation-Recommendations Excellence), a tool designed to evaluate the quality of clinical practice guideline recommendations.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of 322 international stakeholders representing CPG developers, users, and researchers was conducted between December 2015 and March 2019. Advertisements to participate were distributed through professional organizations as well as through the AGREE Enterprise social media accounts and their registered users.

EXPOSURES

Between 2015 and 2017, participants appraised 1 of 161 CPGs using the Draft AGREE-REX tool and completed the AGREE-REX Usability Survey.

MAIN OUTCOMES AND MEASURES

Usability and measurement properties of the tool were assessed with 7-point scales (1 indicating strong disagreement and 7 indicating strong agreement). Internal consistency of items was assessed with the Cronbach α, and the Spearman-Brown reliability adjustment was used to calculate reliability for 2 to 5 raters.

RESULTS

A total of 322 participants (202 female participants [62.7%]; 83 aged 40-49 years [25.8%]) rated the survey items (on a 7-point scale). All 11 items were rated as easy to understand (with a mean [SD] ranging from 5.2 [1.38] for the alignment of values item to 6.3 [0.87] for the evidence item) and easy to apply (with a mean [SD] ranging from 4.8 [1.49] for the alignment of values item to 6.1 [1.07] for the evidence item). Participants provided favorable feedback on the tool's instructions, which were considered clear (mean [SD], 5.8 [1.06]), helpful (mean [SD], 5.9 [1.00]), and complete (mean [SD], 5.8 [1.11]). Participants considered the tool easy to use (mean [SD], 5.4 [1.32]) and thought that it added value to the guideline enterprise (mean [SD], 5.9 [1.13]). Internal consistency of the items was high (Cronbach α = 0.94). Positive correlations were found between the overall AGREE-REX score and the implementability score (r = 0.81) and the clinical credibility score (r = 0.76).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that the AGREE-REX tool can be useful in evaluating CPG recommendations, differentiating among them, and identifying those that are clinically credible and implementable for practicing health professionals and decision makers who use recommendations to inform clinical policy.

Directly Mailing gFOBT Kits to Previous Responders Being Recalled for Colorectal Cancer Screening Increases Participation

Background

Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces CRC-related death. Average risk individuals should be recalled for screening with gFOBT every 2 years in order to maximize effectiveness. However, adherence with repeated testing is often suboptimal. Our aim was to evaluate whether adding a gFOBT kit to a mailed recall letter improves participation compared with a mailed recall letter alone, among previous responders to a mailed invitation.

Methods

We conducted a cluster randomized controlled trial, with the primary care provider as the unit of randomization. Eligible patients had completed a gFOBT and tested negative in an earlier pilot study and were now due for recall. The intervention group received a mailed CRC screening recall letter from their primary care provider plus a gFOBT kit (n = 431) while the control group received a mailed CRC screening mailed recall letter alone (n = 452). The primary outcome was the uptake of gFOBT or colonoscopy within 6 months.

Results

gFOBT uptake was higher in the intervention group (61.3%, n = 264) compared with the control group (50.4%, n = 228) with an absolute difference between the two groups of 10.8% (95% confidence interval [CI]: 1.4 to 20.2%, P = <0.01). Patients in the intervention group were more likely to complete the gFOBT compared with the control group (odds ratio [OR] = 1.4; 95% CI: 1.1 to 1.9).

Conclusion

Our findings show that adding gFOBT kits to the mailed recall letter increased participation among persons recalled for screening. Nine gFOBT kits would have to be sent by mail in order to screen one additional person.

Lessons learned from a cancer knowledge translation grants program: results of an evaluation

Background

A novel way to build capacity in knowledge translation (kt) is through kt-focused grant competitions. Since 2009, the Knowledge Translation Research Network (KT-Net) has had a cancer-related kt grants program. We undertook an evaluation of the program to determine if KT-Net was achieving its aims of building capacity in cancer kt, advancing the science of kt, building partnerships, and leveraging funding.

Methods

An adapted framework guided the evaluation. Nine funded studies from 4 competitions were included. Semi-structured telephone interviews were held with researchers, stakeholders (including knowledge users), members of grant review panels, and experts in kt. Interview transcripts were audio-recorded, transcribed, and analyzed thematically. A review of proposal and report documents was also conducted.

Results

Funded researchers indicated that the grant competition was an essential funding program for cancer kt research. Competitions were perceived to build capacity in cancer kt among early-career researchers and to encourage innovative cancer kt research for which alternative funding sources are limited. The grants program resulted in incremental gains in advancing the science of kt. Suggestions to improve the program included stronger partnerships between the funder and the provincial cancer-system organization to optimize the application of research that is relevant to the organization's strategic objectives.

Conclusions

The grants program met many of its aims by providing cancer researchers with an opportunity to gain capacity in cancer kt and by making incremental advances in kt science. Suggestions to improve the program included closer partnerships between the funder and the cancer-system organization.

Clinical Practice Guidelines: Tools to Support High Quality Patient Care

Clinical practice guidelines (CPGs) are systematically-developed statements aimed to assist decision-making relevant to the clinical encounter, to inform clinical policy, and to strengthen health care systems. The development of a CPG begins with the identification of a problem for which evidence-informed guidance is required. Interdisciplinary panels work to craft - and then execute - a protocol that will serve as a blueprint for the development process. It includes the scope of the project; who is involved and how they will function; the specific systematic review and consensus methods that will be used to ensure quality recommendations and to mitigate bias. CPGs should undergo a formal review of relevant stakeholders and results of this review, actions taken by the panel, and the final recommendations should be documented in the final CPG report. Dissemination activities, including the use of social media platforms, and more purposefully designed implementation activities are required to optimize the adoption of recommendations. Methods to keep recommendations current are required to ensure on-going validity and credibility of the recommendations. Two tools, AGREE II, and the AGREE REX, provide quality criteria related to the whole CPG development process and the CPG recommendations, respectively. The AGREE II is comprised of 23 items within 6 CPG quality domains: scope and purpose, stakeholder involvement, rigor, clarity of presentation, applicability, and editorial independence. The AGREE REX is comprised of 9 items within 3 CPG Recommendation quality domains: clinical applicability, values and preferences, and implementability. CPGs are important tools to an overall quality agenda.

Variable participation of knowledge users in cancer health services research: results of a multiple case study

BACKGROUND

Integrated knowledge translation (IKT) is a research approach in which knowledge users (KUs) co-produce research. The rationale for IKT is that it leads to research that is more relevant and useful to KUs, thereby accelerating uptake of findings. The aim of the current study was to evaluate IKT activities within a cancer health services research network in Ontario, Canada.

METHODS

An embedded multiple case study design was used. The cases were 5 individual studies within an overarching cancer health services research network. These studies focused on one of the following topics: case costing of cancer treatment, lung cancer surgery policy analysis, patient and provider-reported outcomes, colorectal cancer screening, and a team approach to women's survivorship. We conducted document reviews and held semi-structured interviews with researchers, KUs, and other stakeholders within a cancer system organization. The analysis examined patterns across and within cases.

RESULTS

Researchers and their respective knowledge users from 4 of the 5 cases agreed to participate. Eighteen individuals from 4 cases were interviewed. In 3 of 4 cases, there were mismatched expectations between researchers and KUs regarding KU role; participants recommended that expectations be made explicit from the beginning of the collaboration. KUs perceived that frequent KU turnover may have affected both KU engagement and the uptake of study results within the organization. Researchers and KUs found that sharing research results was challenging because the organization lacked a framework for knowledge translation. Uptake of research findings appeared to be related to the researcher having an embedded role in the cancer system organization and/or close alignment of the study with organizational priorities. Document reviews found evidence of planned IKT strategies in 3 of 4 cases; however, actual KU role/engagement on research teams was variable.

CONCLUSIONS

Barriers to KU co-production of cancer health services research include mismatched expectations of KU role and frequent KU turnover. When a research study directly aligns with organizational priorities, it appears more likely that results will be considered in programming. Research teams that take an IKT approach should consider specific strategies to address barriers to KU engagement.

Engaging cancer patients in clinical practice guideline development: a pilot study

Background

Patient engagement is a key quality component of cancer guideline development; however, the optimal strategy for engaging patients in guideline development remains unclear. The feasibility and efficacy of two patient engagement models was tested by Cancer Care Ontario's cancer guideline development program, the Program in Evidence-Based Care (pebc).

Methods

In model 1, patients participated in the guideline development process as active members of a working group. In model 2, patients formed a separate consultation group to review project plans and recommendations generated by multiple working groups. Training included online resources (model 1) and an in-person orientation (model 2). The pebc's standard patient engagement process acted as a control. The study was conducted for 1 year. Surveys measured the satisfaction of patients and members of the guideline working groups with the process and the outcome of each model.

Results

Three guideline projects used model 1 to engage patients, six projects used model 2 to receive feedback, and one project was used as a control group (14 patients total). Most participants, whatever the model, reported satisfaction with their experience. Key challenges to implementation included patient recruitment and long wait times between meetings (model 1), and difficulty focusing on the discussion topic and poor meeting attendance on the part of patients (model 2).

Conclusions

The pilot study demonstrated that, although both models are feasible and effective for the engagement of patients in cancer guideline development, modifications are required to optimize their continued interest. The pebc will use the study results to inform the implementation of a patient engagement strategy for its program.

Uncertain times: A survey of Canadian women's perspectives toward mammography screening

Evolving scientific evidence about mammography has raised new questions about the net benefits of organized screening, yet gaps remain about women's current screening practices, knowledge, attitudes and values toward screening to support informed decision making in this area. We addressed this gap through an online survey of 2000 screen-eligible women from Ontario, Canada in January 2016. Likert-scaled and categorical questions were used to collect information about screening practices, knowledge of benefits and risks of screening and underlying attitudes and values toward screening. Results for all responses were summarized using descriptive statistics. Comparison of results between ever screened versus never screened respondents was performed using chi-squared tests. Most women felt informed about screening yet had doubts about how informed their decisions were. They were more confident in their knowledge of the benefits than the risks which aligned with the emphasis given to benefits in discussions with health care providers. The benefits of screening were linked with lowered anxiety about breast cancer. The never screened were less likely to overstate the benefits of screening, more likely to give weight to the risks, and less likely to report anxiety or worry about breast cancer. Findings highlight the need for improved communication strategies and decision supports that emphasize the provision of current, balanced information about the benefits and risks of screening, both at the population-level (through mass media) and within patient-provider interactions. Sensitivity to the psychosocial factors that shape women's attitudes toward mammography screening should be central to any strategy.

Validity and usability testing of a health systems guidance appraisal tool, the AGREE-HS

Background

Health systems guidance (HSG) provides recommendations to address health systems challenges. No tools exist to inform HSG developers and users about the components of high quality HSG and to differentiate between HSG of varying quality. In response, we developed a tool to assist with the development, reporting and appraisal of HSG – the Appraisal of Guidelines for Research and Evaluation–Health Systems (AGREE-HS). This paper reports on the validity, usability and initial measurement properties of the AGREE-HS.

Methods

To establish face validity (Study 1), stakeholders completed a survey about the AGREE-HS and provided feedback on its content and structure. Revisions to the tool were made in response. To establish usability (Study 2), the revised tool was applied to 85 HSG documents and the appraisers provided feedback about their experiences via an online survey. An initial test of the revised tool’s measurement properties, including internal consistency, inter-rater reliability and criterion validity, was conducted. Additional revisions to the tool were made in response.

Results

In Study 1, the AGREE-HS Overview, User Manual, quality item content and structure, and overall assessment questions were rated favourably. Participants indicated that the AGREE-HS would be useful, feasible to use, and that they would apply it in their context. In Study 2, participants indicated that the quality items were easy to understand and apply, and the User Manual, usefulness and usability of the tool were rated favourably. Study 2 participants also indicated intentions to use the AGREE-HS.

Conclusions

The AGREE-HS comprises a User Manual, five quality items and two overall assessment questions. It is available at agreetrust.org.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0334-9) contains supplementary material, which is available to authorized users.

The PULSES project: Teaching the vital elements of code status discussions to oncology residents

46

Background: Discussions with cancer patients around cardiopulmonary resuscitation, or ‘code status,’ are often led by trainees in oncology, but formal education for this competency is lacking. In this study, we developed and tested a novel communication tool, the PULSES framework, for informed code status decision-making (a six-step approach summarized by the PULSES acronym [see Table]), through an educational workshop. Methods: A multicentre randomized controlled trial was carried out at 3 academic cancer centres in Ontario, Canada. Residents in medical oncology (MO) and radiation oncology (RO) programs completed a workshop and an observed structured clinical exam (OSCE). Participants were randomized to complete the training before the OSCE (experimental arm) or after the OSCE (control arm). Randomization was stratified for centre and oncology discipline. Expert raters evaluated communication with two rating tools: the novel PULSES scale and the communication skills assessment form (CSAF), a validated benchmark tool that is not specific to oncology content. The primary outcome was improvement in PULSES scores. Results: Forty-six residents consented to participate (28 RO and 18 MO). Groups were well balanced for program and year of training. Participants in the experimental group had higher mean PULSES score than those in the control group (80.4±13.5 vs 63.4±9.7; p<.001; maximum score = 108). There was no significant effect for oncology program and no significant interaction between program and training condition. Scores from the PULSES and CSAF scales were highly correlated (R = 0.864). Conclusions: The PULSES training improved performance among oncology residents for code status discussions. Improved communication scores were not scale-specific. The PULSES framework offers a standardized approach and can be incorporated into competency-based curricula for postgraduate oncology programs. Future work will explore whether communication training in this area impacts patient-level outcomes. [Table: see text]

Code status communication training in Canadian postgraduate oncology programs: A needs assessment survey

13

Background: Discussions with cancer patients on cardiopulmonary resuscitation directives, or ‘code status,’ are often led by trainees in oncology. This study was carried out across Canada to identify current educational practices and gaps in training for this communication skill. Methods: Medical and radiation oncology residents and program directors (PDs) from across Canada were invited to complete a survey. Questions addressed current teaching practices, perceived importance of this competency, satisfaction with current education and barriers to teaching code status discussion skills. Relative frequencies of categorical and ordinal responses were calculated. Results: Between November 2016 and February 2017, 95 residents (58.6% response rate [RR]) and 17 PDs (63% RR) completed surveys. Both oncology disciplines and trainees at all levels were represented. Only 54.1% and 48.3% of medical and radiation oncology residents, respectively, had experienced any form of code status communication training before entering an oncology program. During oncology training, 41.1% of residents expect to receive formal teaching on this topic and 47.1% of PDs endorsed inclusion of this topic in curricula. Only 20% of residents reported receiving any formal evaluation for this competency while 41.2% of program directors indicated that formal evaluations are provided. All PDs and 98% of residents positively endorsed the importance of this competency in residency and clinical practice. Among residents, 88% felt that more training would be beneficial, and 82.3% of PDs identified a need for new educational resources in this area. Lack of time, educational resources and evaluation tools were among the most commonly identified barriers to teaching (by PDs and trainees). Conclusions: Canadian medical and radiation oncology residency PDs and trainees feel that code status communication is an important competency, yet teaching and evaluation are limited in this area. Barriers to teaching and skill-building have been identified. Further work is underway to develop novel educational resources for code status communication training to include in postgraduate curricula.

The PULSES project: Teaching the vital elements of code status discussions to oncology residents

10024

Background: Discussions with cancer patients around cardiopulmonary resuscitation (CPR), or ‘code status,’ are often led by trainees in oncology, but formal education for this competency is lacking. In this study, we developed and tested a novel communication tool, the PULSES framework, for informed code status decision-making (a six-step approach summarized by the PULSES acronym [Table 1]), through an educational workshop. Methods: A multicentre randomized controlled trial was carried out at 3 academic cancer centres in Ontario, Canada. Residents in medical oncology (MO) and radiation oncology (RO) programs completed a workshop and an observed structured clinical exam (OSCE). Participants were randomized to complete the training before the OSCE (experimental arm) or after the OSCE (control arm). Randomization was stratified for centre and oncology discipline. Expert raters evaluated communication with two rating tools: the novel PULSES scale and the communication skills assessment form (CSAF), a validated benchmark tool that is not specific to oncology content. The primary outcome was improvement in PULSES scores. Results: Forty-six residents consented to participate (28 RO and 18 MO). Groups were well balanced for program and year of training. Participants in the experimental group had higher mean PULSES score than those in the control group (80.4±13.5 vs 63.4±9.7; p < .001; maximum score = 108). There was no significant effect for program and no significant interaction between program and training condition. Scores for the PULSES and CSAF scales were highly correlated (R = 0.864). Conclusions: The PULSES training improved performance among oncology residents for code status discussions. Improved communication scores were not scale-specific. The PULSES framework offers a standardized approach and can be incorporated into competency-based curricula for postgraduate oncology programs. Future work will explore whether communication training in this area impacts patient-level outcomes. [Table: see text]

Challenges and insights in implementing coordinated care between oncology and primary care providers: a Canadian perspective

We report here on the current state of cancer care coordination in Canada and discuss challenges and insights with respect to the implementation of collaborative models of care. We also make recommendations for future research. This work is based on the findings of the Canadian Team to Improve Community-Based Cancer Care Along the Continuum (canimpact) casebook project. The casebook project identified models of collaborative cancer care by systematically documenting and analyzing Canadian initiatives that aim to improve or enhance care coordination between primary care providers and oncology specialists. The casebook profiles 24 initiatives, most of which focus on breast or colorectal cancer and target survivorship or follow-up care. Current key challenges in cancer care coordination are associated with establishing program support, engaging primary care providers in the provision of care, clearly defining provider roles and responsibilities, and establishing effective project or program planning and evaluation. Researchers studying coordinated models of cancer care should focus on designing knowledge translation strategies with updated and refined governance and on establishing appropriate protocols for both implementation and evaluation.

Understanding optimal approaches to patient and caregiver engagement in the development of cancer practice guidelines: a mixed methods study

Background

Practice guidelines (PGs) can assist health care practitioners and patients to make decisions about health care options. A key component of high quality PGs is the consideration of patient values and preferences. A mixed methods study was conducted to understand optimal approaches to patient engagement in the development of cancer PGs.

Methods

Cancer patients, survivors, family members and caregivers were recruited from cancer clinics, follow-up clinics, community support programs, a provincial patient and family advisory committee, and a provincial cancer PG development program. Participants attended a workshop, completed a survey, or participated in a telephone interview, to provide information about PG awareness, attitudes, information needs, training, engagement approaches and barriers and facilitators.

Results

Forty-one participants (12 workshop attendees, 21 survey respondents and 8 interviewees) provided data. For those with no PG development experience, fewer than half were previously aware of PGs but perceived several benefits to the inclusion of this perspective. Common barriers to participation across the groups were time commitment, duration of the PG development process, and financial costs. Positive beliefs about the contributions that could be made and practical considerations (e.g., orientation and training, defined roles and expectations) were identified as key features in the successful integration of patients into the PG development process. There was no single model of engagement favored over another.

Conclusions

Study results align with similar studies in other contexts and with international patient engagement efforts. Findings are being used to test new patient engagement models in a programmatic PG development initiative in Ontario, Canada.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2107-5) contains supplementary material, which is available to authorized users.

How do organisational characteristics influence teamwork and service delivery in lung cancer diagnostic assessment programmes? A mixed-methods study

OBJECTIVES

Diagnostic assessment programmes (DAPs) can reduce wait times for cancer diagnosis, but optimal DAP design is unknown. This study explored how organisational characteristics influenced multidisciplinary teamwork and diagnostic service delivery in lung cancer DAPs.

DESIGN

A mixed-methods approach integrated data from descriptive qualitative interviews and medical record abstraction at 4 lung cancer DAPs. Findings were analysed with the Integrated Team Effectiveness Model.

SETTING

4 DAPs at 2 teaching and 2 community hospitals in Canada.

PARTICIPANTS

22 staff were interviewed about organisational characteristics, target service benchmarks, and teamwork processes, determinants and outcomes; 314 medical records were reviewed for actual service benchmarks.

RESULTS

Formal, informal and asynchronous team processes enabled service delivery and yielded many perceived benefits at the patient, staff and service levels. However, several DAP characteristics challenged teamwork and service delivery: referral volume/workload, time since launch, days per week of operation, rural-remote population, number and type of full-time/part-time human resources, staff colocation, information systems. As a result, all sites failed to meet target benchmarks (from referral to consultation median 4.0 visits, median wait time 35.0 days). Recommendations included improved information systems, more staff in all specialties, staff colocation and expanded roles for patient navigators. Findings were captured in a conceptual framework of lung cancer DAP teamwork determinants and outcomes.

CONCLUSIONS

This study identified several DAP characteristics that could be improved to facilitate teamwork and enhance service delivery, thereby contributing to knowledge of organisational determinants of teamwork and associated outcomes. Findings can be used to update existing DAP guidelines, and by managers to plan or evaluate lung cancer DAPs. Ongoing research is needed to identify ideal roles for navigators, and staffing models tailored to case volumes.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline

OBJECTIVE

The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise.

SETTING

The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries.

PARTICIPANTS

The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres.

OUTCOME MEASURES

An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed.

RESULTS

7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery.

CONCLUSIONS

The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.

Documenting coordination of cancer care between primary care providers and oncology specialists in Canada

OBJECTIVE

To report on the findings of the CanIMPACT (Canadian Team to Improve Community-Based Cancer Care along the Continuum) Casebook project, which systematically documented Canadian initiatives (ie, programs and projects) designed to improve or support coordination and continuity of cancer care between primary care providers (PCPs) and oncology specialists.

DESIGN

Pan-Canadian environmental scan.

SETTING

Canada.

PARTICIPANTS

Individuals representing the various initiatives provided data for the analysis.

METHODS

Initiatives included in the Casebook met the following criteria: they supported coordination and collaboration between PCPs and oncology specialists; they were related to diagnosis, treatment, survivorship, or personalized medicine; and they included breast or colorectal cancer or both. Data were collected on forms that were compiled into summaries (ie, profiles) for each initiative. Casebook initiatives were organized based on the targeted stage of the cancer care continuum, jurisdiction, and strategy (ie, model of care or type of intervention) employed. Thematic analysis identified similarities and differences among employed strategies, the level of primary care engagement, implementation barriers and facilitators, and initiative evaluation.

MAIN FINDINGS

The CanIMPACT Casebook profiles 24 initiatives. Eleven initiatives targeted the survivorship stage of the cancer care continuum and 15 focused specifically on breast or colorectal cancer or both. Initiative teams implemented the following strategies: nurse patient navigation, multidisciplinary care teams, electronic communication or information systems, PCP education, and multicomponent initiatives. Initiatives engaged PCPs at various levels. Implementation barriers included lack of care standardization across jurisdictions and incompatibility among electronic communication systems. Implementation facilitators included having clinical and program leaders publicly support the initiative, repurposing existing resources, receiving financial support, and establishing a motivated and skilled project or program team. The lack of evaluative data made it difficult to identify the most effective interventions or models of care.

CONCLUSION

The CanIMPACT Casebook documents Canadian efforts to improve or support the coordination of cancer care by PCPs and oncology specialists as a means to improve patient outcomes and cancer system performance.

Interventions to improve care coordination between primary healthcare and oncology care providers: a systematic review

Coordination of patient care between primary care and oncology care providers is vital to care quality and outcomes across the cancer continuum, yet it is known to be challenging. We conducted a systematic review to evaluate current or new models of care and/or interventions aimed at improving coordination between primary care and oncology care providers for patients with adult breast and/or colorectal cancer. MEDLINE, EMBASE, CINAHL, Cochrane Library Database of Systematic Reviews, and the Centre for Reviews and Dissemination were searched for existing English language studies published between January 2000 and 15 May 2015. Systematic reviews, meta-analyses, randomised controlled trials (RCTs) and non-randomised studies were included if they evaluated a specific model/intervention that was designed to improve care coordination between primary care and oncology care providers, for any stage of the cancer continuum, for patients with adult breast and/or colorectal cancer. Two reviewers extracted data and assessed risk of bias. Twenty-two studies (5 systematic reviews, 6 RCTs and 11 non-randomised studies) were included and varied with respect to the targeted phase of the cancer continuum, type of model or intervention tested, and outcome measures. The majority of studies showed no statistically significant changes in any patient, provider or system outcomes. Owing to conceptual and methodological limitations in this field, the review is unable to provide specific conclusions about the most effective or preferred model/intervention to improve care coordination. Imprecise results that lack generalisability and definitiveness provide limited evidence to base the development of future interventions and policies.

TRIAL REGISTRATION NUMBER

CRD42015025006.

The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines

AGREE II is a widely used standard for assessing the methodological quality of practice guidelines. This article describes the development of the AGREE Reporting Checklist, which was designed to improve the quality of practice guideline reporting and aligns with AGREE II in its structure and content.

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

BACKGROUND

Patient-mediated knowledge translation (PKT) interventions engage patients in their own health care. Insight on which PKT interventions are effective is lacking. We sought to describe the type and impact of PKT interventions.

METHODS

We performed a systematic review of PKT interventions, defined as strategies that inform, educate and engage patients in their own health care. We searched MEDLINE, EMBASE and the Cochrane Library from 2005 to 2014 for English language studies that evaluated PKT interventions delivered immediately before, during or upon conclusion of clinical encounters to individual patients with arthritis or cancer. Data were extracted on study characteristics, PKT intervention (theory, content, delivery, duration, personnel, timing) and outcomes. Interventions were characterized by type of patient engagement (inform, activate, collaborate). We performed content analysis and reported summary statistics.

RESULTS

Of 694 retrieved studies, 16 were deemed eligible (5 arthritis, 11 cancer; 12 RCTs, 4 cohort studies; 7 low, 3 uncertain, 6 high risk of bias). PKT interventions included print material in 10 studies (brochures, booklets, variety of print material, list of websites), electronic material in 10 studies (video, computer program, website) and counselling in 2 studies. They were offered before, during and after consultation in 4, 1 and 4 studies, respectively; as single or multifaceted interventions in 10 and 6 studies, respectively; and by clinicians, health educators, researchers or volunteers in 4, 3, 5 and 1 study, respectively. Most interventions informed or activated patients. All studies achieved positive impact in one or more measures of patient knowledge, decision-making, communication and behaviour. This was true regardless of condition, PKT intervention, timing, personnel, type of engagement or delivery (single or multifaceted). No studies assessed patient harms, or interventions for providers to support PKT intervention delivery. Two studies evaluated the impact on providers of PKT interventions aimed at patients.

CONCLUSIONS

Single interventions involving print material achieved beneficial outcomes as did more complex interventions. Few studies were eligible, and no studies evaluated patient harms, or provider outcomes. Further research is warranted to evaluate these PKT interventions in more patients, or patients with different conditions; different types of PKT interventions for patients and for providers; and potential harms associated with interventions.

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

Health systems guidance appraisal--a critical interpretive synthesis

BACKGROUND

Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process.

METHODS

We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed.

RESULTS

We identified 43 papers that met eligibility criteria. No existing review was found on this topic, and no HSG appraisal tool was identified. Over one third of the authors implicitly or explicitly identified the need for a high-quality tool aimed to systematically evaluate HSG and contribute to its development/reporting. We identified 30 concepts that may be relevant to the appraisal of HSG and were able to cluster them into three meaningful domains: process principles, content, and context principles.

CONCLUSIONS

Our study showed the role that the quality criteria play in the development, appraisal, and reporting of HSG and demonstrated the link and resonance within and between the various concepts in the three domains.

Health system guidance appraisal--concept evaluation and usability testing

BACKGROUND

Health system guidance (HSG) provides recommendations aimed to address health system challenges. However, there is a paucity of methods to direct, appraise, and report HSG. Earlier research identified 30 candidate criteria (concepts) that can be used to evaluate the quality of HSG and guide development and reporting requirements. The objective of this paper was to describe two studies aimed at evaluating the importance of these 30 criteria, design a draft HSG appraisal tool, and test its usability.

METHODS

This study involved a two-step survey process. In step 1, respondents rated the 30 concepts for appropriateness to, relevance to, and priority for health system decisions and HSG. This led to a draft tool. In step 2, respondents reviewed HSG documents, appraised them using the tool, and answered a series of questions. Descriptive analyses were computed.

RESULTS

Fifty participants were invited in step 1, and we had a response rate of 82 %. The mean response rates for each concept within each survey question were universally favorable. There was also an overall agreement about the need for a high-quality tool to systematically direct the development, appraisal, and reporting of HSG. Qualitative feedback and a consensus process by the team led to refinements to some of the concepts and the creation of a beta (draft) version of the HSG tool. In step 2, 35 participants were invited and we had a response rate of 74 %. Exploratory analyses showed that the quality of the HSGs reviewed varied as a function of the HSG item and the specific document assessed. A favorable consensus was reached with participants agreeing that the HSG items were easy to understand and easy to apply. Moreover, the overall agreement was high for the usability of the tool to systematically direct the development (85 %), appraisal (92 %), and reporting (81 %) of HSG. From this process, version 1.0 of the HSG appraisal tool was generated complete with 32 items (and their descriptions) and 4 domains.

CONCLUSIONS

The final tool, named the Appraisal of Guidelines for Research and Evaluation for Health Systems (AGREE-HS) (version 1), defines expectations of HSG and facilitates informed decisions among policymakers on health system delivery, financial, and governance arrangements.

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

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

BACKGROUND

Health care professionals (HCPs) are able to make effective decisions regarding patient care through the use of systematically developed clinical practice guidelines (CPGs). These recommendations are especially important in a cancer health care context as patients are exposed to a multitude of interdisciplinary HCPs offering high-quality care throughout diagnosis, treatment, survivorship and palliative care. Although a large number of CPGs targeted towards cancer are widely disseminated, it is unknown whether implementation strategies targeting the use of these guidelines are effective in effecting HCP behaviour and patient outcomes in the cancer care context. The purpose of this systematic review will be to determine the effectiveness of different CPG dissemination and implementation interventions on HCPs' behaviour and patient outcomes in the cancer health care context.

METHODS/DESIGN

Five electronic databases (CINAHL, the Cochrane Controlled Trials Register, MEDLINE via Ovid, EMBASE via Ovid and PsycINFO via Ovid) will be searched to include all studies examining the dissemination and/or implementation of CPGs in a cancer care setting targeting all HCPs. CPG implementation strategies will be included if the CPGs were systematically developed (e.g. literature review/evidence-informed, expert panel, evidence appraisal). The studies will be limited to randomized controlled trials, controlled clinical trials and quasi-experimental (interrupted time series, controlled before-and-after designs) studies. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal.

DISCUSSION

The aim of this review is to inform cancer care health care professionals and policymakers about evidence-based implementation strategies that will allow for effective use of CPGs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019331.

The Guideline Implementability Decision Excellence Model (GUIDE-M): a mixed methods approach to create an international resource to advance the practice guideline field

Background

Practice guideline (PG) implementability refers to PG features that promote their use. While there are tools and resources to promote PG implementability, none are based on an evidence-informed and multidisciplinary perspective. Our objectives were to (i) create a comprehensive and evidence-informed model of PG implementability, (ii) seek support for the model from the international PG community, (iii) map existing implementability tools on to the model, (iv) prioritize areas for further investigation, and (v) describe how the model can be used by PG developers, users, and researchers.

Methods

A mixed methods approach was used. Using our completed realist review of the literature of seven different disciplines as the foundation, an iterative consensus process was used to create the beta version of the model. This was followed by (i) a survey of international stakeholders (guideline developers and users) to gather feedback and to refine the model, (ii) a content analysis comparing the model to existing PG tools, and (iii) a strategy to prioritize areas of the model for further research by members of the research team.

Results

The Guideline Implementability for Decision Excellence Model (GUIDE-M) is comprised of 3 core tactics, 7 domains, 9 subdomains, 44 attributes, and 40 subattributes and elements. Feedback on the beta version was received from 248 stakeholders from 34 countries. The model was rated as logical, relevant, and appropriate. Seven PG tools were selected and compared to the GUIDE-M: very few tools targeted the Contextualization and Deliberations domain. Also, fewer of the tools addressed PG appraisal than PG development and reporting functions. These findings informed the research priorities identified by the team.

Conclusions

The GUIDE-M provides an evidence-informed international and multidisciplinary conceptualization of PG implementability. The model can be used by PG developers to help them create more implementable recommendations, by clinicians and other users to help them be better consumers of PGs, and by the research community to identify priorities for further investigation.

When is good, good enough? Methodological pragmatism for sustainable guideline development

Background

Continuous escalation in methodological and procedural rigor for evidence-based processes in guideline development is associated with increasing costs and production delays that threaten sustainability. While health research methodologists are appropriately responsible for promoting increasing rigor in guideline development, guideline sponsors are responsible for funding such processes.

Discussion

This paper acknowledges that other stakeholders in addition to methodologists should be more involved in negotiating trade-offs between methodological procedures and efficiency in guideline production to produce guidelines that are ‘good enough’ to be trustworthy and affordable under specific circumstances. The argument for reasonable methodological compromise to meet practical circumstances is consistent with current implicit methodological practice. This paper proposes a conceptual tool as a framework to be used by different stakeholders in negotiating, and explicitly reporting, reasonable compromises for trustworthy as well as cost-worthy guidelines. The framework helps fill a transparency gap in how methodological choices in guideline development are made. The principle, ‘when good is good enough’ can serve as a basis for this approach.

Summary

The conceptual tool ‘Efficiency-Validity Methodological Continuum’ acknowledges trade-offs between validity and efficiency in evidence-based guideline development and allows for negotiation, guided by methodologists, of reasonable methodological compromises among stakeholders. Collaboration among guideline stakeholders in the development process is necessary if evidence-based guideline development is to be sustainable.

Do guidelines offer implementation advice to target users? A systematic review of guideline applicability

OBJECTIVE

Providers and patients are most likely to use and benefit from guidelines accompanied by implementation support. Guidelines published in 2007 and earlier assessed with the Appraisal of Guidelines, Research and Evaluation (AGREE) instrument scored poorly for applicability, which reflects the inclusion of implementation instructions or tools. The purpose of this study was to examine the applicability of guidelines published in 2008 or later and identify factors associated with applicability.

DESIGN

Systematic review of studies that used AGREE to assess guidelines published in 2008 or later.

DATA SOURCES

MEDLINE and EMBASE were searched from 2008 to July 2014, and the reference lists of eligible items. Two individuals independently screened results for English language studies that reviewed guidelines using AGREE and reported all domain scores, and extracted data. Descriptive statistics were calculated across all domains. Multilevel regression analysis with a mixed effects model identified factors associated with applicability.

RESULTS

Of 245 search results, 53 were retrieved as potentially relevant and 20 studies were eligible for review. The mean and median domain scores for applicability across 137 guidelines published in 2008 or later were 43.6% and 42.0% (IQR 21.8-63.0%), respectively. Applicability scored lower than all other domains, and did not markedly improve compared with guidelines published in 2007 or earlier. Country (UK) and type of developer (disease-specific foundation, non-profit healthcare system) appeared to be associated with applicability when assessed with AGREE II (not original AGREE).

CONCLUSIONS

Despite increasing recognition of the need for implementation tools, guidelines continue to lack such resources. To improve healthcare delivery and associated outcomes, further research is needed to establish the type of implementation tools needed and desired by healthcare providers and consumers, and methods for developing high-quality tools.

The development of guideline implementation tools: a qualitative study

BACKGROUND

Research shows that guidelines featuring implementation tools (GItools) are more likely to be used than those without GItools, however few guidelines offer GItools and guidance on developing GItools is lacking. The objective of this study was to identify common processes and considerations for developing GItools.

METHODS

Interviews were conducted with developers of 4 types of GItools (implementation, patient engagement, point-of-care decision-making and evaluation) accompanying guidelines on various topics created in 2008 or later identified in the National Guideline Clearinghouse. Participants were asked to describe the GItool development process and related considerations. A descriptive qualitative approach was used to collect and analyze data.

RESULTS

Interviews were conducted with 26 GItool developers in 9 countries. Participants largely agreed on 11 broad steps, each with several tasks and considerations. Response variations identified issues lacking uniform approaches that may require further research including timing of GItool development relative to guideline development; decisions about GItool type, format and content; and whether and how to engage stakeholders. Although developers possessed few dedicated resources, they relied on partnerships to develop, implement and evaluate GItools.

INTERPRETATION

GItool developers employed fairly uniform and rigorous processes for developing GItools. By supporting GItool development, the GItool methods identified here may improve guideline implementation and use.

How does context influence collaborative decision-making for health services planning, delivery and evaluation?

Background

Collaboration among researchers (clinician, non-clinician) and decision makers (managers, policy-makers, clinicians), referred to as integrated knowledge translation (IKT), enhances the relevance and use of research, leading to improved decision-making, policies, practice, and health care outcomes. However IKT is not widely practiced due to numerous challenges. This research explored how context influenced IKT as a means of identifying how IKT could be strengthened.

Methods

This research investigated IKT in three health services programs for colon cancer screening, prostate cancer diagnosis, and the treatment of pancreatic cancer. Qualitative methods were used to explore contextual factors that influenced how IKT occurred, and its impact. Data were collected between September 1, 2012 and May 15, 2013 from relevant documents, observation of meetings, and interviews with researchers and decision-makers, analyzed using qualitative methods, and integrated.

Results

Data were analyzed from 39 documents, observation of 6 meetings, and 36 interviews. IKT included interaction at meetings, joint undertaking of research, and development of guidelines. IKT was most prevalent in one program with leadership, clear goals, dedicated funding and other infrastructural resources, and an embedded researcher responsible for, and actively engaged in IKT. This program achieved a variety of social, research and health service outcomes despite mixed individual views about the value of IKT and the absence of a programmatic culture of IKT. Participants noted numerous challenges including lack of time and incentives, and recommendations to support IKT. A conceptual framework of factors that influence IKT and associated outcomes was generated, and can be used by others to plan or evaluate IKT.

Conclusions

The findings can be applied by researchers, clinicians, managers or policy-makers to plan or improve collaborative decision-making for health services planning, delivery, evaluation or quality improvement. Further research is needed to explore whether these findings are widespread, and further understand how IKT can be optimized.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0545-x) contains supplementary material, which is available to authorized users.

The AGREE Enterprise: a decade of advancing clinical practice guidelines

BACKGROUND

The original AGREE (Appraisal of Guidelines for REsearch and Evaluation) Instrument was published in 2003, and its revision, the AGREE II, in 2009. Together, they filled an important gap in the guideline and quality of care fields. Ten years later, the AGREE Enterprise reflects on a trajectory of projects and international collaboration that have contributed to advancing the science and quality of practice guidelines and the uptake of AGREE/AGREE II.

FINDINGS

The AGREE Enterprise has undertaken activities to improve the tool and to develop resources to support its use. Since 2003, the uptake and adoption of AGREE by the international community has been swift and broad. A total of 33 language translations of the original AGREE Instrument and the current AGREE II are available and were initiated by the international community. A recent scan of the published literature identified over 600 articles that referenced the AGREE tools. The AGREE tools have been widely received and applied, with several organizations having incorporated the AGREE as part of their formal practice guideline programs. Since its redevelopment in 2010, the AGREE Enterprise website (www.agreetrust.org) continues to experience steady increases in visitors per month and currently has over 10,000 registered users.

CONCLUSIONS

The AGREE Enterprise has contributed to the advancements of guidelines through research activities and international participation by scientific and user communities. As we enter a new decade, we look forward to ongoing collaborations and contributing to further advancements to improve quality of care and health care systems.

A framework of the desirable features of guideline implementation tools (GItools): Delphi survey and assessment of GItools

Background

Guidelines are the foundation for healthcare planning, delivery and quality improvement but are not consistently implemented. Few guidelines are accompanied by guideline implementation tools (GItools). Users have requested GItools, and developers have requested guidance on how to develop GItools. First it is necessary to characterize GItools. The purpose of this research was to generate a framework of desirable features of GItools.

Methods

Items representing desirable GItool features were generated by a cross-sectional survey of the international guideline community. Items were confirmed by 31 guideline developers, implementers and researchers in a two-round Delphi survey administered on the Internet. The resulting GItool framework was applied with a sample of GItools accompanying guidelines identified in the National Guideline Clearinghouse.

Results

The cross-sectional survey was completed by 96 respondents from Australia, Canada, the United Kingdom, the United States, The Netherlands, and various other countries. Seven of nine items were rated by the majority as desirable. A total of 31 panelists from 10 countries including Australia, Canada, Germany, New Zealand, Peru, Saudi Arabia, Spain, the United Kingdom, and the United States took part in a two-round Delphi survey. Ten items achieved consensus as desirable GItool features in round #1, and two additional items in round #2. A total of 13 GItools for Resource Planning, Implementation and Evaluation were identified among 149 guidelines on a variety of clinical topics (8.7%). Many GItools did not possess features considered desirable.

Conclusions

Inclusion of higher quality GItools in guidelines is needed to support user adoption of guidelines. The GItool framework can serve as the basis for evaluating and adapting existing GItools, or developing new GItools. Further research is needed to validate the framework, develop and implement instruments by which developers can apply the framework, and specify which guidelines should be accompanied by GItools.

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.

How can diagnostic assessment programs be implemented to enhance inter-professional collaborative care for cancer?

BACKGROUND

Inter-professional collaborative care (ICC) for cancer leads to multiple system, organizational, professional, and patient benefits, but is limited by numerous challenges. Empirical research on interventions that promote or enable ICC is sparse so guidance on how to achieve ICC is lacking. Research shows that ICC for diagnosis could be improved. Diagnostic assessment programs (DAPs) appear to be a promising model for enabling ICC. The purpose of this study was to explore how DAP structure and function enable ICC, and whether that may be associated with organizational and clinical outcomes.

METHODS

A case study approach will be used to explore ICC among eight DAPs that vary by type of cancer (lung, breast), academic status, and geographic region. To describe DAP function and outcomes, and gather information that will enable costing, recommendations expressed in DAP standards and clinical guidelines will be assessed through retrospective observational study. Data will be acquired from databases maintained by participating DAPs and the provincial cancer agency, and confirmed by and supplemented with review of medical records. We will conduct a pilot study to explore the feasibility of estimating the incremental cost-effectiveness ratio using person-level data from medical records and other sources. Interviews will be conducted with health professionals, staff, and referring physicians from each DAP to learn about barriers and facilitators of ICC. Qualitative methods based on a grounded approach will be used to guide sampling, data collection and analysis.

DISCUSSION

Findings may reveal opportunities for unique structures, interventions or tools that enable ICC that could be developed, implemented, and evaluated through future research. This information will serve as a formative needs assessment to identify the nature of ongoing or required improvements, which can be directly used by our decision maker collaborators, and as a framework by policy makers, cancer system managers, and DAP managers elsewhere to strategically plan for and implement diagnostic cancer services.