Personalizing rehabilitation for individuals with musculoskeletal impairments: Feasibility of implementation of the Measures Associated to Prognostic (MAPS) tool.

INTRODUCTION: The Measures Associated to PrognoStic (MAPS) tool is a standardized questionnaire that integrates validated prognostic tools to detect the presence of biopsychosocial prognostic factors in patients consulting for musculoskeletal disorders. PURPOSE: The objectives were to assess the: 1) feasibility of implementation of the MAPS tool, 2) clinicians' acceptability of the dashboard, and 3) patients' acceptability of the MAPS tool. METHODS: Twenty physiotherapists and two occupational therapists from seven outpatient musculoskeletal clinics were recruited to implement the MAPS tool during a 3-month timeframe, where new patients completed the questionnaire upon initial assessment. The results were presented to the clinicians via a dashboard. Surveys and semi-structured interviews were conducted to measure feasibility and acceptability. RESULTS: Six out of 11 feasibility criteria (55%) and 21 out of 24 acceptability criteria (88%) reached the a priori threshold for success. The interviews allowed us to identify three main themes to facilitate implementation: 1) limiting the burden, 2) ensuring patients' understanding of the tool's purpose, and 3) integrating the dashboard as a clinical information tool. CONCLUSION: Our quantitative and qualitative results support the feasibility of implementation and acceptability of the MAPS tool pending minor adjustments. Depicting the patients' prognostic profile has the potential to help clinicians optimize their interventions for patients presenting with musculoskeletal disorders.

Frequency and indication of non-musculoskeletal examinations: a cross-sectional survey of Quebec chiropractors.

BACKGROUND: Approximately 1% of low back pain is estimated to be caused by serious systemic diseases, including cancer, infection, or abdominal aortic dissection. This study aimed to determine the frequency of execution of non-MSK physical examination procedures among Quebec chiropractors and to identify the clinical context that prompts them to use these physical examination procedures. METHODS: Cross-sectional survey containing 44 questions administered to a random sample of Quebec chiropractors using a succession of online, postal and phone questionnaires. The 4-part survey questionnaire contained six demographic questions, 28 single-choice questions to determine the frequency of execution of non-MSK physical examination procedures, seven short clinical vignettes for which the respondents had to select the non-MSK examinations that would be required, and two questions inquiring about the proportion of new patients for which participants' felt non-MSK examinations were necessary and whether appropriate assessments were performed. The questionnaire was pilot tested, and feedback received integrated prior to administration. We conducted descriptive statistics, Pearson correlations, and an ANOVA. RESULTS: The survey was completed by 182 chiropractors (response rate: 36.4%). The most commonly non-musculoskeletal examination performed daily were blood pressure (12.1%) and cranial nerves (4.9%). The most common tests never performed were oxygen saturation (68.7%), cardiac auscultation (69.2%), tibio-brachial index (71.4%), breast (86.8%), rectal (96.7%), testicular (95.6%), and vaginal (99.9%) exams. Female chiropractors and Quebec University in Trois-Rivières graduates reported that a significantly higher proportion of their new patients required a non-musculoskeletal physical examination compared to male participants (37.2% vs 28.3%) or Canadian Memorial Chiropractic College graduates (33.9% vs 19.9%). Reason for not performing a physical examination included the belief that another healthcare professional was better positioned to perform and/or interpret the related tests (76.4%). CONCLUSIONS: Vital signs and cranial nerve examinations were the most frequency performed non-musculoskeletal examinations reported by chiropractors. Apart from the genitourinary exam almost never performed, most participants chose non-musculoskeletal examinations deemed appropriate for the patient's presentation.

Establishing the prognostic profile of patients with work-related musculoskeletal disorders: Development and acceptability of the MAPS questionnaire.

PURPOSE: Work-related musculoskeletal disorders (WRMD) are the most common causes of disability worldwide and are associated with significant use of healthcare. One way to optimize the clinical outcomes of injured workers receiving rehabilitation is to identify and address individual prognostic factors (PF), which can facilitate the personalization of the treatment plan. As there is no pragmatic and systematic method to collect prognostic-related data, the purpose of the study was to develop and assess the acceptability of a set of questionnaires to establish the "prognostic profile" of workers with WRMD. METHODS: We utilized a multistep process to inform the acceptability of the Measures Associated to PrognoStic (MAPS) questionnaire. During STEP-1, a preliminary version of the was developed through a literature search followed by an expert consensus including a patient-advisor. During STEP-2, future users (rehabilitation professionals, healthcare administrators and compensation officers) were consulted through an online survey and were asked to rate the relevance of each content item; items that obtained ≥80% of "totally agree" answers were included. They were also asked to prioritize PF according to their usefulness for clinical decision-making, as well as perceived efficacy to enhance the treatment plan. RESULTS: The questionnaire was developed with three categories: the outcome predicted, the unique PF, and prognostic tools. Personal PF (i.e.: coping strategies, fear-avoidance beliefs), pain related PF (i.e.: pain intensity/severity, duration of pain), and work-related PF (i.e.: work physical demands, work accommodations) were identified to be totally relevant and included in the questionnaire. 84% of the respondents agreed that their patients could complete the MAPS questionnaire in their clinical setting, while 75% totally agreed that the questionnaire is useful to personalize rehabilitation interventions. CONCLUSION: The MAPS questionnaire was deemed acceptable to establish the "prognostic profile" of injured workers and help the clinicians in the treatment decision-making process.

Understanding patient preferences for student clinician attire: a cross-sectional study of a student chiropractic clinic in Australia.

Objectives: Previous studies have investigated the role of clinical attire in establishing patient-held perceptions of professionalism and knowledgeability across various healthcare settings. This study aimed to understand patients' preferences for chiropractic student attire. Methods: Three hundred and twenty patients were recruited from a university chiropractic clinic and asked to complete an online questionnaire. The patients' preferences for five different attires were rated and calculated as the composite score of five domains (knowledgeable, trustworthy, caring, professional, and comfortable). Results: While 71.9% of participants indicated that how students dress was important to them, most (63.4%) disagreed that wearing a white coat was essential for chiropractic student clinicians. The most preferred form of attire was the current clinic shirt. Conclusion: The attire worn by chiropractic student clinicians at a single institution was found to be an influential attribute. Student chiropractic clinicians should dress professionally to make a good first impression. This study provided some guidance with the ongoing debate around students' dress code.

Objectif: Des études antérieures ont examiné le rôle de la tenue vestimentaire en clinique dans l'établissement des perceptions des patients quant au professionnalisme et à la compétence dans divers environnements de soins de santé. Cette étude visait à comprendre les préférences des patients en matière de tenue vestimentaire des étudiants en chiropratique. Méthodologie: Trois cent vingt patients ont été recrutés dans une clinique chiropratique universitaire et invités à remplir un questionnaire en ligne. Les préférences des patients pour cinq tenues différentes ont été évaluées et calculées en tant que score composite de cinq domaines (bien informé, digne de confiance, attentionné, professionnel et confortable). Résultats: Si 71,9 % des participants ont indiqué que la tenue vestimentaire des étudiants était importante pour eux, la plupart (63,4 %) n'étaient pas d'accord avec le fait que le port d'une blouse blanche était essentiel pour les étudiants cliniciens en chiropratique. La tenue vestimentaire la plus appréciée était la chemise de clinique actuelle. Conclusion: La tenue vestimentaire des étudiants cliniciens en chiropratique d'un même établissement s'est révélée être un attribut influent. Les étudiants en chiropratique doivent s'habiller de manière professionnelle pour faire une bonne première impression. Cette étude a permis d'éclairer le débat en cours sur le code vestimentaire des étudiants.

Chiropractic care and research priorities for the pediatric population: a cross-sectional survey of Quebec chiropractors.

BACKGROUND: Chiropractors commonly treat pediatric patients within their private practices. The objectives of this study were (1) to identify the treatment techniques and health advice used by Quebec chiropractors with pediatric patients; (2) to explore the research priorities of Quebec chiropractors for the pediatric population; and (3) to identify Quebec chiropractors' training in the field of pediatric chiropractics. METHODS: A web-based cross-sectional survey was conducted among all licensed Quebec chiropractors (Qc, Canada). Descriptive statistics were used to analyze all quantitative variables. RESULTS: The results showed that among the 245 respondents (22.8% response rate), practitioners adapted their treatment techniques based on their patients' age group, thus using softer techniques with younger pediatric patients and slowly gravitating toward techniques used with adults when patients reached the age of six. In terms of continuing education, chiropractors reported an average of 7.87 h of training on the subject per year, which mostly came from either Quebec's College of Chiropractors (OCQ) (54.7%), written articles (46.9%) or seminars and conferences (43.7%). Both musculoskeletal (MSK) and viscerosomatic conditions were identified as high research priorities by the clinicians. CONCLUSIONS: Quebec chiropractors adapt their treatment techniques to pediatric patients. In light of limited sources of continuing education in the field of pediatric chiropractics, practitioners mostly rely on the training provided by their provincial college and scientific publications. According to practitioners, future research priorities for pediatric care should focus on both MSK conditions and non-MSK conditions.

Prognostic factors specific to work-related musculoskeletal disorders: An overview of recent systematic reviews.

PURPOSE: Work-related injuries affect a considerable number of people each year and represent a significant burden for society. To reduce this burden, optimizing rehabilitation care by integrating prognostic factors (PF) into the clinical decision-making process is a promising way to improve clinical outcomes. The aim of this study was to identify PF specific to work-related musculoskeletal disorders. METHODS: We performed an overview of systematic reviews reporting on PF that had the following outcomes of interest: Return to work, pain, disability, functional status, or poor outcomes. Each extracted PF was categorized according to its level of evidence (grade A or B) and whether it was modifiable or not. The risk of bias of each study was assessed with the ROBIS tool. RESULTS: We retrieved 757 citations from 3 databases. After removing 307 duplicates, 450 records were screened, and 20 studies were retained. We extracted a total of 20 PF with a Grade A recommendation, where 7 were deemed modifiable, 11 non-modifiable and 2 were index test. For example, return to work expectations, previous sick leave, delay in referral and pain intensity were found to be predictors of return-to-work outcomes. We also identified 17 PF with a Grade B recommendation, where 11 were deemed modifiable. For example, poor general health, negative recovery expectations, coping and fear-avoidance beliefs, pain severity, and particularly physical work were found to predict return to work outcomes. CONCLUSION: We found numerous modifiable PFs that can help clinicians personalize their treatment plan beyond diagnostic-related information for work-related musculoskeletal disorders.

Injuries and Health Issues Occurring During Offshore Transoceanic Sailing: A Survey of Recreational Sailors and Cruisers.

INTRODUCTION: Most of the literature on sailing injuries is centered on competitive sailing, often involving a single regatta. The aims of this study were to provide a description of the types of injuries and illnesses sustained during amateur offshore cruising events, estimate their incidence, and investigate potential risk factors for injuries. METHODS: We conducted a cross-sectional survey of self-reported sailing-related injuries and health issues during 4 different events organized by the World Cruising Club between 2014 and 2015. Prior to departure, sailors received an injury or health issue report form to complete during their sailing event. Questionnaires were then collected at the end of each event. Bivariable (Student's t tests and χ2 tests) and mutilvariable logistic regression were used to study the associations among injuries, health issues, and the characteristics of sailors or sailboats. RESULTS: The incidence of injuries and health issues among the respondents was 1.08 and 1.01 per 10,000 nautical miles, respectively. Smaller boats (P<0.001) and crews with less experience with the current boat (P<0.001) were associated with reporting of more injuries. Most of the injuries were reported during favorable weather conditions. Health issues were more frequent on smaller boats and with women (P=0.008), who reported significantly more seasickness (P<0.001), anxiety (P=0.037), and skin rash/fungal infection (P=0.021). CONCLUSIONS: Injuries and health issues are relatively common among amateur offshore recreational sailors, but severe injuries are rare. Smaller boats and having less experience in sailing with the current boat were associated with more injuries. Preventive strategies should include a sailing experience requirement on the boat being sailed for all crew members, increasing the minimum boat size requirement for sailing events, and mandatory first-aid training prior to a cruising event for all crew members.

Chiropractic pediatric patient management and interdisciplinary collaboration: a descriptive cross-sectional study of chiropractors in Quebec.

BACKGROUND: Worldwide, many patients, including minors, seek chiropractic care. The purpose of this study was to investigate the practice characteristics of chiropractors who treat pediatric patients in Quebec, Canada. METHODS: We conducted a web-based cross-sectional survey of all licensed chiropractors working in Quebec (Canada). Data were collected using an adapted questionnaire. Descriptive statistics were produced for all the variables collected. RESULTS: Among our 245 participants (response rate: 21%), 63% were women, and half defined themselves as general musculoskeletal (MSK) health care practitioners. Nearly all participants reported seeing 0-5 new pediatric patients/week, and the most common pediatric age group was 6-12 years old (57%). Pediatric patients were most commonly referred by family members and "word of mouth". The respondents most frequently indicated that they strongly agreed with statements affirming their confidence in their own diagnostic capacities regarding MSK disorders with respect to all age groups as well as non-MSK disorders with regard to young teens. They reported a moderate level of agreement with similar statements concerning the diagnosis of non-MSK disorders in newborns, preschoolers, and children. Chiropractors rarely referred their pediatric patients to a nurse/family doctor or a pediatrician. When presented with potential pediatric red flags, the respondents commonly indicated that they would refer the patient to a physician in an emergency situation or for comanagement. CONCLUSION: Chiropractors in Quebec are confident in their diagnoses of pediatric MSK conditions and refer patients to physicians in the rare event of a worrisome presentation. However, some chiropractors may have expectations that are unsupported by evidence regarding the diagnosis and management of non-MSK complaints.

Distinct care trajectories among persons living with arthritic conditions: A two-year state sequence analysis.

Objectives: Developing solutions to optimize care trajectories (CareTs) requires examining patient journeys through the health care system. This study aimed to describe CareTs among people living with arthritis and evaluate their association with self-reported health outcomes. Methods: Analyses were conducted using the TorSaDE Cohort (n = 102,148), which connects the 2007 to 2016 Canadian Community Health Surveys (CCHS) with Quebec administrative databases (longitudinal claims). CareTs of participants living with arthritis according to CCHS (n = 16,631), over the two years before CCHS completion, were clustered using state sequence analysis (months as a time unit). CareT group membership was then put in association with self-reported outcomes (pain intensity and interference, self-perceived general and mental health). Results: The analysis revealed five CareT groups characterized predominantly by: (1) arthritis-related visits to a specialist (n = 2,756; 16.6%), (2) arthritis-related emergency department visits (n = 2,928; 17.6%), (3) very high all-cause health care utilization and arthritis-related hospitalizations (n = 1,570; 9.4%), (4) arthritis-related medical visits to general practitioners and specialists (n = 2,708; 16.3%), (5) low all-cause health care utilization (n = 6,669; 40.1%). Multivariable results revealed that CareT group membership was associated with higher levels of pain interference (CareT group #3 vs. #5: OR: 1.4, 95%CI: 1.1-1.8) and fair/poor self-perceived general health (CareT group #1 vs. #5: OR: 1.551, 95%CI: 1.319-1.824; #2 vs. #5: OR: 1.244, 95%CI: 1.062-1.457; #3 vs. #5: OR: 1.771, 95%CI: 1.451-2.162; #4 vs. #5: OR: 1.481, 95%CI: 1.265-1.735). Discussion: Sate sequence analysis is an innovative method of studying CareTs and valuable for making evidence-based decisions taking into account inter- and intra-individual variability.

Developing key performance indicators for the Canadian chiropractic profession: a modified Delphi study.

BACKGROUND: The purpose of this study is to develop a list of performance indicators to assess the status of the chiropractic profession in Canada. METHOD: We conducted a 4-round modified Delphi technique (March 2018-January 2020) to reach consensus among experts and stakeholders on key status indicators for the chiropractic profession using online questionnaires. During the first round, experts suggested indicators for preidentified themes. Through the following two rounds, the importance and feasibility of each indicator was rated on an 11-point Likert scale, and their related potential sources of data identified. In the final round, provincial stakeholders were recruited to rate the importance of the indicators within the 90th percentile and identified those most important to their organisation. RESULTS: The first round generated 307 preliminary indicators of which 42 were selected for the remaining rounds, and eleven were preferentially selected by most of the provincial stakeholders. Experts agreed the feasibility of all indicators was high, and that data could be collected through a combination of data obtained from professional liability insurance records and survey(s) of the general population, patients, and chiropractors. CONCLUSIONS: A set of performance indicators to assess the status of the Canadian chiropractic profession emerged from a scientific and stakeholder consensus.

Student attitudes toward the International Clinical and Professional Chiropractic Education Position Statement and Evidence-based practice: a survey of UQTR chiropractic students.

Objective: The aim of this study is to describe the attitude of Université du Québec à Trois-Rivières (UQTR) chiropractic students toward the International Clinical and Professional Chiropractic Education Position Statement and evidence-based practice (EBP) beliefs. Methods: A cross-sectional survey was administered to all the UQTR chiropractic students. Using a five-point Likert scale, students were asked to rate their level of agreement with the position statement (10 items), EBP (2 items), interprofessional collaboration (2 items) and vitalistic philosophy (2 items). Results: Survey response rate was 71%. Students most frequently reported strong agreement with the position statement, EBP and interprofessional collaboration. They also most frequently disagreed with vitalistic philosophy. The attitude toward the position statement was positively correlated with the year of study in the program (r=0.10, p=0.019), EBP (r=0.56, p<0.001) and interprofessional collaboration (r=0.45, p <0.001). Conclusions: UQTR chiropractic students demonstrate high levels of agreement with EBP and the Education Position Statement.

Objectif: L'objectif de cette étude est de décrire la position des étudiants en chiropratique de l'Université du Québec à Trois-Rivières (UQTR) à l'égard de l'Énoncé de position international sur l'enseignement clinique et professionnel de la chiropratique (ICEC) ainsi que les croyances associées aux pratiques fondées sur les données probantes (EBP). Méthode: Une enquête transversale a été menée auprès de tous les étudiants en chiropratique de l'UQTR. À l'aide d'une échelle de Likert de cinq points, les étudiants devaient indiquer leur niveau d'accord avec l'ICEC (10 éléments), les EBP (2 éléments), la collaboration interprofessionnelle (2 éléments) et la philosophie vitaliste (2 éléments). Résultats: Le taux de réponse était de 71 %. De façon générale, les étudiants étaient fortement en accord avec les énoncés de l'ICEC, l'EBP et la collaboration interprofessionnelle. Ils étaient également en désaccord avec la philosophie vitaliste. L'opinion des étudiants à l'égard de l'ICEC était positivement corrélée avec l'année d'études dans le programme (r=0.10, p=0.019), l'EBP (r=0.56, p<0.001) et la collaboration interprofessionnelle (r=0.45, p <0.001). Conclusion: Les étudiants en chiropratique de l'UQTR démontrent des niveaux élevés d'accord avec l'EBP et l'ICEC.

Chiropractic techniques and treatment modalities included in academic programs: A survey of chiropractic educational institutions.

OBJECTIVE: The chiropractic techniques that chiropractors learn during their training strongly influence the nature of treatments provided by chiropractors and their professional identity. The objective of this project is to provide an exhaustive description of all chiropractic techniques and treatment modalities taught in chiropractic educational institutions. METHODS: International experts were solicited to provide feedback on the exhaustivity and clarity of our preliminary questionnaire. Following the expert suggestions, we administered our cross-sectional survey representatives of all chiropractic education institutions listed on the World Federation of Chiropractic website. We also asked the contact information for an additional contact from each institution and surveyed them for triangulation purposes. RESULTS: Among the 47 chiropractic education institutions surveyed, 29 completed our survey (response rate: 62%) of which 18 (62%) had 2 respondents. Among all the chiropractic techniques and treatment modalities investigated, only the Diversified technique was included in the core curriculum of all responding institutions. A considerable proportion of the techniques or modalities studied were not included in the educational activities of the institutions, particularly within the manual tonal or reflex techniques, instrument-assisted articular techniques, as well as the other techniques or modalities categories. Surprisingly, exercise prescription was not included in the core curriculum of all the institutions. Some scientifically challenged approaches were included in the educational activities of more than 40% of the institutions. CONCLUSION: The portfolio of therapeutic teaching varies greatly between chiropractic educational institutions. A more standardized therapeutic curriculum could be beneficial to reduce public and interprofessional confusion toward therapeutic approaches in chiropractic.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature.

BACKGROUND: A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. OBJECTIVES: We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. GLOBAL SUMMIT: The Global Summit took place on September 14-15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. SYSTEMATIC REVIEW OF THE LITERATURE: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. RESULTS: We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. CONCLUSION: Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Association Between Characteristics of Danish Chiropractors and Number of Referred Patients From General Practitioners: A Cross-sectional Study.

OBJECTIVE: The purposes of this study were to quantify the number of patients referred weekly from primary health care general practitioners (GPs) to chiropractors and to identify chiropractor characteristics associated with the number of referrals. METHODS: An online, cross-sectional survey was sent to the 600 active members of the Danish Chiropractic Association. Of those, 364 completed the survey and 286 met our inclusion criteria. We used bivariable analyses and negative binomial multivariable regression to evaluate the association between predetermined characteristics and the weekly number of patients referred by GPs. RESULTS: On average, chiropractors reported that they received 2.5 (standard deviation, 2.2) referrals from GPs per week, representing 31% of all new patients received by chiropractors. Clinics with more than 1 chiropractor and access to diagnostic ultrasound received more GP referrals. Chiropractors reporting expertise in geriatrics and a higher number of new patients per week reported more referrals. Chiropractors who reported referring more patients to GPs also reported receiving more referrals from them. CONCLUSION: Variables related to access to chiropractic care, the type of care provided, and interprofessional communication were positively associated with the number of GP referrals that chiropractors self-reported. This is the first study to report on factors associated with GP referrals to Danish chiropractors.

Making Contributions and Defining Success: An eDelphi Study of the Inaugural Cohort of CIHR Health System Impact Fellows, Host Supervisors and Academic Supervisors.

CONTEXT: The Health System Impact (HSI) Fellowship, an innovative training program developed by the Canadian Institutes of Health Research's Institute of Health Services and Policy Research, provides PhD-trained health researchers with an embedded, experiential learning opportunity within a health system organization. METHODS/DESIGN: An electronic Delphi (eDelphi) study was conducted to: (1) identify the criteria used to define success in the program and (2) elucidate the main contributions fellows made to their organizations. Through an iterative, two-round eDelphi process, perspectives were elicited from three stakeholder groups in the inaugural cohort of the HSI Fellowship: HSI fellows, host supervisors and academic supervisors. DISCUSSION: A consensus was reached on many criteria of success for an embedded research fellowship and on several perceived contributions of the fellows to their host organization and academic institutions. This work begins to identify specific criteria for success in the fellowship that can be used to improve future iterations of the program.

A framework for value-creating learning health systems.

BACKGROUND: Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs. METHODS: The framework was developed by an interdisciplinary team at the Institut national d'excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts. RESULTS: The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs' strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs. CONCLUSIONS: Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.

Which Characteristics are Associated with the Timing of the First Healthcare Consultation, and Does the Time to Care Influence the Duration of Compensation for Occupational Back Pain?

Purpose To identify the characteristics associated with the timing of the first healthcare consultation and to measure the impact of that timing on the duration of the first episode of compensation for occupational back pain following the injury. Methods We analyzed data from a cohort of workers with compensated back pain in 2005 in Ontario obtained from the Workplace Safety and Insurance Board. Cox multivariable survival models were performed to identify factors associated with the time to care and to measure its association with the length of the first episode of 100 % compensation. Results Among the 5520 claims analyzed, 93.7 % of workers accessed care within the first week (average = 2.1 days; median = 1 day). Time to care was shorter for males, for workers who had received previous compensation and for those with access to an early return to work program. Age, number of employees in the company and personal earnings were positively associated with the time to care. More severe nature of injury, employers doubt about the work-relatedness of the injury and consulting a physiotherapist as the first healthcare provider were also associated with longer time to care. Considering potential confounders, longer time to care was significantly associated with a delay in the end of the first episode of compensation (hazard ratio = 0.98; P < 0.001). Conclusion Temporal access to a source of care is not problematic for the vast majority of Ontarian workers who receive compensation for occupational back pain; however, for the minority of workers who do not rapidly access care, the timing of the first healthcare consultation is a significant predictor of the duration of the first episode of compensation.

Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain.

Objective To compare the duration of financial compensation and the occurrence of a second episode of compensation of workers with occupational back pain who first sought three types of healthcare providers. Methods We analyzed data from a cohort of 5511 workers who received compensation from the Workplace Safety and Insurance Board for back pain in 2005. Multivariable Cox models controlling for relevant covariables were performed to compare the duration of financial compensation for the patients of each of the three types of first healthcare providers. Logistic regression was used to compare the occurrence of a second episode of compensation over the 2-year follow-up period. Results Compared with the workers who first saw a physician (reference), those who first saw a chiropractor experienced shorter first episodes of 100 % wage compensation (adjusted hazard ratio [HR] = 1.20 [1.10-1.31], P value < 0.001), and the workers who first saw a physiotherapist experienced a longer episode of 100 % compensation (adjusted HR = 0.84 [0.71-0.98], P value = 0.028) during the first 149 days of compensation. The odds of having a second episode of financial compensation were higher among the workers who first consulted a physiotherapist (OR = 1.49 [1.02-2.19], P value = 0.040) rather than a physician (reference). Conclusion The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker's compensation system. Further investigation is required to understand the between-provider differences.