Effectiveness of monetary incentives to recruit family physicians as study subjects: a randomized controlled trial.

BACKGROUND: Recruiting family physicians to participate as subjects of clinical studies is challenging. Monetary incentives are often used to increase enrolment, but few studies have measured the impact of doing so. As part of a trial seeking to compare two formats of interactive activities within an online continuing medical education (CME) program, we compared family physicians' recruitment rates with and without a monetary incentive. Recruitment took place by email. METHODS: Family physicians listed in the directory of the College of Physicians of the Province of Quebec (Canada) were emailed a one-page letter inviting them to participate in a randomized trial designed to evaluate a three-hour online CME program on rheumatology. Half of physicians were randomly allocated to receive a version of the letter that offered them $300 to participate (incentive group); the other half was not offered compensation (no-incentive group). RESULTS: A total of 1314 (91%) physicians had a valid email address as listed in the directory. The response rate was 7.5% (54/724) in the incentive group and 2.6% (19/724) in the no-incentive group (absolute difference [AD] 4.8%, 95% confidence interval [95% CI] = 2.6 - 7.2%; risk ratio [RR] 2.8, 95% CI = 1.7 - 4.7). Recruitment rates were 3.5% (25/724) in the incentive group and 0.6% (4/724) in the no-incentive group (AD 2.9%, 95% CI = 1.5 - 4.5%; RR 6.3, 95% CI = 2.2 - 17.9). CONCLUSIONS: Monetary incentives significantly increased recruitment, which nonetheless remained low. To reach recruitment targets, researchers are advised to plan for an extensive list of email contacts and to minimize restrictive eligibility criteria.

Validation of a new questionnaire with generic and disease-specific qualities: the McGill COPD Quality of Life Questionnaire.

BACKGROUND: A validated health-related quality of life questionnaire in chronic obstructive pulmonary disease (COPD) with advantages of both generic- and disease-specific questionnaires is needed to capture patients' perspectives of severity and impact of the disease. The McGill COPD questionnaire was created to include these advantages in English and French. It assesses three domains: symptoms, physical function and feelings with 29 items (12 from the 36-item Short-Form Health Survey with 17 from the previously developed COPD-specific module). OBJECTIVE: To evaluate the psychometric properties of this newly developed hybrid questionnaire in subjects with COPD. METHODS: Data from a multicentre, prospective cohort study involving four hospitals with COPD subjects undergoing pulmonary rehabilitation were used. Patient evaluations included health-related quality of life (the new McGill COPD questionnaire, the St Georges Respiratory Questionnaire and the 36-item Short-Form Health Survey) and pulmonary function tests pre-and postrehabilitation. Reliability, validity and responsiveness were tested. RESULTS: The study included 246 COPD subjects (111 females) with a mean age of 66 years, 87% ex- and 8% current smokers (mean 61 pack-years) and mean forced expiratory volume in 1 s of 1.12 L (Global initiative for chronic Obstructive Lung Disease stages: 2, 27%; 3, 33%; and 4, 37%). Missing data were <2% and floor and ceiling effects were <5%. Internal consistency (Cronbach's alpha) was 0.68 to 0.82. Test-retest reliability (intracorrelation coefficients) ranged from 0.74 to 0.96 for the subscales, and 0.95 for the total score. Correlation with the St George's Respiratory Questionnaire was moderately high (r=-0.88 [95% CI -0.91 to -0.84]), consistent with the a priori hypothesis for convergent validity. The effect size was 0.33 (pre-postrehabilitation mean score difference = 6), suggesting a small to moderate change. CONCLUSIONS: The new McGill COPD questionnaire showed high internal consistency, test-retest reliability, validity and moderate responsiveness in COPD subjects.

Combining both generic and disease-specific properties: development of the McGill COPD quality of life questionnaire.

UNLABELLED: Presently, a generic and a disease-specific questionnaire are often co-administered to capture the different domains of quality of life in chronic obstructive pulmonary disease (COPD) subjects. A health-related-quality of life (HRQL) questionnaire in COPD combining both generic and disease-specific properties is needed. OBJECTIVE: To develop a new, hybrid-HRQL questionnaire, the McGill-COPD-questionnaire, with qualities of both generic and disease-specific instruments. Using pre-defined criteria, we selected items from the SF-36 to complement the items from a COPD-specific-module to create the new hybrid-HRQL-questionnaire. Domains were identified via confirmatory factor analysis. The McGill COPD questionnaire is available in English and French; it assesses three domains: symptoms, physical-function and feelings, has 29 items: 17 from the COPD-specific-module and 12 from the SF-36. The symptom sub-scale has 6 items, all from the COPD-specific-module; the feelings sub-scale has 10 items, 5 each from COPD-specific-module and SF-36 and the physical-function sub-scale has 13 items, 6 from COPD-specific-module and 7 from SF-36. The McGill COPD questionnaire was developed using a novel method of combining items from the SF-36 and a COPD-specific-module. Thus, this new questionnaire has items from a generic-questionnaire and a disease-specific-module and, hence, is promising to be a stand alone quality-of-life questionnaire for COPD subjects.

Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial.

BACKGROUND: Home-based rehabilitation is a promising approach to improve access to pulmonary rehabilitation. OBJECTIVE: To assess whether self-monitored, home-based rehabilitation is as effective as outpatient, hospital-based rehabilitation in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Randomized, multicenter, noninferiority trial. SETTING: 10 academic and community medical centers in Canada. PATIENTS: 252 patients with moderate to severe COPD. INTERVENTION: After a 4-week education program, patients took part in home-based rehabilitation or outpatient, hospital-based rehabilitation for 8 weeks. They were followed for 40 weeks to complete the 1-year study. MEASUREMENTS: The primary outcome was the change in Chronic Respiratory Questionnaire dyspnea subscale score at 1 year. The primary analysis took a modified intention-to-treat approach by using all patients who provided data at the specified follow-up time, regardless of their level of adherence. The analysis used regression modeling that adjusted for the effects of center, sex, and baseline level. All differences were computed as home intervention minus outpatient intervention. RESULTS: Both interventions produced similar improvements in the Chronic Respiratory Questionnaire dyspnea subscale at 1 year: improvement in dyspnea of 0.62 (95% CI, 0.43 to 0.80) units in the home intervention (n = 107) and 0.46 (CI, 0.28 to 0.64) units in the outpatient intervention (n = 109). The difference between the 2 treatments at 1 year was small and clinically unimportant. The 95% CI of the difference did not exceed the prespecified noninferiority margin of 0.5: difference in dyspnea score of 0.16 (CI, -0.08 to 0.40). Most adverse events were related to COPD exacerbations. No serious adverse event was considered to be related to the study intervention. LIMITATION: The contribution of the educational program to the improvement in health status and exercise tolerance cannot be ascertained. CONCLUSION: Home rehabilitation is a useful, equivalent alternative to outpatient rehabilitation in patients with COPD.

Making interprofessional education work: the strategic roles of the academy.

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Asthma worsenings: approaches to prevention and management from the Asthma Worsenings Working Group.

Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or night-time symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods.To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary care physicians, pharmacists and specialists is likely to have the greatest impact on the identification, prevention and management of asthma worsenings.

Playing cards on asthma management: a new interactive method for knowledge transfer to primary care physicians.

OBJECTIVES: To describe an interactive playing card workshop in the communication of asthma guidelines recommendations, and to assess the initial evaluation of this educational tool by family physicians. DESIGN: Family physicians were invited to participate in the workshop by advertisements or personal contacts. Each physician completed a standardized questionnaire on his or her perception of the rules, content and properties of the card game. SETTING: A university-based continuing medical education initiative. PARTICIPANTS: Primary care physicians. MAIN OUTCOME MEASURES: Physicians' evaluation of the rules, content and usefulness of the program. RESULTS: The game allowed the communication of relevant asthma-related content, as well as experimentation with a different learning format. It also stimulated interaction in a climate of friendly competition. Participating physicians considered the method to be an innovative tool that facilitated reflection, interaction and learning. It generated relevant discussions on how to apply guideline recommendations to current asthma care. CONCLUSIONS: This new, interactive, educational intervention, integrating play and scientific components, was well received by participants. This method may be of value to help integrate current guidelines into current practice, thus facilitating knowledge transfer to caregivers.

First myringotomy with insertion of a modified Goode T-Tube: changing the perforation paradigm.

BACKGROUND: Goode T-Tubes (Medtronic Xomed, Inc) have a bad reputation because of their residual tympanic perforation rate. However, these long-term tubes are mostly used in patients with chronic middle ear problems. On the other hand, "safer," short-term tubes may need to be reinserted in up to 20% of children. OBJECTIVE: To demonstrate that modified Goode T-Tubes inserted at the first myringotomy in normal children leave a perforation rate comparable to the rate reported in the literature for short-term tubes and may be extracted safely in the outpatient clinic when eustachian tube function is thought to be adequate. METHOD: This prospective study followed 58 children (100 ears) who had their modified Goode T-Tubes electively removed in the clinic, from October 2003 to November 2004. RESULTS: We found only one persistent perforation at the third follow-up (mean time 5.2 months). The tubes had been in place for an average of 2.9 years. The perforation healing rate was inversely related to intubation duration. Adenotonsillectomy seemed to favourably influence the speed of healing. The perforations healed faster when tubes were inserted for chronic middle ear effusion compared with recurrent acute otitis media. Age, gender, and the site of intubation were not related to persistent perforation. All of the tubes spontaneously extruded (13) healed without perforation. CONCLUSION: Modified Goode T-Tubes inserted at the first myringotomy and electively extracted allow for a longer middle ear ventilation period and have a perforation rate comparable to that of short-term tubes.

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD.

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

A Canadian, multicentre, randomized clinical trial of home-based pulmonary rehabilitation in chronic obstructive pulmonary disease: rationale and methods.

BACKGROUND: Pulmonary rehabilitation remains largely underused. Self-monitored, home-based rehabilitation is a promising approach to improving the availability of pulmonary rehabilitation. OBJECTIVE: To report the rationale and methods of a trial comparing the effectiveness of self-monitored, home-based rehabilitation with hospital-based, outpatient rehabilitation in patients with chronic obstructive pulmonary disease (COPD). STUDY DESIGN: A parallel-group, randomized, noninferiority, multicentre trial will be performed with 240 patients with moderate to severe COPD. INTERVENTION: Patients will be randomly assigned to conventional, supervised, hospital-based outpatient rehabilitation or self-monitored, home-based rehabilitation. Both interventions will include a standardized, comprehensive self-management program, in addition to the hospital-based outpatient or home-based exercise program. After the three-month intervention, patients in both groups will be encouraged to continue exercising at home. Patients will be assessed monthly with telephone interviews and in person at enrollment, three months and 12 months. OUTCOMES: The dyspnea domain of the Chronic Respiratory Questionnaire (CRQ) at 12 months is the primary outcome variable. Secondary outcome variables include total and domain-specific CRQ scores; exercise tolerance and activity of daily living; health service use over the one-year study period; and direct and indirect costs of COPD treatment. ANALYSIS: An intent-to-treat approach will be used as the primary analysis. The primary analysis will focus on the change in the CRQ dyspnea score using a two-sided t distribution based on 95% CIs. The same approach will be used for secondary continuous outcome variables. CONCLUSION: The present trial will address two unresolved issues in pulmonary rehabilitation for patients with COPD: the short-term and long-term effectiveness of home-based pulmonary rehabilitation strategies. The authors will also determine if home-based pulmonary rehabilitation can reduce health service use (eg, hospitalizations and emergency visits) and if it can be done at a lower cost than the traditional hospital-based outpatient pulmonary rehabilitation.

French-Canadian version of the Chronic Respiratory and St George's Respiratory questionnaires: an assessment of their psychometric properties in patients with chronic obstructive pulmonary disease.

BACKGROUND: French versions of the Chronic Respiratory Questionnaire (CRQ) and the St George's Respiratory Questionnaire (SGRQ) have largely been used in Canada, although the process by which they were translated remains unknown and the psychometric properties of these translated versions have not been assessed in a properly designed study. OBJECTIVE: To translate and evaluate the psychometric properties of the French-Canadian versions of the CRQ and the SGRQ. METHODS: The questionnaires were translated according to standardized guidelines for cross-cultural adaptation. Measurements were made at baseline and again after two weeks in 27 chronic obstructive pulmonary disease (COPD) patients known to have stable disease. Measurements were also taken pre- and post-treatment in patients with acute exacerbation of COPD (33 patients) or in pulmonary rehabilitation (32 patients). RESULTS: The CRQ showed high test-retest reliability (the majority above 0.70), although it was slightly lower for the dyspnea dimension (0.58 to 0.65). The SGRQ also showed high test-retest reliability (above 0.80), although it was lower for the symptoms dimension (0.54 to 0.58). The internal consistency reliability coefficients ranged from 0.73 to 0.90 for the CRQ and above 0.80 for the SGRQ, except for the symptoms dimension. The Pearson's correlation coefficients were low (less than 0.30) between most of the translated questionnaire dimension scores and forced expiratory volume in 1 s, 6 min walking test and dyspnea measures. The correlation was generally high (greater than 0.50) between the two questionnaires and the 36-item short form health survey, and for those domains that measured the same construct. The changes in the total and subscale scores of the CRQ and the SGRQ (except for the symptoms domain) were all largely above the variability of the score in the stable disease group. CONCLUSION: The present study confirms that the French-Canadian translated versions of the CRQ and the SGRQ perform well with respect to their psychometric properties. They are both suitable for their intended purpose, ie, to detect change in health status in patients with COPD when assessing if a treatment is beneficial. However, the symptoms domain of the SGRQ cannot be used to assess acute change with respect to a given therapy.

Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention.

BACKGROUND: Self-management interventions improve various outcomes for many chronic diseases. The definite place of self-management in the care of chronic obstructive pulmonary disease (COPD) has not been established. We evaluated the effect of a continuum of self-management, specific to COPD, on the use of hospital services and health status among patients with moderate to severe disease. METHODS: A multicenter, randomized clinical trial was carried out in 7 hospitals from February 1998 to July 1999. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and patient health status. RESULTS: Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group (P =.01), and admissions for other health problems were reduced by 57.1% (P =.01). Emergency department visits were reduced by 41.0% (P =.02) and unscheduled physician visits by 58.9% (P =.003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months. CONCLUSIONS: A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice.

Comparison of nebulized budesonide and oral prednisolone with placebo in the treatment of acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial.

Nebulized budesonide has been used successfully to treat acute asthma exacerbation, and we hypothesized that it could also be effective for exacerbations of chronic obstructive pulmonary disease (COPD). In this multicenter, double-blind, randomized, placebo-controlled trial, the efficacy of nebulized budesonide (Pulmicort Respules/Nebuamp), oral prednisolone, and placebo was compared in 199 patients with acute exacerbations of COPD requiring hospitalization. Patients received from randomization (H(0)) to 72 h (H(72)), 2 mg of budesonide every 6 h (n = 71), 30 mg of oral prednisolone every 12 h (n = 62), or placebo (n = 66). All received standard treatment, including nebulized beta(2)-agonists, ipratropium bromide, oral antibiotics, and supplemental oxygen. The mean change (95% confidence interval) in postbronchodilator FEV(1) from H(0) to H(72) was greater with active treatments than with placebo: budesonide versus placebo, 0.10 L (0.02 to 0.18 L); prednisolone versus placebo, 0.16 L (0.08 to 0.24 L). The difference in FEV(1) between budesonide and prednisolone was not significant, -0.06 L (-0.14 to 0.02 L). The occurrence of serious adverse events was similar for all groups. Budesonide had less systemic activity than prednisolone as indicated by a higher incidence of hyperglycemia observed with prednisolone. Both budesonide and prednisolone improved airflow in COPD patients with acute exacerbations when compared with placebo. Nebulized budesonide may be an alternative to oral prednisolone in the treatment of nonacidotic exacerbations of COPD but further studies should be done to evaluate its long-term impact on clinical outcomes after an initial episode of COPD exacerbation.

Type III tympanoplasties: the Sherbrooke experience.

OBJECTIVES: To review short- and longer-term results of type III tympanoplasties as performed by the senior author and to compare these results with those reported in the literature. METHOD: Retrospective review of 96 type III tympanoplasties, with and without mastoidectomy, performed between April 1996 and August 2000. RESULTS: At a mean of 384 days postoperatively, 57.3% of patients had an air-bone gap of less than 20 dB. The average postoperative gap is 21.4 dB. Gap closure is best at 2000 Hz, with an average drop of 51% from initial value, compared with 34%, 39%, and 18% at 500, 1000, and 4000 Hz, respectively. CONCLUSION: Our results are similar to those published previously. We emphasize the improvement at 2000 Hz, which is an important frequency for speech discrimination. It would be interesting to see if it correlates with an improvement in quality of life.