Using chart reviews to evaluate a continuing medical education (CME) program.

Context Moore's Expanded Outcomes Framework is a 7 level framework commonly used to assess the outcomes of continuing medical education (CME) programs. Levels 1 to 5 are provider-level outcomes (participation, satisfaction, knowledge, competence, and performance) while levels 6 and 7 are patient- and community-level outcomes. Chart reviews are one method to assess level 5 (performance). ECHO Ontario Chronic Pain and Opioid Stewardship ("ECHO") is a CME telementoring program that aims to increase capacity and access for primary care providers (PCPs) who manage patients with chronic pain. Objective This study uses chart reviews to evaluate ECHO's impact on PCP performance and to discuss the feasibility of performing chart reviews for evaluation purposes as per Moore's framework. Study Design Retrospective chart review Setting The practices of 12 primary care providers across Ontario who attended ECHO between June 2014 to August 2018. The inclusion criteria for PCPs was 1) attended a minimum of four ECHO sessions, and 2) clinic site must be approving of a site visit for chart reviews. Population Studied 47 patient charts were included. For each patient chart reviewed, PCPs were asked to choose patients in their practice on whom they had used ECHO-taught knowledge. Inclusion criteria for patients was 1) have chronic pain and be managed by the ECHO-participating PCP, 2) was prescribed opioids during the time frame of the study, and 3) not presented during ECHO sessions. Informed consent was obtained prior to each site visit. 1) Increased use of ECHO-taught pain and opioid management strategies 2) Feasibility of using chart reviews to evaluate PCP performance following a CME activity Results 25 (53%) patients were male and the average age was 59 (± 14) years. 24 (51%) patients had two or more pain diagnoses at baseline, with musculoskeletal pain being the most prevalent at 81%. 26 (55%) patients had comorbid mental health conditions and 13 (28%) had sleep disorders. Trends in results showed marginal, but non-significant, improvements in PCP performance after ECHO as indicated by increased use of pain and opioid management strategies. Conclusions Conducting chart reviews was a challenging method to assess provider performance. Future work to assess provider performance should include a qualitative component (in-depth interviews or focus groups) in order to complement the quantitative data and provide context for care and management decisions.

Promoting an interprofessional approach to chronic pain management in primary care using Project ECHO.

Chronic pain is a complex multidimensional condition that requires management with multiple professions' expertise. Healthcare training programs tend to adhere to curricula within their own profession with very few interactions with other groups. Project ECHO (Extension for Community Healthcare Outcomes) Chronic Pain and Opioid Stewardship is a model for interprofessional education, using tele-mentoring, case-base discussions and clinically focused presentations. The goal is to improve competency and confidence in managing complex cases in primary care. This qualitative study engaged twenty healthcare practitioners from multiple professions who had participated in ECHO in focus group discussions about managing patients with chronic pain, about their reasons for and the effect of participating in Project ECHO Ontario Chronic Pain/Opioid Stewardship, and about their perspectives on interprofessional care. The results show that participating in ECHO resulted in personal and professional benefit, and increased understanding about their own roles and limitations, as well as other healthcare professionals' roles. The participants described changes in their attitudes toward patients with chronic pain, and their colleagues from other professions. Non-physician participants were more likely to approach physicians to discuss their assessment and diagnosis as well as prescriptions. The interprofessional nature of the program was seen as positive and contributed to perceived changes in practice collaboration. These results show that healthcare professionals from multiple professions expressed mainly positive views of ECHO's emphasis on interprofessional care, with different professions appreciating different aspects of that approach.

Project ECHO Telementoring Intervention for Managing Chronic Pain in Primary Care: Insights from a Qualitative Study.

Objective: Family physicians in Canada receive little training in chronic pain management; concomitantly, they face increasing pressure to reduce their prescribing of opioids. Project ECHO Ontario Chronic Pain/Opioid Stewardship (ECHO) is a telementoring intervention for primary care practitioners that enhances their pain management skills. This qualitative study reports participants' experiences and assessment of ECHO. Design: An opportunistic sample of multidisciplinary primary care providers attending one of three residential weekend workshops participated in focus group discussions. Setting: University or hospital facilities in Toronto, Thunder Bay, and Kingston, Ontario, Canada. Subjects: Seventeen physicians and 20 allied health professionals. Methods: Six focus group discussions were conducted at three different sites during 2014 and 2015. Transcripts were analyzed using a qualitative-descriptive approach involving analytic immersion in the data, reflection, and achieving consensus around themes discerned from transcribed discussions. Results: Findings resolved into five main themes: 1) challenges of managing chronic pain in primary care; 2) ECHO participation and improvement in patient-provider interaction and participant knowledge; 3) the diffusion of knowledge gained through ECHO to participants' colleagues and patients; 4) ECHO participation generating a sense of community; and 5) disadvantages associated with participating in ECHO. Conclusions: Managing patients with chronic pain in primary care can be difficult, particularly in remote or underserved practices. Project ECHO offers guidance to primary care practitioners for their most challenging patients, promotes knowledge acquisition and diffusion, and stimulates the development of a "community of practice."

"Keep trying": a qualitative investigation into what patients with chronic pain gain from Project ECHO.

Objective: The study aims to investigate the patient perspective on the pathway from healthcare practitioners' presentations of their cases at a Project ECHO (Extension for Community Healthcare Outcomes) tele-clinic to the management of those patients' chronic pain. Introduction: Managing patients with chronic and complex pain constitutes a prevalent, stressful challenge in the primary care setting. Primary care physicians typically have received little training in treating such patients and, until recently, have relied heavily on opioid and other pharmaceutical therapies as part of their regimen. Project ECHO Ontario Chronic Pain and Opioid Stewardship is an interprofessional telementoring program connecting pain specialists to primary care practitioners with the aim of supporting them in managing their patients with chronic pain, although the patients concerned do not generally participate in the telementoring sessions. While a number of papers have described the benefits accruing to healthcare professionals through participating in Project ECHO, there has been little exploration concerning patients' perceptions of their care subsequent to case presentation. Methods: Using data from in-depth interviews with 20 patients along with their associated case presentation forms and the recommendations following the presentation, we look at the alignment of patient and practitioner views and inquire about the patient's perceptions of how Project ECHO affects them. Results: Results suggest that the impact on patients is indirect but positive: most respondents express pleasure in contributing to research around chronic pain management, though only two of them identified a direct impact on their own treatment. They also appreciated their practitioner's efforts to bring expert attention to the patient's situation. Conclusions: Patients whose cases are presented to Project ECHO sessions experience positive emotions at being part of the process of research and quality improvement, regardless of changes in their own conditions. This study highlights the importance to patients of their practitioners' commitment to managing their chronic pain.

Health care providers' experiences and perceptions participating in a chronic pain telementoring education program: A qualitative study.

BACKGROUND: Chronic pain affects one in five Canadians. Frontline health care providers (HCPs) manage the majority of patients with chronic pain yet receive minimal training to do so. The Extension for Community Healthcare Outcomes (ECHO) model™ is an education intervention aimed at HCPs (not patients) to support and improve care in underserviced communities. ECHO Ontario Chronic Pain and Opioid Stewardship (ECHO PAIN) is an adaptation of the ECHO model where the program goals are to support and improve chronic pain and opioid management in the province of Ontario, Canada. AIMS: This study aimed to investigate the perceptions of HCPs participating in ECHO PAIN. METHODS: Thirteen HCPs attending ECHO PAIN participated in in-depth semistructured phone interviews. Resulting data were analyzed through a qualitative descriptive lens. RESULTS: Analysis uncovered four themes: (1) HCPs' motivation for joining ECHO PAIN, (2) interprofessional collaboration through ECHO PAIN, (3) the use of opioids for pain management, and (4) barriers and facilitators to participation and satisfaction in ECHO PAIN. HCPs joined ECHO PAIN because of their struggles managing their complex patients with chronic pain. HCPs also recognized the importance of interprofessional collaboration in pain management and shared examples of integration of different professional approaches in their clinical teams. Opioids for pain management remained a controversial issue, and ECHO served as an opportunity to decrease this knowledge gap. Finally, HCPs described how time constraints, organizational support, and session structure acted as barriers to their participation and satisfaction in the ECHO PAIN program; technology mediated satisfaction. CONCLUSIONS: This study was the first in Canada to explore the motivations of HCPs in attending a chronic pain telementoring program as well as to examine the interprofessional effects of participation. HCPs increased their knowledge about management of chronic pain and increased their interprofessional approach.

Contexte: La douleur chronique touche un Canadien sur cinq. Les prestataires de soins de santé de première ligne prennent en charge la majorité des patients souffrant de douleur chronique, mais reçoivent une formation minimale pour le faire. Le modèle Extension for Community Healthcare Outcomes ™ (ECHO) est une intervention éducative destinée aux prestataires de soins de santé (et non aux patients) pour soutenir et améliorer les soins dans les communautés mal desservies. Le programme ECHO Ontario Chronic Pain and Opioid Stewardship (ci-après appelé « ECHO PAIN ¼) est une adaptation du modèle ECHO dont les objectifs sont de soutenir et d'améliorer la prise en charge de la douleur chronique et la gestion des opioïdes dans la province de l'Ontario, au Canada.Objectifs: Cette étude visait à étudier les perceptions des prestataires de soins de santé participant au programme ECHO PAIN.Méthodes: Treize prestataires de soins de santé participant au programme ECHO PAIN ont participé à des entretiens téléphoniques semi-structurés approfondis. Les données découlant de ces entretiens ont été analysées à l'aide d'une grille descriptive qualitative.Résultats: L'analyse a révélé quatre thèmes : 1) la motivation des prestataires de soins de santé à participer au programme ECHO PAIN ; 2) la collaboration interprofessionnelle dans le cadre du programme ECHO PAIN ; 3) l'utilisation des opioïdes pour la prise en charge de la douleur et 4) les barrières et les facilitateurs en ce qui en trait à la participation au programme ECHO PAIN et à la satisfaction à l'égard de celui-ci. Les prestataires de soins de santé se sont joints à ECHO PAIN en raison de leurs difficultés à prendre en charge leurs patients complexes souffrant de douleur chronique. Les prestataires de soins de santé ont également reconnu l'importance de la collaboration interprofessionnelle dans la prise en charge de la douleur et ont partagé des exemples d'intégration de différentes approches professionnelles dans leurs équipes cliniques. Les opioïdes pour la prise en charge de la douleur sont demeurés une question controversée, et ECHO a permis de réduire ces lacunes dans les connaissances. Enfin, les prestataires de soins de santé ont décrit comment les contraintes de temps, le soutien organisationnel et la structure des sessions ont constitué des obstacles à leur participation au programme ECHO PAIN et à leur satisfaction à l'égard de celui-ci, tandis que la technologie a favorisé leur satisfaction.Conclusions: Cette étude a été la première au Canada à étudier les motivations des prestataires de soins de santé à participer à un programme de télémentorat sur la douleur chronique, ainsi qu'à examiner les effets interprofessionnels de la participation à ce programme. Les prestataires de soins de santé ont amélioré leurs connaissances sur la prise en charge des patients souffrant de douleur chronique et ont renforcé leur approche interprofessionnelle.

Improving opioid guideline adherence: evaluation of a multifaceted, theory-informed pilot intervention for family physicians.

OBJECTIVES: Opioid-related deaths continue to increase in North America, an epidemic that was initiated by high rates of opioid prescribing. We designed a multifaceted, theory-informed Opioid Self-Assessment (OSA) package, to increase adherence to the Canadian Opioid Guideline among family physicians. This study aimed to assess changes in Canadian family physicians' knowledge and practices after completing the OSA package. DESIGN: We conducted a mixed-method evaluation using a pre-test and post-test design that involved the collection of both qualitative and quantitative data. SETTING: This research was conducted in the primary care setting in Ontario, Canada. PARTICIPANTS: We recruited a purposive sample of nine family physicians in Ontario who use long-term opioid therapy to treat patients with chronic pain. INTERVENTIONS: The OSA package included four components: an online knowledge test, an online learning programme, a safe medication practice self-assessment questionnaire and chart audit with feedback. OUTCOME MEASURES: Our measures included changes in knowledge, opioid safety practices and physicians' perspectives on the OSA package. RESULTS: We found statistically significant improvements between pre-test and post-test knowledge scores at both baseline and 6-month follow-up. Physicians' scores improved significantly on five of the seven core characteristics of the practice self-assessment questionnaire. On the chart audits, we observed an improvement in patient education between baseline and 6 months. Qualitative interviews showed that participants appreciated embedded resources in the OSA package. The completion of the package stimulated identification of gaps or deficits in practice and served as a useful reminder to discuss risk and safety with patients. Participants described the chart review as helpful in prompting discussions with their patients, identifying deficits and strengths and a 'primary motivator' for project participation. CONCLUSIONS: The OSA package has the potential to improve medication safety practices in primary care related to opioid monitoring and adherence to current opioid guidelines.

Exploring Canadian surgeons' decisions about postoperative weight bearing for their hip fracture patients.

For older adults with osteoporosis, a fall resulting in hip fracture is a life-changing event from which only one-third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue "weight-bearing-as-tolerated" (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long-term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight-bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight-bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have "rules to break the rules." In an era when "good" medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly.

Understanding Referral Patterns for Bone Mineral Density Testing among Family Physicians: A Qualitative Descriptive Study.

Introduction. Evidence of inappropriate bone mineral density (BMD) testing has been identified in terms of overtesting in low risk women and undertesting among patients at high risk. In light of these phenomena, the objective of this study was to understand the referral patterns for BMD testing among Ontario's family physicians (FPs). Methods. A qualitative descriptive approach was adopted. Twenty-two FPs took part in a semi-structured interview lasting approximately 30 minutes. An inductive thematic analysis was performed on the transcribed data in order to understand the referral patterns for BMD testing. Results. We identified a lack of clarity about screening for osteoporosis with a tendency for baseline BMD testing in healthy, postmenopausal women and a lack of clarity on the appropriate age for screening for men in particular. A lack of clarity on appropriate intervals for follow-up testing was also described. Conclusions. These findings lend support to what has been documented at the population level suggesting a tendency among FPs to refer menopausal women (at low risk). Emphasis on referral of high-risk groups as well as men and further clarification and education on the appropriate intervals for follow-up testing is warranted.

ECHO Ontario Chronic Pain & Opioid Stewardship: Providing Access and Building Capacity for Primary Care Providers in Underserviced, Rural, and Remote Communities.

Chronic pain is a prevalent and serious problem in the province of Ontario. Frontline primary care providers (PCPs) manage the majority of chronic pain patients, yet receive minimal training in chronic pain. ECHO (Extension for Community Healthcare Outcomes) Ontario Chronic Pain & Opioid Stewardship aims to address the problem of chronic pain management in Ontario. This paper describes the development, operation, and evaluation of the ECHO Ontario Chronic Pain project. We discuss how ECHO increases PCP access and capacity to manage chronic pain, the development of a community of practice, as well as the limitations of our approach. The ECHO model is a promising approach for healthcare system improvement. ECHO's strength lies in its simplicity, adaptability, and use of existing telemedicine infrastructure to increase both access and capacity of PCPs in underserviced, rural, and remote communities.

To see or not to see: a qualitative interview study of patients' views on their own diagnostic images.

OBJECTIVES: To ascertain what meaning individuals attach to perceiving images of their own interior body and how the images and their meanings affect the clinical consultation. DESIGN: Face-to-face semistructured interviews. PARTICIPANTS: 25 adult patients in southern England who, within the preceding 12 months, had been referred for diagnostic imaging. SETTING: Community. RESULTS: For patients, being shown their own X-rays, MRIs or CT images creates a variety of effects: (1) a sense of better understanding of the diagnosis; (2) validation of their sensory and emotional response to the illness or injury and (3) an alteration to the tenor and nature of the clinical encounter between patient and physician. In addition to meanings attached to these images, patients also impute meaning to the physician's decision not to share an image with them. The desire to see their image was greater in those patients with a skeletal injury; patients are less keen on viewing abdominal or other soft tissue images. CONCLUSIONS: Viewing images of one's interior, invisible body is powerful and resonant in a number of ways. The experience of not seeing, whether through the patient's or the physician's choice, is also fraught with meaning.

Double vision: an exploration of radiologists' and general practitioners' views on using picture archiving and communication systems (PACS).

This article explores the perspectives of two user groups, general practitioners (GPs) and consultant radiologists (CRs), on the rollout of picture archiving and communications systems (PACS) within acute trusts and eventually to primary care as part of the electronic patient record. Qualitative interviews were conducted with 16 CRs and 31 GPs. Analysis was carried out using a grounded theory approach. Radiologists expressed positive views about the implementation of PACS in secondary care, but were wary of GPs accessing radiological images. GPs expressed concerns about the added burdens that PACS might bring to primary care, but most felt that sharing images with patients could benefit doctor-patient communication and increase patient satisfaction. This study highlights both impediments and pathways to the implementation of PACS in primary care, and illustrates the importance of regarding PACS as socially embedded and users as culturally disparate.

Social networks and coronary heart disease risk factors in South Asians and Europeans in the UK.

OBJECTIVES: To compare the social networks of South Asian (Indians, Pakistanis and Bangladeshis) and European-origin participants in the Newcastle Heart Project, and to examine the relationships between social network sizes and coronary heart disease (CHD) risk factors in both groups, testing the hypothesis that part of the reason for high rates of CHD in the South Asian UK population may be social isolation. DESIGN: Participants were 684 South Asian (259 Indians, 305 Pakistanis, 120 Bangladeshis) and 825 European men and women aged 25-74 years, who completed a questionnaire and were screened for CHD risk factors in a cross-sectional study. RESULTS: South Asians were more likely to be married than Europeans, had bigger households and were more likely to attend a place of worship regularly. Europeans saw more friends and relatives on a regular basis than did South Asians. There was also some heterogeneity between the South Asian groups. Europeans who reported bigger social networks were less likely to smoke than those with smaller networks, but there was little evidence of an association between social network size and waist circumference, blood pressure or TC:HDL ratio in either Europeans or South Asians. CONCLUSION: The results provided only partial support for the hypothesis that South Asians in the UK are socially isolated, and suggest that South Asians and Europeans in the UK utilise different sources of social support. Future work should acknowledge variation in sources of social support between ethnic groups, and should explore the possibility that different mechanisms link social support and health in different ethnic groups.