Developing an interprofessional decision support tool for diabetic foot ulcers management in primary care within the family medicine group model: a Delphi study in Canada.

BACKGROUND: Primary care professionals encounter difficulties coordinating the continuum of care between primary care providers and second-line specialists and adhere to practice guidelines pertaining to diabetic foot ulcers management. Family medicine groups are providing primary care services aimed to improve access, interdisciplinary care, coordination and quality of health services, and reduce emergency department visits. Most professionals working in family medicine groups are primary care physicians and registered nurses. The aim of this study was to develop and validate an interprofessional decision support tool to guide the management of diabetic foot ulcers for primary care professionals working within the family medicine group model. METHODS: A one-page decision tool developed by the research team was validated by an expert panel using a three-round Delphi protocol held between December 2019 and August 2021. The tool includes 43 individual actions and a care pathway from initial presentation to secondary prevention. Data collection was realized with both paper and electronic questionnaires, and answers were compiled in an electronic spreadsheet. Data was analyzed with use of descriptive statistics, and consensus for each item was defined as ≥ 80% agreement. RESULTS: Experts from 12 pre-identified professions of the diabetic foot ulcer interdisciplinary care team were included, 39 participants out of the 59 invited to first round (66.1%), 34 out of 39 for second (87.2%) and 22 out of 34 for third (64.7%) rounds. All items included in the final version of the decision support tool reached consensus and were deemed clear, relevant and feasible. One or more professionals were identified to be responsible for every action to be taken. CONCLUSIONS: This study provided a comprehensive decision support tool to guide primary care professionals in the management of diabetic foot ulcers. Implementation and evaluation in the clinical setting will need to be undertaken in the future.

Competency Framework for Podiatric Medicine Training: A Validation Report Based on an Adapted E-Delphi Across Canada.

OBJECTIVES: Competency-based medical education has been introduced into many health professional curricula. Based on CanMEDs, a framework has recently been developed for podiatric medicine education in Canada. This study aimed to validate the framework through a consensus of various podiatric medicine experts across Canada. METHODS: An adapted Delphi method was used for content validation. Two structured online questionnaires were used to gather expert opinions and agreement on the roles and core competencies described in the framework previously developed. The validation consensus threshold was set at a minimum of 80% agreement. The summary of comments and suggestions was used to reformulate certain items after the research team reached a consensus. RESULTS: Out of the 51 experts invited from the Canadian Podiatric Medicine Association, 19 completed the first-round questionnaire (mean podiatric experience = 24.5 years; standard deviation 17.6). After the first round, "Podiatric Expert", "Communicator" and "Scholar" roles have been modified. After these modifications, a consensus was obtained at the second round completed by 13 experts. Overall, 95% of the experts agreed that the competency framework was relevant even if some indicators would need to be adapted to suit the requirements of each province and territory. CONCLUSION: This validated framework supports the excellence and the quality of our podiatric educational program. It also promotes the adoption of a uniform education of podiatrists in Canada and worldwide.

Factors influencing the engagement of older adults with neurocognitive disorders in the design of decision aids: A qualitative descriptive study.

OBJECTIVE: To identify factors influencing the engagement of older adults with neurocognitive disorders (NCDs) in the design of decision aids (DAs). METHODS: We conducted a qualitative descriptive study using semi-structured interviews with 23 older adults with NCDs who were accompanied by 27 caregivers. This is a secondary analysis of a published study to identify the features of DAs designed for this population and their caregivers. RESULTS: Several behaviours and attitudes of caregivers and researchers hindered the older adults' engagement in the DA design process. Specific communication strategies can be employed to support their engagement and overcome the communication challenges inherent to this population, such as memory, attention, hearing, or visual impairments. Adopting the appropriate attitude, taking the time, and providing guidance to the older person can help them focus on the topic, while developing trust between participants is a facilitator to obtain their feedback. CONCLUSION: Findings from this project could serve to inform the communication and co-design of DAs with older people with NCDs and their caregivers. PRACTICE IMPLICATIONS: Caregivers and researchers have key roles to play in facilitating communication with older persons with NCDs so they are empowered to help in co-designing DAs.

The Impact of Advance Care Planning on Healthcare Professionals' Well-being: A Systematic Review.

CONTEXT: Advance care planning (ACP) improves care for patients with chronic illnesses and reduces family stress. However, the impact of ACP interventions on healthcare professionals' well-being remains unknown. OBJECTIVE: To systematically review the literature evaluating the impact of ACP interventions on healthcare professionals' well-being. METHODS: We followed the Joanna Briggs Institute methodology for systematic reviews and registered the protocol in PROSPERO (CRD42022346354). We included primary studies in all languages that assessed the well-being of healthcare professionals in ACP interventions. We excluded any studies on ACP in psychiatric care and in palliative care that did not address goals of care. Searches were conducted on April 4, 2022, and March 6, 2023 in Embase, CINAHL, Web of Science, and PubMed. We used the Mixed Methods Appraisal Tool for quality analysis. We present results as a narrative synthesis because of their heterogeneity. RESULTS: We included 21 articles published in English between 1997 and 2021 with 17 published after 2019. All were conducted in high-income countries, and they involved a total of 1278 participants. Three reported an interprofessional intervention and two included patient partners. Studies had significant methodological flaws but most reported that ACP had a possible positive impact on healthcare professionals' well-being. CONCLUSION: This review is the first to explore the impact of ACP interventions on healthcare professionals' well-being. ACP interventions appear to have a positive impact, but high-quality studies are scarce. Further research is needed, particularly using more rigorous and systematic methods to implement interventions and report results.

The Longevity Protein Klotho: A Promising Tool to Monitor Lifestyle Improvements.

Aging is not a disease; it is a natural evolution of human physiology. Medical advances have extended our life expectancy, but chronic diseases and geriatric syndrome continue to affect the increasingly aging population. Yet modern medicine perpetuates an approach based on treatment rather than prevention and education. In order to help solve this ever-growing problem, a new discipline has emerged: lifestyle medicine. Nutrition, physical activity, stress management, restorative sleep, social connection, and avoidance of risky substances are the pillars on which lifestyle medicine is founded. The aim of this discipline is to increase healthspan and reduce the duration of morbidity by making changes to our lifestyle. In this review, we propose the use of klotho protein as a novel biomarker for lifestyle medicine in order to quantify and monitor the health status of individuals, as no integrative tool currently exists.

Do Exercise Programs Improve Fitness, Mobility, and Functional Capacity in Adults With Lower Limb Amputation? A Systematic Review on the Type and Minimal Dose Needed.

OBJECTIVE: To answer the following questions: (1) Do physical activity (PA) and exercise improve fitness, mobility, and functional capacity among adults with lower limb amputation (LLA) and (2) What is the type and minimum dose of PA (frequency, intensity and duration) needed? DESIGN: Systematic review. SETTING: Outpatient intervention, outside of the prosthetic rehabilitation phase. PARTICIPANTS: Adults with lower limb amputation living in the community. INTERVENTION: Any physical activity or exercise intervention. OUTCOMES AND MEASURES: Any fitness, mobility, or functional capacity indicators and measurements. RESULTS: Twenty-three studies were included, totaling 408 adults with LLA. Studies evaluated the effect of structured PA sessions on fitness, mobility, and functional capacity. The highest evidence is for mixed exercise programs, that is, programs combining aerobic exercise with strengthening or balance exercise. There is moderate confidence that 1-3 sessions of 20-60 minutes of exercise per week improves balance, walking speed, walking endurance, and transfer ability in adults with LLA above the ankle. As for flexibility, cardiorespiratory health, lower-limb muscles strength, and functional capacity, there was low confidence that exercise improves these fitness components because of the lack of studies. CONCLUSION: Exercise 1-3 times per week may improve balance, walking speed, walking endurance, and transfer ability in adults with LLA, especially when combining aerobic exercises with lower limb strengthening or balance exercises. There is a need for most robust studies focusing on the effect of PA on cardiorespiratory health, muscles strength, flexibility, and functional status.

Engagement of Older Adults Receiving Home Care Services and Their Caregivers in Health Decisions in Partnership With Clinical Teams: Protocol for a Multimethod Study to Prioritize and Culturally Adapt Decision Aids for Home Care.

BACKGROUND: Older adults (people aged 65 years and older) face many difficult decisions. Patient decision aids (PtDAs) can help them and their families make informed value-congruent decisions. Some PtDAs have been developed for the home care context, but little is known about scaling them for use with older adults in a different culture. OBJECTIVE: This study aims to (1) assess the scalability of existing PtDAs for older adults in the home care context; (2) prioritize those that best match the decisional needs of older adults in home care; and (3) culturally adapt the prioritized PtDAs so they can be scaled successfully to the Quebec health care system. METHODS: This multimethod study includes 3 phases. All phases will be overseen by a steering committee of older adults, caregivers, health professionals, decision makers, community organization representatives, and researchers with the needed expertise. In phase 1, we will use the Innovation Scalability Self-administered Questionnaire, a validated scalability self-assessment tool, to assess the scalability of 33 PtDAs previously identified in a systematic review. Based on their scalability, their quality (based on the International Patient Decision Aids Standards), and the importance of the decision point, we will retain approximately a third of these. In phase 2, we will conduct a 2-round web-based Delphi to prioritize the PtDAs selected in phase 1. Using a snowball recruitment strategy, we aim to recruit 60 Delphi participants in the province of Quebec, including older adults, caregivers, health professionals, decision makers involved in home care services, and PtDA experts. In the first round, we will ask participants to rate the importance of several PtDA decision points according to various criteria such as prevalence and difficulty on a 5-point Likert scale (1=not important to 5=very important). Approximately 6 of the highest-rated PtDAs will be retained for presentation in the second round, and we will select up to 3 PtDAs judged as having the highest priority for cultural adaptation. In phase 3, using the Chenel framework and user-centered design methods, we will update and adapt the PtDAs to the Quebec health care system and integrate these PtDAs into an interprofessional shared decision-making training program for home care teams. The adapted PtDAs will respect the International Patient Decision Aids Standards criteria. RESULTS: This study was funded in March 2022 by the Canadian Institutes of Health Research. Data collection for the web-based Delphi began in October 2023. Results are expected to be published in May 2024. CONCLUSIONS: This project will provide relevant and culturally appropriate decision support tools for older adults making difficult decisions and their home care teams that will be ready for scaling across the province of Quebec. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/53150.

Reporting of Rehabilitation Outcomes in the Traumatic Lower Limb Amputation Literature: A Systematic Review.

OBJECTIVE: To synthesize the outcomes reported in the rehabilitation and community literature for adults with traumatic lower limb amputation (LLA). DATA SOURCES: The search strategy was conducted in 3 databases (Medline, EMBASE, and CINAHL) from inception to April 2022. STUDY SELECTION: To be eligible, articles could be of any design but were required to have at least 50% adult individuals with traumatic LLA and had to report on interventions and outcomes in either a rehabilitation or community setting. DATA EXTRACTION: The extracted outcomes were classified using Dodd's framework, which is designed for organizing research outcomes. Heterogeneity was observed in the outcome measures (OMs) used for evaluation. Two reviewers independently conducted the data extraction, which was verified by a third reviewer. DATA SYNTHESIS: Of the 7,834 articles screened, 47 articles reporting data on 692 individuals with traumatic LLA, met our inclusion criteria. Four core areas encompassing 355 OMs/indicators were identified: life effect (63.4%), physiological/clinical (30.1%), resource use (5.1%), and adverse events (1.4%). Physical functioning (eg, gait, mobility) was the most frequently reported outcome domain across studies, followed by nervous system outcomes (eg, pain) and psychiatric outcomes (eg, depression, anxiety). Domains such as global quality of life and role/emotional functioning were seldomly reported. CONCLUSION: The study provides a list of outcome indicators explicitly published for adults with traumatic LLA, highlighting inconsistent reporting of outcome indicators. The lack of a standardized set of OMs is a barrier to performing meta-analyses on interventions, preventing the identification of effective care models and clinical pathways. Developing a core outcome set that includes OMs relevant to the needs of the traumatic LLA population may address these issues.

Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens.

Introduction: Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens. Methods: A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR). Results: Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA. Discussion: This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare. Conclusion: Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting. Systematic review registration: Open Science Framework https://osf.io/j9pu7, identifier j9pu7.

Prescribing Home Digital Thermometry Coupled with Activity Dosing and Optimized Offloading to Prolong Diabetic Foot Remission: A Case Report.

People with a history of diabetic foot ulcers (DFUs) experience diminished health-related quality of life and are at a 40% annual risk of DFU recurrence. Due to a fear of DFU recurrence, people in DFU remission participate less in physical activity and moderate-intensity exercise when compared to people with diabetes who have not had wounds. There is novel evidence to suggest that too little activity during DFU remission contributes to only low magnitudes of repetitive tissue loading creating a higher susceptibility to skin trauma during inadvertent high-activity bouts. Conversely, a hasty return to too much activity could lead to rapid recurrence. There is now high-level evidence from multiple meta-analyses to indicate that home-based foot temperature monitoring, coupled with activity modification and daily inspection of the feet for impending signs of ulceration, could reduce the risk of ulcer recurrence by 50%. There is little evidence, however, to guide the decision-making regarding the appropriate quantity and frequency of physical activity during DFU remission and the acceptability from the patient perspective. This has resulted in limited uptake of this novel intervention in clinical practice. Earlier, we proposed that activity can be dosed for people in foot ulcer remission, just like insulin or medication is dosed. Here, we describe a patient-centered approach to implementing home foot temperature monitoring coupled with daily foot checks and dosage-based return to physical activity in a patient in DFU remission, including his perspective. We believe using such an approach could maximize ulcer-free days in remission, thereby improving quality of life.

Collaboration and Partnership in a 5-Level Engagement Framework for Diabetic Foot Ulcer Management: A Patient-oriented Scoping Review.

OBJECTIVE: The management of diabetic foot ulcers (DFUs) is complex, and patient engagement is essential for DFU healing, but it often comes down to the patient's consultation. Therefore, we sought to document patients' engagement in terms of collaboration and partnership for DFUs in 5 levels (direct care, organizational, policy level, research, and education), as well as strategies for patient engagement using an adapted engagement framework. METHODS: We conducted a scoping review of the literature from inception to April 2022 using the Joanna Briggs Institute method and a patient-oriented approach. We also consulted DFU stakeholders to obtain feedback on the findings. The data were extracted using PROGRESS+ factors for an equity lens. The effects of engagement were described using Bodenheimer's quadruple aims for value-based care. RESULTS: Of 4,211 potentially eligible records, 15 studies met our eligibility criteria, including 214 patients involved in engagement initiatives. Most studies were recent (9 of 15 since 2020) and involved patient engagement at the direct medical care level (8 of 15). Self-management (7 of 15) was the principal way to clinically engage the patients. None of the studies sought to define the direct influence of patient engagement on health outcomes. CONCLUSIONS: Very few studies described patients' characteristics. Engaged patients were typically men from high-income countries, in their 50s, with poorly managed type 2 diabetes. We found little rigorous research of patient engagement at all levels for DFUs. There is an urgent need to improve the reporting of research in this area and to engage a diversity of patients.

Using a contralateral shoe lift to reduce gait deterioration during an offloading fast-walk setting in diabetic peripheral neuropathy: A comparative feasibility study.

AIMS: Diabetic peripheral neuropathy (DPN) is a predictor of foot ulcers and leads to sedentary behaviour. This comparative study evaluated gait and feasibility of a 20-minute fast walk, at 40-60% of cardiopulmonary capacity, in individuals with DPN wearing an offloading boot and a contralateral shoe balancer. METHODS: Gait parameters were measured with inertial sensors on 32 individuals (group with DPN [n = 16], group with diabetes but without DPN [n = 9], and a group without diabetes/DPN [n = 7]). Feasibility was assessed by feedback on perceived effort and adverse events. Gait outcomes were compared between groups with or without a shoe balancer using one-way ANOVAs. RESULTS: The three groups were equivalent in terms of activity level and age and gender except for the body mass index. Both groups with diabetes exhibited minimal decreased gait speed (p > 0.005) and the DPN group exhibited increased double-support percentage (+4.6%, p = 0.01) while walking with an offloading boot and contralateral shoe balancer. The use of a contralateral shoe balancer reduced gait asymmetry. Lower physical activity level was associated with further gait deterioration in all groups. Few adverse events were reported, and 91% of participants reported that the proposed activity would be feasible daily. CONCLUSIONS: The offloading boot deteriorated gait function, but a contralateral shoe balancer minimized its impact, especially in the context of physical activity in people with diabetes and DPN.

Upstream comprehensive management of individuals with diabetes with multimorbidity and frailty to act against amputation.

This manuscript constitutes a commentary on: "Retrospective cohort study of long-term outcomes and prognostic factors for survival after lower extremity amputation in patients with diabetes" by Vuorlaakso et al. (2023). We aim to contribute to the reflection of their findings to support the comprehensive management of vulnerable individuals with multimorbidity and/frailty for limb preservation. There is an urgent need to understand the effects of frailty on overall survival after amputation, survival without major amputation, and the effect modification with multimorbidity.

Provision of Compassionate and Empathic Care as a Well-Being Preservation Tool for Emergency Physicians: A Scoping Review.

Objective: Compassion and physician well-being are two key components related to quality care in health including emergency medicine. The objective of this study was to explore the impact of compassion in care on the well-being of emergency physicians. We conducted a scoping review to explore the impact of provision of compassionate care by emergency physicians on their well-being and subconcepts. Methods: Four electronic databases and grey literature were searched to find evidence related to compassion, empathy, self-compassion, and their impact on emergency physicians' well-being. Following title and abstract review, two reviewers independently screened full-text articles, and extracted data. Data were presented using descriptive statistics and a narrative analysis. Results: A total of 803 reports were identified in databases. Three articles met eligibility criteria for data extraction. None directly examined compassion and well-being. Included studies addressed empathy and burnout in emergency medicine professionals. Conclusion: No high-quality evidence could be found on the topic in the population of interest. Literature related to the topic of compassion in physicians, especially in emergency physicians, a field known for its high demand and stress levels, is currently scarce and additional evidence is needed to better describe and understand the association between physicians' compassion and well-being.

Canadian Older Adults' Intention to Use an Electronic Decision Aid for Housing Decisions: Cross-sectional Web-Based Survey.

BACKGROUND: Older adults with disabilities such as loss of autonomy face the decision of whether to stay at home or move to a health care facility such as a nursing home. Therefore, they may need support for this difficult decision. OBJECTIVE: We assessed the intention of Canadian older adults to use an electronic decision aid (eDA) to make housing decisions and identified the factors that influenced their intention. METHODS: We conducted a cross-sectional study using a web-based survey targeting older adults across 10 Canadian provinces and 3 territories. We included respondents from a web-based panel who were aged ≥65 years, understood English or French, had access to an electronic device with an internet connection, and had made a housing decision over the past few months or were planning to make a decision in the coming year. We based the web-based survey on the Unified Theory of Acceptance and Use of Technology (UTAUT). We adapted 17 UTAUT items to measure respondents' intention to use the eDA for housing decisions, as well as items measuring 4 intention constructs (performance expectancy, effort expectancy, social influence, and facilitating conditions). We also assessed eHealth literacy using both subjective and objective scales. We used descriptive statistics and multivariable linear regression analyses to identify the factors influencing the intention to use the eDA. RESULTS: Of the 11,972 invited panelists, 1176 (9.82%) met the eligibility criteria, and 1000 (85.03%) respondents completed the survey. The mean age was 72.5 (SD 5.59) years. Most respondents were male (548/1000, 54.8%), White (906/1000, 90.6%), English speakers (629/1000, 62.9%), and lived in Ontario or Quebec (628/1000, 62.8%) and in urban areas (850/1000, 85%). The mean scores were 27.8 (SD 5.88) out of 40 for subjective eHealth literacy and 3.00 (SD 0.97) out of 5 for objective eHealth literacy. In our sample, the intention score was 4.74 (SD 1.7) out of 7. The mean scores of intention constructs out of 7 were 5.63 (SD 1.28) for facilitating conditions, 4.94 (SD 1.48) for performance expectancy, 5.61 (SD 1.35) for effort expectancy, and 4.76 (SD 1.59) for social influence. In the final model, the factors associated with intention included mother tongue (ß=.30; P<.001), objective eHealth literacy (ß=-.06; P=.03), performance expectancy (ß=.55; P<.001), social influence (ß=.37; P<.001), and facilitating conditions (ß=.15; P<.001). CONCLUSIONS: Findings from this pan-Canadian web-based survey on Canadian older adults suggest that their intention to use the eDA to make housing decisions is similar to the findings in other studies using UTAUT. The factors identified as influencing intention were mother tongue, objective eHealth literacy, performance expectancy, social influence, and facilitating conditions. These will guide future strategies for the implementation of the eDA.

Frailty in People with Chronic Limb Threatening Ischemia and Diabetes-Related Foot Ulcers: A Systematic Review.

BACKGROUND: Frailty represents a state of multisystem impairment that may adversely impact people presenting with chronic limb-threatening ischemia (CLTI) and diabetes-related foot ulcers (DFUs). The aim of this systematic review was to explore the association between frailty and outcomes from CLTI and DFUs. METHODS: We performed a systematic literature search of electronic databases to find studies using a validated measure of frailty in individuals with CLTI and/or DFUs. The primary outcomes were the impact of frailty on the severity of initial clinical presentation and unfavorable follow-up outcomes including readmissions, major limb amputation, cardiovascular events, revascularization, and wound healing. RESULTS: Ten cohort studies were included. Two studies had a low risk of bias, 1 was unable to be assessed, 5 had moderate risk of bias, and 2 high risk of bias. The prevalence of frailty in people presenting with CLTI ranged from 27% to 88% and was 71% in people with DFUs. The presence of frailty in both people with CLTI and DFUs was associated with substantially increased severity at presentation (severity of ischemia and tissue loss) and poorer outcomes at follow-up (risk of readmission, limb amputation, and all-cause mortality). CONCLUSIONS: The presence of frailty in both people with CLTI and DFUs is likely associated with substantially higher complexity at presentation followed by a greater risk for readmission, amputation, and death during follow-up. Heterogeneity in the tools used to screen for frailty, poor definition of frailty, and unclear evaluation of exposure and outcomes limit further interpretation of findings.

Remaining Question: Does Exercise Improve Healing of Diabetic Foot Ulcers?

Even though it is reasonable to think that exercise is beneficial to diabetic foot ulcer healing, there are currently no exercise recommendations for this population. A systematic review published recently attempted to answer this question. However, because of both the scarce and heterogenous literature on the subject identified by the selected study design and the chosen quality appraisal tool that is too permissive and overestimates the treatment effects, no clinical recommendations can be drawn from this review. We advocate for research on this topic in order to obtain more direct evidence that exercise benefits wound healing, and to close the persistent gap of knowledge regarding the impact of exercise on diabetic foot ulcer wound healing.

Effectiveness of Shared Decision-making Training Programs for Health Care Professionals Using Reflexivity Strategies: Secondary Analysis of a Systematic Review.

BACKGROUND: Shared decision-making (SDM) leads to better health care processes through collaboration between health care professionals and patients. Training is recognized as a promising intervention to foster SDM by health care professionals. However, the most effective training type is still unclear. Reflexivity is an exercise that leads health care professionals to question their own values to better consider patient values and support patients while least influencing their decisions. Training that uses reflexivity strategies could motivate them to engage in SDM and be more open to diversity. OBJECTIVE: In this secondary analysis of a 2018 Cochrane review of interventions for improving SDM by health care professionals, we aimed to identify SDM training programs that included reflexivity strategies and were assessed as effective. In addition, we aimed to explore whether further factors can be associated with or enhance their effectiveness. METHODS: From the Cochrane review, we first extracted training programs targeting health care professionals. Second, we developed a grid to help identify training programs that used reflexivity strategies. Third, those identified were further categorized according to the type of strategy used. At each step, we identified the proportion of programs that were classified as effective by the Cochrane review (2018) so that we could compare their effectiveness. In addition, we wanted to see whether effectiveness was similar between programs using peer-to-peer group learning and those with an interprofessional orientation. Finally, the Cochrane review selected programs that were evaluated using patient-reported or observer-reported outcome measurements. We examined which of these measurements was most often used in effective training programs. RESULTS: Of the 31 training programs extracted, 24 (77%) were interactive, among which 10 (42%) were considered effective. Of these 31 programs, 7 (23%) were unidirectional, among which 1 (14%) was considered effective. Of the 24 interactive programs, 7 (29%) included reflexivity strategies. Of the 7 training programs with reflexivity strategies, 5 (71%) used a peer-to-peer group learning strategy, among which 3 (60%) were effective; the other 2 (29%) used a self-appraisal individual learning strategy, neither of which was effective. Of the 31 training programs extracted, 5 (16%) programs had an interprofessional orientation, among which 3 (60%) were effective; the remaining 26 (84%) of the 31 programs were without interprofessional orientation, among which 8 (31%) were effective. Finally, 12 (39%) of 31 programs used observer-based measurements, among which more than half (7/12, 58%) were effective. CONCLUSIONS: Our study is the first to evaluate the effectiveness of SDM training programs that include reflexivity strategies. Its conclusions open avenues for enriching future SDM training programs with reflexivity strategies. The grid developed to identify training programs that used reflexivity strategies, when further tested and validated, can guide future assessments of reflexivity components in SDM training.

Competency Framework for Podiatric Medicine Training in Canada: An Adapted Delphi Study.

Purpose: Podiatrists are generally defined as professionals with high-level skills in the prevention and management of local foot conditions that are not systemic diseases. Across countries, different academic trainings are implemented due to the specific context and practice of podiatric medicine. It is thus essential to support country-specific podiatry education for the development of highly skilled podiatrists. Therefore, we report the development of a podiatric medicine competency framework to support training in Canada. Participants and Methods: A Delphi process was conducted by 12 stakeholders (including 8 podiatry experts) from the University of Québec at Trois-Rivières which is the only university offering the degree of Doctor of Podiatric Medicine (DPM) in Canada. The developed framework is (1) based on the seven key roles of the Canadian medical education directives of specialists (CanMEDs) and, (2) closely aligned with the requirement of the College of Podiatrists of Québec which sets the standards of entry to practice in Québec. Results: The developed framework represents the state of the development process and the consensus of the podiatry experts. It reflects the expected profile of the institution's DPM graduates based on seven key roles (podiatry expert, communicator, collaborator, health advocate, leader and manager, scholar, and professional). This developed framework is an arborescence of complex skills defined in tangible indicators that characterize each expected part of a core competency. Twenty-four core competencies have been determined and divided into 84 enabling competencies and 288 observable indicators. Conclusion: This competency framework has been designed to support high-quality education and to develop podiatry. Next steps include: (1) validation of this framework by external experts, (2) development of rigorous evaluation methods and, (3) concrete actions for its implementation and assessment. This framework would help to define the scope of practice and capabilities of podiatric medicine, both in Canada and internationally.