Minimal renal pelvis dilation in cats diagnosed with benign ureteral obstruction by antegrade pyelography: a retrospective study of 82 cases (2012-2018).

OBJECTIVES: The aim of the study was to describe renal pelvis (RP) and ureteral ultrasonographic measurements in a population of cats with confirmed benign ureteral obstruction (UO) by antegrade pyelography. The secondary objective was to further describe clinical findings associated with minimally dilated obstructed kidneys in an attempt to better understand its occurrence. METHODS: Retrospective case series of cats diagnosed with benign UO were confirmed by antegrade pyelography. Medical records were reviewed and signalment, diagnostic imaging results, serum creatinine (SCr) concentration and urine culture results were recorded. Each obstructed kidney was categorized into two groups: group 1 included all RP measurements ⩽4 mm and group 2 included all RP measurements >4 mm. RESULTS: A total of 82 cats with 114 obstructed ureters met the inclusion criteria. Fifty (61%) cats had a unilateral UO and 32 (39%) had a bilateral UO. Thirty (26%) kidneys were included in group 1 while 84 (74%) were included in group 2. Nine (8%) kidneys had an RP dilation ⩽2 mm. Median RP and ureteral diameters were 6.6 mm (range 1.1-37.0 mm) and 3.2 mm (range 0.0-11.0 mm), respectively. RP size correlated positively with ureteral diameter in the study population (P <0.0001), but not in group 1 when analyzed separately (P = 0.47). UO was secondary to stones in 80 (70%) ureters. Seventeen (21%) cats had a positive urine culture. At admission, 79 (96%) cats were azotemic with a median preoperative SCr concentration of 444 µmol/l (range 108-1326 µmol/l). The mean (95% confidence interval [CI]) preoperative SCr concentration was significantly higher in group 1 (762 µmol/l [498-1165 µmol/l]) than in group 2 (409 µmol/l [333-502 µmol/l]). RP size in the two groups correlated negatively with preoperative SCr concentration (P = 0.0002). CONCLUSIONS AND RELEVANCE: Feline UO may be associated with minimal RP dilation and the severity of RP and ureteral dilation can be highly variable. Absence of significant RP dilation does not rule out UO in cats.

Application of the Andersen's health care utilization framework to secondary complications of spinal cord injury: a scoping review.

PURPOSE: The purpose of this scoping review was to identify research priority areas related to secondary complications and associated health care use for individuals with spinal cord injury (SCI). DATA SOURCES: Peer-reviewed journals were identified using CINAHL, MEDLINE, PubMed, Embase, Social Sciences Abstracts, Social Works Abstract and PsycInfo search engines. Key references were hand searched. STUDY SELECTION: A total of 289 abstracts were identified from the initial search strategy. We removed studies that did not measure health care and those that did not involve analytical investigation. DATA EXTRACTION: The selected 31 studies were reviewed in detail using a coding template based on the domains and sub-components of the Andersen model (i.e. environmental, population characteristics, health behavior and outcome). RESULTS: Most studies measured predisposing characteristics (e.g., age, gender) and need characteristics (e.g., level of injury). There was a notable absence of environmental characteristics (e.g., health system, neighborhood variables), enabling characteristics and health behaviors (beyond diet and nutrition). CONCLUSIONS: We identified a gap in the SCI literature. Future research should focus on longitudinal study designs with more representation of non-traumatic spinal cord injury, as well as utilizing more advanced statistical analyses (i.e., multivariate level) to adjust for confounding variables.

The efficiency and effectiveness of utilizing diagrams in interviews: an assessment of participatory diagramming and graphic elicitation.

BACKGROUND: This paper focuses on measuring the efficiency and effectiveness of two diagramming methods employed in key informant interviews with clinicians and health care administrators. The two methods are 'participatory diagramming', where the respondent creates a diagram that assists in their communication of answers, and 'graphic elicitation', where a researcher-prepared diagram is used to stimulate data collection. METHODS: These two diagramming methods were applied in key informant interviews and their value in efficiently and effectively gathering data was assessed based on quantitative measures and qualitative observations. RESULTS: Assessment of the two diagramming methods suggests that participatory diagramming is an efficient method for collecting data in graphic form, but may not generate the depth of verbal response that many qualitative researchers seek. In contrast, graphic elicitation was more intuitive, better understood and preferred by most respondents, and often provided more contemplative verbal responses, however this was achieved at the expense of more interview time. CONCLUSION: Diagramming methods are important for eliciting interview data that are often difficult to obtain through traditional verbal exchanges. Subject to the methodological limitations of the study, our findings suggest that while participatory diagramming and graphic elicitation have specific strengths and weaknesses, their combined use can provide complementary information that would not likely occur with the application of only one diagramming method. The methodological insights gained by examining the efficiency and effectiveness of these diagramming methods in our study should be helpful to other researchers considering their incorporation into qualitative research designs.

Stakeholder preferences for cancer care performance indicators.

PURPOSE: The purpose of this paper is to show that performance data use could be promoted with a better understanding of the type of indicators that are important to different stakeholders. This study explored patient, nurse, physician and manager preferences for cancer care quality indicators. DESIGN/METHODOLOGY/APPROACH: Interviews were held with 30 stakeholders between March and June 2004. They were asked to describe how they would use a cancer "report card", and which indicators they would want reported. Transcripts were reviewed using qualitative analysis. FINDINGS: Role (patient, nurse, physician, manager) influenced preferences and perceived use of performance data. Patients and physicians were more skeptical than nurses and managers; patients and managers expressed some preferences distinct from nurses and physicians; and patients and nurses interpreted indicators more broadly than physicians and managers. All groups preferred technical process over outcome or interpersonal process indicators. RESEARCH LIMITATIONS/IMPLICATIONS: Expressed views are not directly applicable beyond this setting, or to the general public but findings are congruent with attitudes to performance data for other conditions, and serve as a conceptual basis for further study. PRACTICAL IMPLICATIONS: Strategies for maximizing the relevance of performance reports might include technical process indicators, selection by multi-stakeholder deliberation, information that facilitates information application and customizable report interfaces. ORIGINALITY/VALUE: Performance data preferences have not been thoroughly examined, particularly in the context of cancer care. Factors were identified that influence stakeholder views of performance data, and this framework could be used to confirm findings among larger and different populations.

Barriers to patient involvement in health service planning and evaluation: an exploratory study.

OBJECTIVE: Patient involvement in health service planning and evaluation is considered important yet not widely practiced. This study explored stakeholder beliefs about patient participation in performance indicator selection to better understand hypothesized barriers. METHODS: Interviews with 30 cancer patients and health professionals from two teaching hospitals were analyzed qualitatively. RESULTS: All groups believed patients, not members of the public, should be involved in the selection of indicators. Ongoing, interactive methods such as committee involvement, rather than single, passive efforts such as surveys were preferred. Health professionals recommended patients assume a consultative, rather than decision-making role. Older patients agreed with this. CONCLUSION: Variable patient interest, health professional attitudes, and a lack of insight on appropriate methods may be limiting patient involvement in this, and other service planning and evaluation activities. More research is required to validate expressed views among the populations these stakeholders represent, and to establish effective methods for engaging patients. PRACTICE IMPLICATIONS: Efforts to encourage a change in health professional attitude may be required, along with dedicated organizational resources, coordinators and training. Methods to engage patients should involve deliberation, which can be achieved through modified Delphi panel or participatory research approaches.

The impact of context on evidence utilization: a framework for expert groups developing health policy recommendations.

Should the same evidence lead to the same decision outcomes in different decision-making contexts? In order to improve comprehension of this issue, this study considers how context influences evidence utilization in the development of health policy recommendations. We used an embedded multiple case study design to study how four expert groups formulated policy recommendations for breast, cervical, colorectal, and prostate cancer screening in Ontario, Canada. We interviewed expert group members and analysed meeting agendas/minutes, interim/final reports and other case-related documents. Our analyses revealed varying policy objectives; the use, neglect, or overextended consideration of three key decision support tools; the varying skills/abilities of expert group members in using different decision support tools; the varying impact of effect modifiers, resource constraints and political interests; and the differing development/consideration of context-specific evidence to address uncertainty in the external decision-making context. While more work is needed to determine if these findings are generalizable beyond cancer screening policy, we believe the central challenge for evidence-based policy is not to develop international evidence, but rather to develop more systematic, rigorous, and global methods for identifying, interpreting, and applying evidence in different decision-making contexts. Our analyses suggest that identification of evidence must distinguish between different policy objectives in order to link a broad conceptualization of evidence to appropriate policy questions. Interpretation of evidence must acknowledge the varying nature of evidence for different policy objectives, balancing existing emphasis on evidentiary quality with more sophisticated methods for assessing the generalizability of evidence. The application of evidence must also acknowledge different policy objectives, appropriately employing rule-based grading schemes and agreement-based consensus methods that are sensitive to the nature of the evidence and contexts involved.

Consensus guidelines on analgesia and sedation in dying intensive care unit patients.

BACKGROUND: Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. METHODS: Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1) Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9); 2) Deputy chief provincial coroners (N = 5); 3) Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12). RESULTS: After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. CONCLUSION: Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.

Physicians in health care management: 2. Managing performance: who, what, how and when?

Physicians are becoming more involved in performance management as hospitals restructure to increase effectiveness. Although physicians are not hospital employees, they are subject to performance appraisals because the hospitals are accountable to patients and the community for the quality of hospital services. The performance of a health care professional may be appraised by the appropriate departmental manager, by other professionals in a team or program or by peers, based on prior agreement on expectations. Appraisal approaches vary. They include behavioural approaches such as rating scales, peer rating, ranking or nomination and outcome approaches such as management by objectives and goal setting. Professionals should give and receive timely feedback on a flexible schedule. Feedback can be provided one-on-one, by a group assessing quality of care or through an anonymous survey.