Improving social justice in observational studies: protocol for the development of a global and Indigenous STROBE-equity reporting guideline.

BACKGROUND: Addressing persistent and pervasive health inequities is a global moral imperative, which has been highlighted and magnified by the societal and health impacts of the COVID-19 pandemic. Observational studies can aid our understanding of the impact of health and structural oppression based on the intersection of gender, race, ethnicity, age and other factors, as they frequently collect this data. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, does not provide guidance related to reporting of health equity. The goal of this project is to develop a STROBE-Equity reporting guideline extension. METHODS: We assembled a diverse team across multiple domains, including gender, age, ethnicity, Indigenous background, disciplines, geographies, lived experience of health inequity and decision-making organizations. Using an inclusive, integrated knowledge translation approach, we will implement a five-phase plan which will include: (1) assessing the reporting of health equity in published observational studies, (2) seeking wide international feedback on items to improve reporting of health equity, (3) establishing consensus amongst knowledge users and researchers, (4) evaluating in partnership with Indigenous contributors the relevance to Indigenous peoples who have globally experienced the oppressive legacy of colonization, and (5) widely disseminating and seeking endorsement from relevant knowledge users. We will seek input from external collaborators using social media, mailing lists and other communication channels. DISCUSSION: Achieving global imperatives such as the Sustainable Development Goals (e.g., SDG 10 Reduced inequalities, SDG 3 Good health and wellbeing) requires advancing health equity in research. The implementation of the STROBE-Equity guidelines will enable a better awareness and understanding of health inequities through better reporting. We will broadly disseminate the reporting guideline with tools to enable adoption and use by journal editors, authors, and funding agencies, using diverse strategies tailored to specific audiences.

Attitudes towards chiropractic: a repeated cross-sectional survey of Canadian family physicians.

BACKGROUND: Many primary care patients receive both medical and chiropractic care; however, interprofessional relations between physicians and chiropractors are often suboptimal which may adversely affect care of shared patients. We surveyed Canadian family physicians in 2010 to explore their attitudes towards chiropractic and re-administered the same survey a decade later to explore for changes in attitudes. METHODS: A 50-item survey administered to a random sample of Canadian family physicians in 2010, and again in 2019, that inquired about demographic variables, knowledge and use of chiropractic. Imbedded in our survey was a 20-item chiropractic attitude questionnaire (CAQ); scores could range from 0 to 80 with higher scores indicating more positive attitudes toward chiropractic. We constructed a multivariable regression model to explore factors associated with CAQ scores. RESULTS: Among eligible physicians, 251 of 685 in 2010 (37% response rate) and 162 of 2429 in 2019 (7% response rate) provided a completed survey. Approximately half of respondents (48%) endorsed a positive impression of chiropractic, 27% were uncertain, and 25% held negative views. Most respondents (72%) referred at least some patients for chiropractic care, mainly due to patient request or lack of response to medical care. Most physicians believed that chiropractors provide effective therapy for some musculoskeletal complaints (84%) and disagreed that chiropractic care was beneficial for non-musculoskeletal conditions (77%). The majority agreed that chiropractic care was a useful supplement to conventional care (65%) but most respondents (59%) also indicated that practice diversity among chiropractors presented a barrier to interprofessional collaboration. In our adjusted regression model, attitudes towards chiropractic showed trivial improvement from 2010 to 2019 (0.31 points on the 80-point CAQ; 95%CI 0.001 to 0.62). More negative attitudes were associated with older age (- 1.55 points for each 10-year increment from age 28; 95%CI - 2.67 to - 0.44), belief that adverse events are common with chiropractic care (- 1.41 points; 95% CI - 2.59 to - 0.23) and reported use of the research literature (- 6.04 points; 95% CI - 8.47 to - 3.61) or medical school (- 5.03 points; 95% CI - 7.89 to - 2.18) as sources of knowledge on chiropractic. More positive attitudes were associated with endorsing a relationship with a specific chiropractor (5.24 points; 95% CI 2.85 to 7.64), family and friends (4.06 points; 95% CI 1.53 to 6.60), or personal treatment experience (4.63 points; 95% CI 2.14 to 7.11) as sources of information regarding chiropractic. CONCLUSIONS: Although generally positive, Canadian family physicians' attitudes towards chiropractic are diverse, and most physicians felt that practice diversity among chiropractors was a barrier to interprofessional collaboration.

Reporting of financial conflicts of interest by Canadian clinical practice guideline producers: a descriptive study.

BACKGROUND: The producers of clinical practice guidelines (CPGs) may not disclose industry funding in their CPGs. We reviewed Canadian national CPGs to examine the existence and disclosure of industry-related organizational funding in the CPGs, financial conflicts of interest of committee members and organizational procedures for managing financial conflicts of interest. METHODS: For this descriptive study, we searched the asset map of the Strategy for Patient-Oriented Research Evidence Alliance and the CPG Infobase for CPGs published between Jan. 1, 2016, and Nov. 30, 2018. Eligible guidelines had to have a national focus and either a first-line drug recommendation or a screening recommendation leading to drug treatment. One investigator reviewed all CPG titles to exclude those that were clearly ineligible. Two reviewers independently reviewed all remaining guidelines and extracted data. We analyzed the data descriptively. RESULTS: We included 21 CPGs: 3 from government-sponsored organizations, 9 from disease or condition interest groups and 9 from medical professional societies. None of the 3 government-sponsored organizations reported industry funding, and none of their committee members disclosed financial conflicts of interest. Among the 18 disease or condition interest groups and medical professional societies, 14 (93%) of the 15 that disclosed funding sources on websites (3 did not disclose) reported organizational funding from industry, but none disclosed this information in the CPGs; 12 (86%) of the 14 with conflict-of-interest disclosure statements in the CPG (4 did not include disclosures) had at least 1 committee member with a financial conflict (mean proportion of committee members with a conflict 56%); and for all 8 CPGs with identifiable chairs or cochairs (chairs or cochairs not reported for 10) at least 1 of these people had a financial conflict of interest. None of the guidelines described a plan to manage organizational financial conflicts of interest. INTERPRETATION: Canadian CPGs are vulnerable to industry influence through funding of producers of guidelines and through the financial conflicts of interest of committee members. The CPG producers that receive industry funding should disclose organizational financial conflicts in the CPGs, should engage independent oversight committees and should restrict voting on recommendations to guideline panelists who have no financial conflicts.

Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression: Systematic Review and Meta-analysis.

Importance: The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9. Objective: To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression. Data Sources: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018). Study Selection: Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview. Data Extraction and Synthesis: Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27. Results: Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%). Conclusions and Relevance: In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.

Gathering, strategizing, motivating and celebrating: the team huddle in a teaching general practice.

OBJECTIVES: To understand how implementing a daily team huddle affected the function of a complex interprofessional team including learners. DESIGN: A qualitative descriptive study using semi-structured interviews in focus groups. SETTING: An academic general practice teaching practice. PARTICIPANTS: All members of one interprofessional team, including nurses, general practitioners, junior doctors, and support staff. METHOD: Focus group interviews using semi-structured guidance were transcribed and the results analysed using qualitative content analysis. MAIN FINDINGS: Four interrelated themes were identified: communication and knowledge sharing; efficiency of care; relationship and team building; and shared responsibility for team function. The implementation of the daily team huddle was seen by participants to enhance the collaboration within the team and to contribute to work life enjoyment. Participants perceived that problems were anticipated and solved quickly. Clinical updates and information about patients benefited the team including learners. Junior doctors quickly understood the scope of practice of other team members, but some felt reluctant to offer clinical opinions. CONCLUSION: The implementation of a daily team huddle was viewed as worthwhile by this large interprofessional general practice team. The delivery of patient care was more efficient, knowledge was readily distributed, and problem solving was shared across the team, including junior doctors.

Using patient values and preferences to inform the importance of health outcomes in practice guideline development following the GRADE approach.

BACKGROUND: There are diverse opinions and confusion about defining and including patient values and preferences (i.e. the importance people place on the health outcomes) in the guideline development processes. This article aims to provide an overview of a process for systematically incorporating values and preferences in guideline development. METHODS: In 2013 and 2014, we followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to adopt, adapt and develop 226 recommendations in 22 guidelines for the Ministry of Health of the Kingdom of Saudi Arabia. To collect context-specific values and preferences for each recommendation, we performed systematic reviews, asked clinical experts to provide feedback according to their clinical experience, and consulted patient representatives. RESULTS: We found several types of studies addressing the importance of outcomes, including those reporting utilities, non-utility measures of health states based on structured questionnaires or scales, and qualitative studies. Guideline panels used the relative importance of outcomes based on values and preferences to weigh the balance of desirable and undesirable consequences of alternative intervention options. However, we found few studies addressing local values and preferences. CONCLUSIONS: Currently there are different but no firmly established processes for integrating patient values and preferences in healthcare decision-making of practice guideline development. With GRADE Evidence-to-Decision (EtD) frameworks, we provide an empirical strategy to find and incorporate values and preferences in guidelines by performing systematic reviews and eliciting information from guideline panel members and patient representatives. However, more research and practical guidance are needed on how to search for relevant studies and grey literature, assess the certainty of this evidence, and best summarize and present the findings.

Leadership training in a family medicine residency program: Cross-sectional quantitative survey to inform curriculum development.

OBJECTIVE: To assess the current status of leadership training as perceived by family medicine residents to inform the development of a formal leadership curriculum. DESIGN: Cross-sectional quantitative survey. SETTING: Department of Family Medicine at McMaster University in Hamilton, Ont, in December 2013. PARTICIPANTS: A total of 152 first- and second-year family medicine residents. MAIN OUTCOME MEASURES: Family medicine residents' attitudes toward leadership, perceived level of training in various leadership domains, and identified opportunities for leadership training. RESULTS: Overall, 80% (152 of 190) of residents completed the survey. On a Likert scale (1 = strongly disagree, 4 = neutral, 7 = strongly agree), residents rated the importance of physician leadership in the clinical setting as high (6.23 of 7), whereas agreement with the statement "I am a leader" received the lowest rating (5.28 of 7). At least 50% of residents desired more training in the leadership domains of personal mastery, mentorship and coaching, conflict resolution, teaching, effective teamwork, administration, ideals of a healthy workplace, coalitions, and system transformation. At least 50% of residents identified behavioural sciences seminars, a lecture and workshop series, and a retreat as opportunities to expand leadership training. CONCLUSION: The concept of family physicians as leaders resonated highly with residents. Residents desired more personal and system-level leadership training. They also identified ways that leadership training could be expanded in the current curriculum and developed in other areas. The information gained from this survey might facilitate leadership development among residents through application of its results in a formal leadership curriculum.

Primary care physicians' perspectives on facilitating older patients' access to community support services: Qualitative case study.

OBJECTIVE: To understand how family physicians facilitate older patients' access to community support services (CSSs) and to identify similarities and differences across primary health care (PHC) models. DESIGN: Qualitative, multiple-case study design using semistructured interviews. SETTING: Four models of PHC delivery, specifically 2 family health teams (FHTs), 4 non-FHTs family health organizations, 4 fee-for-service practices, and 2 community health centres in urban Ontario. PARTICIPANTS: Purposeful sampling of 23 family physicians in solo and small and large group practices within the 4 models of PHC. METHODS: A multiple-case study approach was used. Semistructured interviews were conducted and data were analyzed using within- and cross-case analysis. Case study tactics to ensure study rigour included memos and an audit trail, investigator triangulation, and the use of multiple, rather than single, case studies. MAIN FINDINGS: Three main themes were identified: consulting and communicating with the health care team to create linkages; linking patients and families to CSSs; and relying on out-of-date resources and ineffective search strategies for information on CSSs. All participants worked with their team members; however, those in FHTs and community health centres generally had a broader range of health care providers available to assist them. Physicians relied on home-care case managers to help make linkages to CSSs. Physicians recommended the development of an easily searchable, online database containing available CSSs. CONCLUSION: This study shows the importance of interprofessional teamwork in primary care settings to facilitate linkages of older patients to CSSs. The study also provides insight into the strategies physicians use to link older persons to CSSs and their recommendations for change. This understanding can be used to develop resources and approaches to better support physicians in making appropriate linkages to CSSs.

Recommendations on routine screening pelvic examination: Canadian Task Force on Preventive Health Care adoption of the American College of Physicians guideline.

OBJECTIVE: To review the 2014 American College of Physicians (ACP) guideline on the use of pelvic examinations to screen for cancer (other than cervical), pelvic inflammatory disease, or other benign gynecologic conditions to determine whether the ACP guideline on routine pelvic examinations was consistent with Canadian Task Force on Preventive Health Care (CTFPHC) standards and could be adapted or adopted. METHODS: The SNAP-IT (Smooth National Adaptation and Presentation of Guidelines to Improve Thrombosis Treatment) method was used to determine whether the ACP guideline was consistent with CTFPHC standards and could be adapted or adopted. RECOMMENDATIONS: The CTFPHC recommends not performing a screening pelvic examination to screen for noncervical cancer, pelvic inflammatory disease, or other gynecological conditions in asymptomatic women. This is a strong recommendation with moderate-quality evidence. CONCLUSION: The CTFPHC adopts the recommendation on screening pelvic examination as published by the ACP in 2014.

Development of a periodic health examination form for the frail elderly in long-term care.

OBJECTIVE: To create an evidence-based periodic health examination (PHE) form geared to long-term care (LTC) residents. DESIGN: Two-phase study: literature review to develop a quantitative, cross-sectional, self-administered survey, and administration of the survey followed by a focus group. A PHE form for LTC residents was developed based on participants' recommendations. SETTING: Hamilton, Ont. PARTICIPANTS: A total of 106 health care professionals completed the survey; 10 LTC physicians participated in the focus group. MAIN OUTCOME MEASURES: The items deemed most important and most likely to be performed during a PHE; themes from focus group discussions. RESULTS: Respondents' top 4 most important PHE items were also the top 4 items they thought were most likely to be performed during a PHE in LTC: reviewing active health status, reviewing pain control, reviewing medications, and screening for falls. Thematic analysis from the focus group discussion generated 3 main themes: current physician perspectives on the existing annual health examination in LTC, conceptual ideas for the new PHE form, and physician perspectives on the optimization of care in LTC settings. The findings from the survey, along with the themes from the focus group, were incorporated to create a PHE form for LTC residents. CONCLUSION: The proposed PHE form emphasizes tracking a patient's functional course over time and combines evidence-based preventive health interventions and health assessments with what is clinically important for LTC.

Minding the gap: Prioritization of care issues among nurse practitioners, family physicians and geriatricians when caring for the elderly.

Accumulating health problems of the elderly requires recognition of geriatric syndromes, while shifting away from a conventional disease-specific approach. We surveyed 179 practitioners representing Family Physicians (FPs), Nurse Practitioners (NPs) and geriatricians in Ontario, in order to quantify how they prioritize syndromes, diseases and conditions in the elderly. Identifying differences may inform opportunities for interprofessional sharing of expertise among professionals pursuing a common goal, which is expected to improve interprofessional collaboration. Our survey (response rate 36%) identifies that NP, FP and geriatrician respondents all recognize co-occurrence of "multiple morbidities" as one of the most frequently encountered issues when serving the elderly, however FPs and NPs place higher priority on managing individual chronic diseases than explicitly prioritizing geriatric syndromes. Our findings identify a need for a more clearly defined role for the geriatrician as syndrome-educator and implies further need for collaborative approaches to caring for seniors that values different professional's expertise.

Educational role of nurse practitioners in a family practice centre: perspectives of learners and nurses.

OBJECTIVE: To examine the role of nurse practitioners (NPs) as educators of family medicine residents in order to better understand the interprofessional educational dynamics in a clinical teaching setting. DESIGN: A qualitative descriptive approach, using purposive sampling. SETTING: A family practice centre that is associated with an academic department of family medicine and is based in an urban area in southern Ontario. PARTICIPANTS: First-year (8 of 9) and second-year (9 of 10) family medicine residents whose training program was based at the family practice centre, and all NPs (4 of 4) who worked at the centre. METHODS: Semistructured interviews were conducted, which were audiotaped and transcribed. An iterative approach was used for coding and analysis. Data management software guided organization and analysis of the data. MAIN FINDINGS: Four interconnected themes were identified: role clarification, professional identity formation, factors that enhance the educational role of NPs, and factors that limit the educational role of NPs. Although residents recognized NPs' value in team functioning and areas of specialized knowledge, they were unclear about NPs' scope of practice. Depending on residents' level of training, residents tended to respond differently to teaching by NPs. More of the senior residents believed they needed to think like physicians and preferred clinical teaching from physician teachers. Junior residents valued the step-by-step instructional approach used by NPs, and they had a decreased sense of vulnerability when being taught by NPs. Training in teaching skills was helpful for NPs. Barriers to providing optimal education included opportunity, time, and physician attitudes. CONCLUSION: The lack of an intentional orientation of family medicine residents to NPs' scope of practice and educational role can lead to difficulties in interprofessional education. More explicit recognition of the evolving professional identity of family medicine residents might decrease resistance to teaching by NPs and ensure that interprofessional teaching and learning strategies are effective. Faculty development opportunities for all educators are required to manage these issues, both to ensure teaching competencies and to reinforce positive interprofessional collaboration.