Feasibility of an Electronic Health Tool to Promote Physical Activity in Primary Care: Pilot Cluster Randomized Controlled Trial.

BACKGROUND: Physical inactivity is associated with increased health risks. Primary care providers (PCPs) are well positioned to support increased physical activity (PA) levels through screening and provision of PA prescriptions. However, PCP counseling on PA is not common. OBJECTIVE: This study aimed to assess the feasibility of implementing an electronic health (eHealth) tool to support PA counseling by PCPs and estimate intervention effectiveness on patients' PA levels. METHODS: A pragmatic pilot study was conducted using a stepped wedge cluster randomized trial design. The study was conducted at a single primary care clinic, with 4 pre-existing PCP teams. Adult patients who had a periodic health review (PHR) scheduled during the study period were invited to participate. The eHealth tool involved an electronic survey sent to participants before their PHR via an email or a tablet; data were used to automatically produce tailored resources and a PA prescription in the electronic medical record of participants in the intervention arm. Participants assigned to the control arm received usual care from their PCP. Feasibility was assessed by the proportion of completed surveys and patient-reported acceptability and fidelity measures. The primary effectiveness outcome was patient-reported PA at 4 months post-PHR, measured as metabolic equivalent of task (MET) minutes per week. Secondary outcomes assessed determinants of PA, including self-efficacy and intention to change based on the Health Action Process Approach behavior change theory. RESULTS: A total of 1028 patients receiving care from 34 PCPs were invited to participate and 530 (51.55%) consented (intervention [n=296] and control [n=234]). Of the participants who completed a process evaluation, almost half (88/178, 49.4%) stated they received a PA prescription, with only 42 receiving the full intervention including tailored resources from their PCP. A cluster-level linear regression analysis yielded a non-statistically significant positive difference in MET-minutes reported per week at follow-up between intervention and control conditions (mean difference 1027; 95% CI -155 to 2209; P=.09). No statistically significant differences were observed for secondary outcomes. CONCLUSIONS: Our results suggest that it is feasible to build an eHealth tool that screens and provides tailored resources for PA in a primary care setting but suboptimal intervention fidelity suggests greater work must be done to address PCP barriers to resource distribution. Participant responses to the primary effectiveness outcome (MET-minutes) were highly variable, reflecting a need for more robust measures of PA in future trials to address limitations in patient-reported data. TRIAL REGISTRATION: ClinicalTrials.gov NCT03181295; https://clinicaltrials.gov/ct2/show/NCT03181295.

How should family physicians provide physical activity advice? Qualitative study to inform the design of an e-health intervention.

OBJECTIVE: To explore patient attitudes toward interacting with family physicians regarding physical activity in order to inform the development of an e-health intervention aimed at helping family physicians support patients in becoming more physically active. DESIGN: Qualitative study. SETTING: Women's College Hospital in Toronto, Ont. PARTICIPANTS: Ten patients recruited from the academic family practice health centre. METHODS: Semistructured interviews were conducted with patients using maximum variation sampling until thematic saturation was reached. Interviews explored past experiences and preferences for receiving physical activity advice from family physicians, and tools or techniques that might support increasing physical activity. Interviews were audiorecorded, transcribed, and coded independently by members of the research team before undergoing thematic analysis. MAIN FINDINGS: Patient interviews revealed 4 overarching themes that offered insight to physical activity discussions. Family physicians might provide more meaningful and useful physical activity advice to patients by providing individualized recommendations focused on proximal (ie, near-term) health and functional goals; recognizing and addressing unique environmental and social factors influencing physical activity levels; balancing candour and sensitivity in advice provision while incorporating a broad definition of physical activity; and recommending tools that incorporate planning, goal-setting, and goal-monitoring features. CONCLUSION: Ultimately, physical activity recommendations from family physicians cannot make a difference if patients do not act on them. This study elicits input from patients to develop preliminary strategies that might help family physicians provide physical activity advice in a more patient-centred fashion. Further research is needed to test interventions that help implement these strategies and to assess their effect.

"I sleep better at night:" How peer review of radiation treatment plans indirectly improves quality of care across radiation treatment programs.

PURPOSE: Peer review of radiation oncology treatment plans is increasingly recognized as an important component of quality assurance in radiation treatment planning and delivery. Peer review of treatment plans can directly improve the quality of those plans and can also have indirect effects on radiation treatment programs. We undertook a systematic, qualitative approach to describing the indirect benefits of peer review, factors that were seen to facilitate or act as barriers to the implementation of peer review, and strategies to address these barriers across a provincial jurisdiction of radiation oncology programs (ROPs). METHODS AND MATERIALS: Semistructured qualitative interviews were held with radiation oncology department heads and radiation therapy managers (or delegates) in all 14 ROPs in Ontario, Canada. We used a theoretically guided phenomenological qualitative approach to design and analyze the interview content. Themes were recorded by 2 independent reviewers, and any discordance was resolved by consensus. RESULTS: A total of 28 interviews were completed with 32 interviewees. Twenty-two unique themes addressed perceived benefits of peer review, relating to either peer review structure (n = 3), process (n = 9), or outcome (n = 10). Of these 22 themes, 19 related to indirect benefits to ROPs. In addition, 18 themes related to factors that facilitated peer review activities and 30 themes related to key barriers to implementing peer review were identified. Findings were consistent with, and enhanced the understanding of, previous survey-based assessments of the benefits and challenges of implementing peer review programs. CONCLUSIONS: Although challenges and concerns regarding the implementation of peer review were evident, the indirect benefits to radiation programs are numerous, far outweigh the implementation challenges, and strongly complement the direct individual-patient benefits that result from peer review quality assurance of radiation treatment plans.

Directly Improving the Quality of Radiation Treatment Through Peer Review: A Cross-sectional Analysis of Cancer Centers Across a Provincial Cancer Program.

PURPOSE: To describe the outcomes of peer review across all 14 cancer centers in Ontario. METHODS AND MATERIALS: We identified all peer-reviewed, curative treatment plans delivered in Ontario within a 3-month study period from 2013 to 2014 using a provincial cancer treatment database and collected additional data on the peer-review outcomes. RESULTS: Considerable variation was found in the proportion of peer-reviewed plans across the centers (average 70.2%, range 40.8%-99.2%). During the study period, 5561 curative plans underwent peer review. Of those, 184 plans (3.3%) had changes recommended. Of the 184 plans, the changes were major (defined as requiring repeat planning or having a major effect on planning or clinical outcomes, or both) in 40.2% and minor in 47.8%. For the remaining 12.0%, data were missing. The proportions of recommended changes varied among disease sites (0.0%-7.0%). The disease sites with the most recommended changes to treatment plans after peer review and with the greatest potential for benefit were the esophagus (7.0%), uterus (6.7%), upper limb (6.3%), cervix and lower limb (both 6.0%), head and neck and bilateral lung (both 5.9%), right supraclavicular lymph nodes (5.7%), rectum (5.3%), and spine (5.0%). Although the heart is an organ at risk in left-sided breast treatment plans, the proportions of recommended changes did not significantly differ between the left breast treatment plans (3.0%, 95% confidence interval 2.0%-4.5%) and right breast treatment plans (2.4%, 95% confidence interval 1.5%-3.8%). The recommended changes were more frequently made when peer review occurred before radiation therapy (3.8%) than during treatment (1.4%-2.8%; P=.0048). The proportion of plans with recommended changes was not significantly associated with patient volume (P=.23), peer-review performance (P=.36), or center academic status (P=.75). CONCLUSIONS: Peer review of treatment plans directly affects the quality of care by identifying important clinical and planning changes. Provincial strategies are underway to optimize its conduct in radiation oncology.

Improving the Quality of Radiation Treatment for Patients in Ontario: Increasing Peer Review Activities on a Jurisdictional Level Using a Change Management Approach.

PURPOSE: Peer review of radiation treatment (RT) plans is a key component of quality assurance programs in radiation medicine. A 2011 current state assessment identified considerable variation in the percentage of RT plans peer reviewed across Ontario's 14 cancer centers.In response, Cancer Care Ontario launched an initiative to increase peer review of plans for patients receiving radical intent RT. METHODS: The initiative was designed consistent with the Kotter eight-step process for organizational transformation. A multidisciplinary team conducted site visits to promote and guide peer review and to develop education and implementation processes in collaboration with the centers. A centralized reporting infrastructure enabled the monitoring of the percentage of RT courses peer reviewed and the timing of peer review (before completion of 25%of treatment visits, after completion of >25%treatment visits). RESULTS: The initiative is ongoing, but early results indicate that the proportion of radical intent RT courses peer reviewed province wide increased from 43.5% (April 2013) to 68.0%(March 2015). This proportion is now a quality metric in Ontario and is publicly reported through the Cancer System Quality Index. The performance target for this metric was initially set at 50%(cases treated with radical intent) and revised to 60% in 2014. Provincial performance exceeded targets in both years (58.2% and 68.2%, respectively). Considerable variation was observed, however, in rates and timing of peer review among Cancer Care Ontario centers. CONCLUSION: This initiative demonstrates that a change management framework can be useful for planning and achieving substantial increases in jurisdictional peer review activities.