Assessing the sustainability and scalability of a diabetes eHealth innovation: a mixed-methods study.

BACKGROUND: To date, little is known about the sustainability and scalability of MyDiabetesPlan, an eHealth innovation designed to facilitate shared decision-making within diabetes care. To avoid the possibility of its short-lived implementation and promote wider adoption so as to promote patient-centred diabetes care, it is critical to understand MyDiabetesPlan's sustainability and scalability in order to ensure its long-term impact at a greater scale. We sought to identify the sustainability and scalability potential of MyDiabetesPlan and its limiting factors. METHODS: Using a concurrent triangulation mixed-methods approach, data were collected from 20 individuals involved in the development and implementation of MyDiabetesPlan. The National Health Services Sustainability Model (NHSSM) and the Innovation Scalability Self-administered Questionnaire (ISSaQ) were administered using a 'think-aloud' approach and subsequently, short semi-structured interviews were conducted. Mean aggregate scores and stakeholder-specific scores were generated for the NHSSM and ISSaQ, to quantitatively determine facilitating and limiting factors to sustainability and scalability. Content analysis occurred iteratively with qualitative data, to examine commonalities and differences with the quantitative findings. RESULTS: The top facilitating factor to sustaining MyDiabetesPlan was "Staff involvement and training to sustain the process.", whereas the top limiting factors were: "Adaptability of Improved Process", "Senior Leadership Engagement" and "Infrastructure for Sustainability". The top three facilitating factors for scale-up were "Acceptability", "Development with Theory" and "Consistency with Policy Directives." Conversely, the top three limiting factors were "Financial and Human Resources", "Achievable Adoption" and "Broad Reach". Qualitative findings corroborated the limiting/facilitating factors identified. CONCLUSIONS: Addressing staff involvement throughout the dynamic care contexts, and resource constraints impacting scale-up can enhance the sustainability and scalability of MyDiabetesPlan. As such, future plans will focus on garnering organizational leadership buy-in and support, which may address the resource constraints associated with sustainability and scalability and improve the capacity for adequate staff involvement. eHealth researchers will be able to prioritize these limiting factors from the outset of their tool development to purposefully optimize its sustainability and scalability performance.

Is Sociodemographic Status Associated with Empathic Communication and Decision Quality in Diabetes Care?

OBJECTIVE: To assess the relationship between empathic communication, shared decision-making, and patient sociodemographic factors of income, education, and ethnicity in patients with diabetes. RESEARCH DESIGN AND METHODS: This was a cross-sectional study from five primary care practices in the Greater Toronto Area, Ontario, Canada, participating in a randomized controlled trial of a diabetes goal setting and shared decision-making plan. Participants included 30 patients with diabetes and 23 clinicians (physicians, nurses, dietitians, and pharmacists), with a sample size of 48 clinical encounters. Clinical encounter audiotapes were coded using the Empathic Communication Coding System (ECCS) and Decision Support Analysis Tool (DSAT-10). RESULTS: The most frequent empathic responses among encounters were "acknowledgement with pursuit" (28.9%) and "confirmation" (30.0%). The most frequently assessed DSAT components were "stage" (86%) and knowledge of options (82.0%). ECCS varied by education (p=0.030) and ethnicity (p=0.03), but not income. Patients with only a college degree received more empathic communication than patients with bachelor's degrees or more, and South Asian patients received less empathic communication than Asian patients. DSAT varied with ethnicity (p=0.07) but not education or income. White patients experienced more shared decision-making than those in the "other" category. CONCLUSIONS: We identified a new relationship between ECCS, education and ethnicity, as well as DSAT and ethnicity. Limitations include sample size, heterogeneity of encounters, and predominant white ethnicity. These associations may be evidence of systemic biases in healthcare, with hidden roots in medical education.

The Cost-Effectiveness of Intermediate-Acting, Long-Acting, Ultralong-Acting, and Biosimilar Insulins for Type 1 Diabetes Mellitus: A Systematic Review.

OBJECTIVES: The incidence of type 1 diabetes mellitus is increasing every year requiring substantial expenditure on treatment and complications. A systematic review was conducted on the cost-effectiveness of insulin formulations, including ultralong-, long-, or intermediate-acting insulin, and their biosimilar insulin equivalents. METHODS: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, HTA, and NHS EED were searched from inception to June 11, 2021. Cost-effectiveness and cost-utility analyses were included if insulin formulations in adults (≥ 16 years) with type 1 diabetes mellitus were evaluated. Two reviewers independently screened titles, abstracts, and full-text articles, extracted study data, and appraised their quality using the Drummond 10-item checklist. Costs were converted to 2020 US dollars adjusting for inflation and purchasing power parity across currencies. RESULTS: A total of 27 studies were included. Incremental cost-effectiveness ratios ranged widely across the studies. All pairwise comparisons (11 of 11, 100%) found that ultralong-acting insulin was cost-effective compared with other long-acting insulins, including a long-acting biosimilar. Most pairwise comparisons (24 of 27, 89%) concluded that long-acting insulin was cost-effective compared with intermediate-acting insulin. Few studies compared long-acting insulins with one another. CONCLUSIONS: Long-acting insulin may be cost-effective compared with intermediate-acting insulin. Future studies should directly compare biosimilar options and long-acting insulin options and evaluate the long-term consequences of ultralong-acting insulins.

Evaluation of Experiences and Impact of Patient Engagement on e-Health Research: A Qualitative Study.

BACKGROUND: Health technology has increasingly moved toward adopting a "user-centred design" approach to include the user/patient throughout the innovation and design process; however, few studies have evaluated the patient's experience of such an engagement. OBJECTIVE: The aim of this study was to explore the role of patient engagement (PE) within e-health innovation research. METHOD: Using qualitative descriptive methodology, semi-structured interviews were conducted with eight participants (patient partners and research/development team members). FINDINGS: Key themes were centred on enablers of, challenges to and methods of improving PE. CONCLUSION: PE must be prioritized from study conception, explicitly programmed into study conduct and valued by integrating patient partner input.

Comparative Efficacy and Safety of Ultra-Long-Acting, Long-Acting, Intermediate-Acting, and Biosimilar Insulins for Type 1 Diabetes Mellitus: a Systematic Review and Network Meta-Analysis.

BACKGROUND: Increasing availability of competing biosimilar alternatives makes it challenging to make treatment decisions. The purpose of this review is to evaluate the comparative efficacy and safety of ultra-long-/long-/intermediate-acting insulin products and biosimilar insulin compared to human/animal insulin in adults with type 1 diabetes mellitus (T1DM). METHODS: MEDLINE, EMBASE, CENTRAL, and grey literature were searched from inception to March 27, 2019. Randomized controlled trials (RCTs), quasi-experimental studies, and cohort studies of adults with T1DM receiving ultra-long-/long-/intermediate-acting insulin, compared to each other, as well as biosimilar insulin compared to human/animal insulin were eligible for inclusion. Two reviewers independently screened studies, abstracted data, and appraised risk-of-bias. Pairwise meta-analyses and network meta-analyses (NMA) were conducted. Summary effect measures were mean differences (MD) and odds ratios (OR). RESULTS: We included 65 unique studies examining 14,200 patients with T1DM. Both ultra-long-acting and long-acting insulin were superior to intermediate-acting insulin in reducing A1c, FPG, weight gain, and the incidence of major, serious, or nocturnal hypoglycemia. For fasting blood glucose, long-acting once a day (od) was superior to long-acting twice a day (bid) (MD - 0.44, 95% CI: - 0.81 to - 0.06) and ultra-long-acting od was superior to long-acting bid (MD - 0.73, 95% CI - 1.36 to - 0.11). For weight change, long-acting od was inferior to long-acting bid (MD 0.58, 95% CI: 0.05 to 1.10) and long-acting bid was superior to long-action biosimilar od (MD - 0.90, 95% CI: - 1.67 to - 0.12). CONCLUSIONS: Our results can be used to tailor insulin treatment according to the desired results of patients and clinicians and inform strategies to establish a competitive clinical market, address systemic barriers, expand the pool of potential suppliers, and favor insulin price reduction. PROSPERO REGISTRATION: CRD42017077051.

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial.

BACKGROUND: MyDiabetesPlan is a web-based, interactive patient decision aid that facilitates patient-centred, diabetes-specific, goal-setting and shared decision-making (SDM) with interprofessional health care teams. OBJECTIVE: Assess the feasibility of (1) conducting a cluster randomized controlled trial (RCT) and (2) integrating MyDiabetesPlan into interprofessional primary care clinics. METHODS: We conducted a cluster RCT in 10 interprofessional primary care clinics with patients living with diabetes and at least two other comorbidities; half of the clinics were assigned to MyDiabetesPlan and half were assigned to usual care. To assess recruitment, retention, and resource use, we used RCT conduct logs and financial account summaries. To assess intervention fidelity, we used RCT conduct logs and website usage logs. To identify barriers and facilitators to integration of MyDiabetesPlan into clinical care across the IP team, we used audiotapes of clinical encounters in the intervention groups. RESULTS: One thousand five hundred and ninety-seven potentially eligible patients were identified through searches of electronic medical records, of which 1113 patients met the eligibility criteria upon detailed chart review. A total of 425 patients were randomly selected; of these, 213 were able to participate and were allocated (intervention: n = 102; control: n = 111), for a recruitment rate of 50.1%. One hundred and fifty-one patients completed the study, for a retention rate of 70.9%. A total of 5745 personnel-hours and $6104 CAD were attributed to recruitment and retention activities. A total of 179 appointments occurred (out of 204 expected appointments-two per participant over the 12-month study period; 87.7%). Forty (36%), 25 (23%), and 32 (29%) patients completed MyDiabetesPlan at least twice, once, and zero times, respectively. Mean time for completion of MyDiabetesPlan by the clinician and the patient during initial appointments was 37 min. From the clinical encounter transcripts, we identified diverse strategies used by clinicians and patients to integrate MyDiabetesPlan into the appointment, characterized by rapport building and individualization. Barriers to use included clinician-related, patient-related, and technical factors. CONCLUSION: An interprofessional approach to SDM using a decision aid was feasible. Lower than expected numbers of diabetes-specific appointments and use of MyDiabetesPlan were observed. Addressing facilitators and barriers identified in this study will promote more seamless integration into clinical care. Trial registration Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: February 11, 2015. Protocol version: Version 1; February 26, 2015.

Impact of a Comprehensive Guideline Dissemination Strategy on Diabetes Diagnostic Test Rates: an Interrupted Time Series.

BACKGROUND: Diabetes Canada launched a comprehensive Dissemination and Implementation (D&I) strategy to optimize uptake of their 2013 Clinical Practice Guidelines; the strategy involved continuing professional development courses, webinars, an interactive website, applications for mobile devices, point-of-care decision support tools, and media awareness campaigns. It included a focus on promoting HbA1c as the recommended diagnostic test for diabetes. OBJECTIVE: To determine the impact of Diabetes Canada's 2013 D&I strategy on physician test-ordering behavior, specifically HbA1c testing, for the diagnosis of diabetes, using provincial healthcare administrative data. DESIGN: Population-based interrupted time series. SETTING: Ontario, Canada. PARTICIPANTS: Ontario residents aged 40-79 not previously diagnosed with diabetes. MEASUREMENTS: For each quarter between January 2005 and December 2014, we conducted an interrupted time series analysis on the first-order difference of the proportion of patients receiving HbA1c tests per quarter with an autoregressive integrated moving average model with the intervention step occurring in quarter 2 of 2013. Subgroup analyses by rurality, physician graduation year, and practice size were also conducted. RESULTS: There were 32 quarters pre-intervention and 6 post-intervention; average sample size per quarter was 5,298,686 individuals. Pre-intervention, the quarter-to-quarter growth was 1.51 HbA1c tests per quarter per 1000 people. Post-intervention, the quarter-to-quarter growth increased by 8.45 tests per 1000 people (p < 0.005). Growth of HbA1c ordering differed significantly by region, years since physician graduation, and practice size. LIMITATIONS: Incomplete data collection, inadequate stratification, and other unidentified confounders. CONCLUSION: The D&I strategy resulted in a significant increase in the growth of HbA1c tests. The successful uptake of this recommendation may be due to its simplicity; guideline developers should consider this when drafting recommendations. Furthermore, differential uptake by user groups suggests that future strategies should include targeted barrier analysis and interventions to these groups.

Beyond pros and cons - developing a patient decision aid to cultivate dialog to build relationships: insights from a qualitative study and decision aid development.

BACKGROUND: An individualized approach using shared decision-making (SDM) and goal setting is a person-centred strategy that may facilitate prioritization of treatment options. SDM has not been adopted extensively in clinical practice. An interprofessional approach to SDM with tools to facilitate patient participation may overcome barriers to SDM use. The aim was to explore decision-making experiences of health professionals and people with diabetes (PwD), then develop an intervention to facilitate interprofessional shared decision-making (IP-SDM) and goal-setting. METHODS: This was a multi-phased study. 1) Feasibility: Using a descriptive qualitative study, individual interviews with primary care physicians, nurses, dietitians, pharmacists, and PwD were conducted. The interviews explored their experiences with SDM and priority-setting, including facilitators and barriers, relevance of a decision aid for priority-setting, and integration of SDM and a decision aid into practice. 2) Development: An evidence-based SDM toolkit was developed, consisting of an online decision aid, MyDiabetesPlan, and implementation tools. MyDiabetesPlan was reviewed by content experts for accuracy and comprehensiveness. Usability assessment was done with 3) heuristic evaluation and 4) user testing, followed by 5) refinement. RESULTS: Seven PwD and 10 clinicians participated in the interviews. From interviews with PwD, we identified that: (1) approaches to decision-making were diverse and dynamic; (2) a trusting relationship with the clinician and dialog were critical precursors to SDM; and, (3) goal-setting was a dynamic process. From clinicians, we found: (1) complementary (holistic and disease specific) approaches to the complex patient were used; (2) patient-provider agendas for goal-setting were often conflicting; (3) a flexible approach to decision-making was needed; and, (4) conflict could be resolved through SDM. Following usability assessment, we redesigned MyDiabetesPlan to consist of data collection and recommendation stages. Findings were used to finalize a multi-component toolkit and implementation strategy, consisting of MyDiabetesPlan, instructional card and videos, and orientation meetings with participating patients and clinicians. CONCLUSIONS: A decision aid can provide information, facilitate clinician-patient dialog and strengthen the therapeutic relationship. Implementation of the decision aid can fit into a model of team care that respects and exemplifies professional identity, and can facilitate intra-team communication. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.

Diabetes Canada 2018 clinical practice guidelines: Key messages for family physicians caring for patients living with type 2 diabetes.

OBJECTIVE: To summarize the 2018 Diabetes Canada clinical practice guidelines, focusing on high-priority recommendations for FPs managing people who live with type 2 diabetes. QUALITY OF EVIDENCE: A prioritization process was conducted to focus the efforts of Diabetes Canada's guideline dissemination and implementation efforts. The resulting identified key messages for FPs to consider when managing patients with type 2 diabetes are described. Evidence supporting the guideline recommendations ranges from levels I to IV and grades A to D. MAIN MESSAGE: Three key messages were identified from the 2018 guidelines as priorities for FPs: discussing opportunities to reduce the risk of diabetes complications, discussing opportunities to ensure safety and prevent hypoglycemia, and discussing progress on self-management goals and addressing barriers. A theme cutting across these key messages was the need to tailor discussions to the needs and preferences of each person. These important guideline recommendations are highlighted, along with information about relevant tools for implementing the recommendations in real-world practice. CONCLUSION: High-quality diabetes care involves a series of periodic conversations about self-management and about pharmacologic and nonpharmacologic treatments that fit with each patient's goals (ie, shared decision making). Incorporating these conversations into regular practice provides FPs with opportunities to maximize likely benefits of treatments and decrease the risk of harms, to support patients in initiating and sustaining desired lifestyle changes, and to help patients cope with the burdens of diabetes and comorbid conditions.

"There's no billing code for empathy" - Animated comics remind medical students of empathy: a qualitative study.

BACKGROUND: Physician empathy is associated with improved diabetes outcomes. However, empathy declines throughout medical school training. This study seeks to describe how comics on diabetes affect learning processes for empathy in medical students. METHODS: All first- or second-year students at a Canadian medical school were invited to provide written reflections on two comics regarding diabetes and participate in a focus group. Responses were analyzed qualitatively for emergent themes. Students completed the Jefferson Scale of Physician Empathy (JSPE) at baseline, after the comic, and after the focus group. Linear mixed model statistical analyses were performed. RESULTS: Thirteen first-year and 12 second-year students participated. Qualitative analysis revealed four themes: 1) Empathy decline and its barriers; 2) Impact of the comic and focus group on knowledge, attitudes and skills; 3) Role of the comic in the curriculum as a reminder tool of the importance of empathy; 4) Comics as an effective medium. Baseline mean JSPE scores were 116.4 (SD 10.5) and trended up to 117.2 (SD 12.5) and 119.6 (SD 15.2) after viewing the comics and participating in the focus groups, respectively (p = 0.08). CONCLUSIONS: Animated comics on diabetes are novel methods of reminding students about empathy by highlighting the patient perspective.

The ABCs of DKA: Development and Validation of a Computer-Based Simulator and Scoring System.

BACKGROUND: Clinical management of diabetic ketoacidosis (DKA) continues to be suboptimal; simulation-based training may bridge this gap and is particularly applicable to teaching DKA management skills given it enables learning of basic knowledge, as well as clinical reasoning and patient management skills. OBJECTIVES: 1) To develop, test, and refine a computer-based simulator of DKA management; 2) to collect validity evidence, according to National Standard's validity framework; and 3) to judge whether the simulator scoring system is an appropriate measure of DKA management skills of undergraduate and postgraduate medical trainees. DESIGN: After developing the DKA simulator, we completed usability testing to optimize its functionality. We then conducted a preliminary validation of the scoring system for measuring trainees' DKA management skills. PARTICIPANTS: We recruited year 1 and year 3 medical students, year 2 postgraduate trainees, and endocrinologists (n = 75); each completed a simulator run, and we collected their simulator-computed scores. MAIN MEASURES: We collected validity evidence related to content, internal structure, relations with other variables, and consequences. KEY RESULTS: Our simulator consists of six cases highlighting DKA management priorities. Real-time progression of each case includes interactive order entry, laboratory and clinical data, and individualised feedback. Usability assessment identified issues with clarity of system status, user control, efficiency of use, and error prevention. Regarding validity evidence, Cronbach's α was 0.795 for the seven subscales indicating favorable internal structure evidence. Participants' scores showed a significant effect of training level (p < 0.001). Scores also correlated with the number of DKA patients they reported treating, weeks on Medicine rotation, and comfort with managing DKA. A score on the simulation exercise of 75 % had a sensitivity and specificity of 94.7 % and 51.8%, respectively, for delineating between expert staff physicians and trainees. CONCLUSIONS: We demonstrate how a simulator and scoring system can be developed, tested, and refined to determine its quality for use as an assessment modality. Our evidence suggests that it can be used for formative assessment of trainees' DKA management skills.

Effect of an educational toolkit on quality of care: a pragmatic cluster randomized trial.

BACKGROUND: Printed educational materials for clinician education are one of the most commonly used approaches for quality improvement. The objective of this pragmatic cluster randomized trial was to evaluate the effectiveness of an educational toolkit focusing on cardiovascular disease screening and risk reduction in people with diabetes. METHODS AND FINDINGS: All 933,789 people aged ≥40 years with diagnosed diabetes in Ontario, Canada were studied using population-level administrative databases, with additional clinical outcome data collected from a random sample of 1,592 high risk patients. Family practices were randomly assigned to receive the educational toolkit in June 2009 (intervention group) or May 2010 (control group). The primary outcome in the administrative data study, death or non-fatal myocardial infarction, occurred in 11,736 (2.5%) patients in the intervention group and 11,536 (2.5%) in the control group (p = 0.77). The primary outcome in the clinical data study, use of a statin, occurred in 700 (88.1%) patients in the intervention group and 725 (90.1%) in the control group (p = 0.26). Pre-specified secondary outcomes, including other clinical events, processes of care, and measures of risk factor control, were also not improved by the intervention. A limitation is the high baseline rate of statin prescribing in this population. CONCLUSIONS: The educational toolkit did not improve quality of care or cardiovascular outcomes in a population with diabetes. Despite being relatively easy and inexpensive to implement, printed educational materials were not effective. The study highlights the need for a rigorous and scientifically based approach to the development, dissemination, and evaluation of quality improvement interventions. TRIAL REGISTRATION: http://www.ClinicalTrials.gov NCT01411865 and NCT01026688.

A web-based intervention to support self-management of patients with type 2 diabetes mellitus: effect on self-efficacy, self-care and diabetes distress.

BACKGROUND: Management of diabetes mellitus is complex and involves controlling multiple risk factors that may lead to complications. Given that patients provide most of their own diabetes care, patient self-management training is an important strategy for improving quality of care. Web-based interventions have the potential to bridge gaps in diabetes self-care and self-management. The objective of this study was to determine the effect of a web-based patient self-management intervention on psychological (self-efficacy, quality of life, self-care) and clinical (blood pressure, cholesterol, glycemic control, weight) outcomes. METHODS: For this cohort study we used repeated-measures modelling and qualitative individual interviews. We invited patients with type 2 diabetes to use a self-management website and asked them to complete questionnaires assessing self-efficacy (primary outcome) every three weeks for nine months before and nine months after they received access to the website. We collected clinical outcomes at three-month intervals over the same period. We conducted in-depth interviews at study conclusion to explore acceptability, strengths and weaknesses, and mediators of use of the website. We analyzed the data using a qualitative descriptive approach and inductive thematic analysis. RESULTS: Eighty-one participants (mean age 57.2 years, standard deviation 12) were included in the analysis. The self-efficacy score did not improve significantly more than expected after nine months (absolute change 0.12; 95% confidence interval -0.028, 0.263; p = 0.11), nor did clinical outcomes. Website usage was limited (average 0.7 logins/month). Analysis of the interviews (n = 21) revealed four themes: 1) mediators of website use; 2) patterns of website use, including role of the blog in driving site traffic; 3) feedback on website; and 4) potential mechanisms for website effect. CONCLUSIONS: A self-management website for patients with type 2 diabetes did not improve self-efficacy. Website use was limited. Although its perceived reliability, availability of a blog and emailed reminders drew people to the website, participants' struggles with type 2 diabetes, competing priorities in their lives, and website accessibility were barriers to its use. Future interventions should aim to integrate the intervention seamlessly into the daily routine of end users such that it is not seen as yet another chore.

User-centered design of a web-based self-management site for individuals with type 2 diabetes - providing a sense of control and community.

BACKGROUND: To design and test a web-based self-management tool for patients with type 2 diabetes for its usability and feasibility. METHODS: An evidence-based, theory-driven website was created for patients with type 2 diabetes. Twenty-three patients with type 2 diabetes aged ≥ 25 years were recruited from 2 diabetes care centers in Toronto, Canada. We employed focus group methodology to assess acceptability, sustainability, strengths and weaknesses of the self-management website. Based on these results, revisions were made to the website. Three cycles of individual usability testing sessions using cognitive task analysis were conducted with patients with type 2 diabetes. Revisions to the website were made based on results from this testing. RESULTS: We identified five themes concerning participants' experiences of health care and related unmet needs: 1) Desire for information and for greater access to timely and personalized care to gain a sense of control of their disease; 2) Desire for community (sharing experiences with others) to fulfill practical and emotional needs; 3) Potential roles of an online self-management website in self-empowerment, behavior change, self-management and health care delivery; 4) Importance of a patient-centered perspective in presenting content (e.g. common assumptions, medical nomenclature, language, messaging, sociocultural context); 5) Barriers and facilitators to use of a self-management website (including perceived relevance of content, incorporation into usual routine, availability for goal-directed use, usability issues). CONCLUSIONS: Participants outlined a series of unmet health care needs, and stated that they wanted timely access to tailored knowledge about their condition, mechanisms to control and track their disease, and opportunities to share experiences with other patients. These findings have implications for patients with type 2 diabetes of diverse ages, socioeconomic backgrounds, and disease severity, as well as to the design of other computer-based resources for chronic disease management.

Lignes directrices de pratique clinique 2018 de Diabète Canada: Principaux messages à l'intention des médecins de famille qui traitent les patients atteints de diabète de type 2.

OBJECTIF: Résumer les lignes directrices de pratique clinique 2018 de Diabète Canada en s'attardant aux recommandations prioritaires pour les médecins de famille qui traitent des personnes vivant avec le diabète de type 2. QUALITÉ DES DONNÉES: Un processus de priorisation a été réalisé dans le but de canaliser les efforts de dissémination et de mise en oeuvre des lignes directrices de Diabète Canada. Il en a résulté une description des principaux messages à l'intention des médecins de famille qui soignent des patients de diabète de type 2. Les données étayant les recommandations des lignes directrices varient des niveaux I à IV, et des catégories A à D. MESSAGE PRINCIPAL: Trois principaux messages prioritaires pour les médecins de famille ont été relevés dans les lignes directrices 2018 : parler des occasions de réduire le risque de complications du diabète, parler des occasions d'assurer la sécurité et de prévenir l'hypoglycémie, et parler des progrès vers l'atteinte des objectifs d'autoprise en charge et de l'élimination des obstacles. Ces principaux messages ont fait ressortir un thème : celui d'adapter les conversations aux besoins et aux préférences de chacun. Ces importantes recommandations sont mises en lumière, de même que l'information sur les outils pertinents pour mettre en oeuvre les recommandations en pratique réelle. CONCLUSION: Les soins du diabète de grande qualité comprennent une série de conversations périodiques sur l'autoprise en charge, et sur les traitements pharmacologiques et non pharmacologiques adaptés aux objectifs de chaque patient (c.-à-d. prise de décision partagée). Lorsque les médecins de famille incorporent ces conversations dans la pratique régulière, ils ont la chance d'optimiser les bienfaits possibles du traitement et de réduire le risque d'effets nuisibles, d'encourager les patients à instaurer et à maintenir les modifications désirées du mode de vie, et de les aider à composer avec le fardeau du diabète et des comorbidités.

Prolactinoma and Adenomyosis - More than Meets the Eye: A Case Report.

Background/Objective: To report a case of adenomyosis in a woman with hyperprolactinemia which resolved after initiation of dopamine agonist therapy. Case Report: A 35-year-old woman with a history of Graves' disease was referred for evaluation of hyperthyroidism in March 2020. She was started on methimazole and thyroid function normalized. The patient also had a history of a pituitary microadenoma and was previously treated with cabergoline which was stopped after 12 months as she became pregnant.In July 2020, the patient began to have polymenorrhea. Hyperprolactinemia was thought to be an unlikely cause as it most often causes hypogonadotropic hypogonadism with amenorrhea. A pelvic ultrasound demonstrated a bulky uterus with adenomyosis. Gynecology recommended treating adenomyosis by lowering her prolactin levels. She was started on cabergoline 0.25 mg weekly in October 2021. Within 2 months of initiation of cabergoline, she had resolution of symptoms and radiological resolution of adenomyosis. Discussion: Prolactin has been implicated in the pathogenesis of adenomyosis, endometriosis and leiomyomas suggesting that a decrease in prolactin levels may suppress these lesions. The pathogenesis of adenomyosis has been related to direct prolactin effects in the promotion of gland/cell proliferation and function. Conclusion: We conclude that prolonged elevation in prolactin may result in the development of adenomyosis and subsequent prolonged abnormal uterine bleeding. Dopamine agonists, like cabergoline, inhibit the synthesis and secretion of prolactin from the pituitary gland and may have a role in the management of adenomyosis in patients with hyperprolactinemia.

The effect of patient care order sets on medical resident education: a prospective before-after study.

BACKGROUND: Patient care order sets are increasingly being used to optimize care. While studies have evaluated the impact of order sets on provider performance and patient outcomes, their impact on postgraduate medical trainee knowledge remains unknown. We sought to evaluate the impact of order sets on respirology knowledge, order-writing skills, and self-reported learning. METHODS: We conducted a prospective before-after study. Postgraduate trainees completing a Respirology rotation at a quaternary-care hospital 6 months before (no order set period) and 12 months after (order set period) order set introduction. Guideline-based admission order sets with educational prompts detailing recommended management of cystic fibrosis and chronic obstructive pulmonary disease were implemented on the respirology ward. Each resident completed a test before and after the rotation assessing knowledge and order-writing. Residents in the order set period additionally completed a questionnaire regarding the impact of order set use on their learning. ANALYSIS: The primary outcome, the difference between pre and post rotation scores was compared between residents in the no order set period and residents in the order set period, using univariate linear regression. Test validity was assessed with a 2-sample t-test, analysis of variance and Pearson's correlation coefficient. Self-reported impact of order set use were descriptively analyzed, and written responses were collated and coded. RESULTS: Investigators consecutively recruited 11 subjects before and 28 subjects after order set implementation. Residents in the order set period had a greater improvement in post-rotation test scores than residents in the no order set period (p = 0.04); after adjustment for baseline scores, this was not significant (p = 0.3). The questionnaire demonstrated excellent convergent, discriminant and construct validity. Residents reported that order sets improved their knowledge and skills and provided a systematic approach to care. CONCLUSIONS: Order sets do not appear to impair resident education, and may impart a benefit. This will require validation in larger studies and across diseases.

Effective web-based clinical practice guidelines resources: recommendations from a mixed methods usability study.

BACKGROUND: Clinical practice guidelines (CPG) are an important knowledge translation resource to help clinicians stay up to date about relevant clinical knowledge. Effective communication of guidelines, including format, facilitates its implementation. Despite the digitalization of healthcare, there is little literature to guide CPG website creation for effective dissemination and implementation. Our aim was to assess the effectiveness of the content and format of the Diabetes Canada CPG website, and use our results to inform recommendations for other CPG websites. METHODS: Fourteen clinicians (family physicians, nurses, pharmacists, and dieticians) in diabetes care across Canada participated in this mixed-methods study (questionnaires, usability testing and interviews). Participants "thought-aloud" while completing eight usability tasks on the CPG website. Outcomes included task success rate, completion time, click per tasks, resource used, paths, search attempts and success rate, and error types. Participants were then interviewed. RESULTS: The Diabetes Canada CPG website was found to be usable. Participants had a high task success rate of 79% for all tasks and used 144 (standard deviation (SD) = 152) seconds and 4.6 (SD = 3.9) clicks per task. Interactive tools were most frequently used compared to full guidelines and static tools. Misinterpretation accounted for 48% of usability errors. Participants overall found the website intuitive, with effective content and design elements. CONCLUSION: Different versions of CPG information (e.g. interactive tools, quick reference guide, static tools) can help answer clinical questions more quickly. Effective web design should be assessed during CPG website creation for effective guideline dissemination and implementation.

Designing and evaluating a web-based self-management site for patients with type 2 diabetes--systematic website development and study protocol.

BACKGROUND: Given that patients provide the majority of their own diabetes care, patient self-management training has increasingly become recognized as an important strategy with which to improve quality of care. However, participation in self management programs is low. In addition, the efficacy of current behavioural interventions wanes over time, reducing the impact of self-management interventions on patient health. Web-based interventions have the potential to bridge the gaps in diabetes care and self-management. METHODS: Our objective is to improve self-efficacy, quality of life, self-care, blood pressure, cholesterol and glycemic control and promote exercise in people with type 2 diabetes through the rigorous development and use of a web-based patient self-management intervention. This study consists of five phases: (1) intervention development; (2) feasibility testing; (3) usability testing; (4) intervention refinement; and (5) intervention evaluation using mixed methods. We will employ evidence-based strategies and tools, using a theoretical framework of self-efficacy, then elicit user feedback through focus groups and individual user testing sessions. Using iterative redesign the intervention will be refined. Once finalized, the impact of the website on patient self-efficacy, quality of life, self-care, HbA1c, LDL-cholesterol, blood pressure and weight will be assessed through a non-randomized observational cohort study using repeated measures modeling and individual interviews. DISCUSSION: Increasing use of the World Wide Web by consumers for health information and ongoing revolutions in social media are strong indicators that users are primed to welcome a new era of technology in health care. However, their full potential is hindered by limited knowledge regarding their effectiveness, poor usability, and high attrition rates. Our development and research agenda aims to address these limitations by improving usability, identifying characteristics associated with website use and attrition, and developing strategies to sustain patient use in order to maximize clinical outcomes.