Tools for Enhancement and Quality Improvement of Peer Assessment and Clinical Care in Endocrinology and Metabolism.

Members of the College of Physicians and Surgeons of Ontario Endocrinology and Metabolism Peer Review Network have been involved in a quality improvement project to help standardize the peer assessment of physicians practicing in endocrinology and metabolism. This has included developing state-of-the-art summaries of common endocrine problems by Canadian experts in endocrinology and metabolism. These tools have been developed in response to the educational needs, as identified by peer reviewers, of practicing endocrinologists in Ontario. These pedagogical tools aim not only to standardize the documentation of the clinical performance of endocrinologists but also to make the process more transparent and to improve the quality of patient care in Ontario. This article summarizes the project and also provides the tools developed for the endocrinology and metabolism section of the College of Physicians and Surgeons of Ontario.

Effect of a course-based intervention and effect of medical regulation on physicians' opioid prescribing.

OBJECTIVE: To examine the effects of an intensive 2-day course on physicians' prescribing of opioids. DESIGN: Population-based retrospective observational study. SETTING: College of Physicians and Surgeons of Ontario (CPSO) in Toronto. PARTICIPANTS: Ontario physicians who took the course between April 1, 2000, and May 30, 2008. INTERVENTION: A 2-day opioid-prescribing course with a maximum of 12 physician participants. Educational methods included didactic presentations, case discussions, and standardized patients. A detailed syllabus and office materials were provided. MAIN OUTCOME MEASURES: Participants were matched with control physicians using specific variables. The primary outcome was the rate of opioid prescribing, expressed as milligrams of morphine equivalent per quarter. RESULTS: One hundred thirty-eight course participants (120 family physicians, 15 specialists, and 3 physicians whose status was uncertain) were eligible for analysis. Of these, 68.1% were self-referred and 31.9% were referred by the CPSO. Overall, among physicians referred by the CPSO, the rate of opioid prescribing decreased dramatically in the year before course participation compared with matched control physicians. The course had no added effect on the rate of physicians' opioid prescribing in the subsequent 2 years. There was no statistically significant effect on the rate of opioid prescribing observed among the self-referred physicians. Among 15 of the self-referred physicians who, owing to the high quantities of opioids they prescribed, were not matched with control physicians, the rate of opioid prescribing decreased by 43.9% in the year following course completion. CONCLUSION: Physicians markedly reduced the quantities of opioids they prescribed after medical regulators referred them to an opioid-prescribing course. The course itself did not lead to significant additional reductions; however, a subgroup of physicians who prescribed high quantities of opioids might have responded to what was taught in the course.

Self-study of values, beliefs, and conflict of interest: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

STUDY DESIGN: Observation and survey of values, beliefs, and conflicts of interest. OBJECTIVE: To study the values, beliefs, and potential conflicts of interest that the Neck Pain Task Force brought to their deliberations. SUMMARY OF BACKGROUND DATA: Researchers' values and beliefs were studied to uncover areas of divergence and to develop guiding principles to assist decision making. METHODS: An observer used direct observation and survey of the Neck Pain Task Force, facilitated discussion, and developed a "disclosure tool" to collect information about relationships between researchers, funders, and others with a vested interest in the outcome. RESULTS: Clinicians and research methodologists brought different imperatives to the research process. Clinicians focused on offering useful advice, whereas methodologists guarded investigative rigor to ensure that evidence actually supported advice. Group conflict did not polarize along "clinical discipline lines." The Advisory Committee had greater impact when given a clear task and time to work as a group. The Neck Pain Task Force agreed on a set of "guiding principles," which became an overarching doctrine to guide their work. The disclosure questionnaires described relationships between Neck Pain Task Force members and other entities that might have had a financial interest in the topic. CONCLUSION: This study describes a process used to assess values, beliefs, and conflicts of interest among members of a scientific task force, and how this was used to create "guiding principles" to assist the research team in deliberations, particularly when conflict arose. Most members of the Neck Pain Task Force had potential conflicts of interest with various stakeholders, but there was marked diffusion of these potential conflicts and no evidence that any funder or other vested interest stakeholder was likely to have a significant impact on the deliberations or conclusions of the Neck Pain Task Force.

Redeveloping a workplace-based assessment program for physicians using Kane's validity framework.

This paper describes the use of Kane's validity framework to redevelop a workplace-based assessment program for practicing physicians administered by the College of Physicians and Surgeons of Ontario. The developmental process is presented according to the four inferences in Kane's model. Scoring was addressed through the creation of specialty-specific assessment criteria and global, narrative-focused reports. Generalization was addressed through standardized sampling protocols and assessor training and consensus-building. Extrapolation was addressed through the use of real-world performance data and an external review of the scoring tools by practicing physicians. Implications were theoretically supported through adherence to formative assessment principles and will be assessed through an evaluation accompanying the implementation of the redeveloped program. Kane's framework was valuable for guiding the redevelopment process and for systematically collecting validity evidence throughout to support the use of the assessment for its intended purpose. As the use of workplace-based assessment programs for physicians continues to increase, practical examples are needed of how to develop and evaluate these programs using established frameworks. The dissemination of comprehensive validity arguments is vital for sharing knowledge about the development and evaluation of WBA programs and for understanding the effects of these assessments on physician practice improvement.

Functional assessment of injured workers: a profile of assessor practices.

BACKGROUND: Considerable controversy and limited information surrounds the use of performance-based functional assessments for determining an injured worker's ability to function at work. PURPOSE: Amidst a variety of protocols, philosophies and tools, the key aspects of different assessment approaches are described and compared across a range of assessment provider organizations. METHOD: Qualitative and quantitative strategies were used to generate an in-depth understanding of the different assessment practices among 23 Southern Ontario assessment providers. RESULTS: Assessment approaches share common elements and variations that can be described along the continua of five dimensions: nature of assessor-evaluee interactions, fixed or flexible protocol delivery, efforts to contextualize, perceptions and use of evidence, and provider organizational environment. These approach dimensions are offered as a focus for appraising practices. PRACTICE IMPLICATIONS: Assessors need to reflect upon to what extent they are using a whole person, client-centred approach directed by clinical reasoning amidst a market driven industry.

Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review.

BACKGROUND: The purpose of this systematic review is to assess the effectiveness of brief interventions (BIs) as part of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances. METHODS: Bibliographic databases (including MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO to April 2012) and gray literature sources were searched. We included randomized controlled trials that opportunistically screened adolescents or adults and then provided a one-to-one, verbal BI to those at risk of substance-use harm. Of interest was the nonmedical use of psychoactive substances (for example, drugs prohibited by international law), excluding alcohol, nicotine, and caffeine. Interventions comprised four or fewer sessions and were compared with no/delayed intervention or provision of information only. Studies were assessed for bias using the Cochrane risk of bias tool. Results were synthesized narratively. Evidence was interpreted according to the GRADE framework. RESULTS: We identified 8,836 records. Of these, five studies met our inclusion criteria. Two studies compared BI with no BI, and three studies compared BI with information only. Studies varied in characteristics such as substances targeted, screening procedures, and BI administered. Outcomes were mostly reported by a single study, leading to limited or uncertain confidence in effect estimates. CONCLUSIONS: Insufficient evidence exists as to whether BIs, as part of SBIRT, are effective or ineffective for reducing the use of, or harms associated with nonmedical use of, psychoactive substances when these interventions are administered to nontreatment-seeking, screen-detected populations. Updating this review with emerging evidence will be important. TRIAL REGISTRATION: CRD42012002414.

The opioid manager: a point-of-care tool to facilitate the use of the Canadian Opioid Guideline.

The Opioid Manager is designed to be used as a point-of-care tool for providers prescribing opioids for chronic noncancer pain. It condenses the key elements from the Canadian Opioid Guideline and can be used as a chart insert. The Opioid Manager has been validated and is available for download from the Guideline's Web site http://nationalpaincentre.mcmaster.ca/opioidmanager/. The Opioid Manager is divided into the following four parts: A) before you write the first script, B) initiation trial, C) maintenance and monitoring, and D) when is it time to decrease the dose or stop the opioid completely? The Opioid Manager has been downloaded by 1,432 users: 47 percent family physicians, 18 percent pharmacists, 13 percent other physicians, and 22 percent miscellaneous. To show how to use the Opioid Manager, the authors created a 10-minute video that is available on the Internet. The Opioid Manager is being translated to French, Spanish, Portuguese, and Farsi.

Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the non-medical use of psychoactive substances: a systematic review protocol.

BACKGROUND: There is a significant public health burden associated with substance use in Canada. The early detection and/or treatment of risky substance use has the potential to dramatically improve outcomes for those who experience harms from the non-medical use of psychoactive substances, particularly adolescents whose brains are still undergoing development. The Screening, Brief Intervention, and Referral to Treatment model is a comprehensive, integrated approach for the delivery of early intervention and treatment services for individuals experiencing substance use-related harms, as well as those who are at risk of experiencing such harm. METHODS: This article describes the protocol for a systematic review of the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment model for reducing the non-medical use of psychoactive substances. Studies will be selected in which brief interventions target non-medical psychoactive substance use (excluding alcohol, nicotine, or caffeine) among those 12 years and older who are opportunistically screened and deemed at risk of harms related to psychoactive substance use. We will include one-on-one verbal interventions and exclude non-verbal brief interventions (for example, the provision of information such as a pamphlet or online interventions) and group interventions. Primary, secondary and adverse outcomes of interest are prespecified. Randomized controlled trials will be included; non-randomized controlled trials, controlled before-after studies and interrupted time series designs will be considered in the absence of randomized controlled trials. We will search several bibliographic databases (for example, MEDLINE, EMBASE, CINAHL, PsycINFO, CORK) and search sources for grey literature. We will meta-analyze studies where possible. We will conduct subgroup analyses, if possible, according to drug class and intervention setting. DISCUSSION: This review will provide evidence on the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment protocol aimed at the non-medical use of psychoactive substances and may provide guidance as to where future research might be most beneficial.

Self-study of values, beliefs, and conflict of interest: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

STUDY DESIGN: Observation and survey of values, beliefs, and conflicts of interest. OBJECTIVE: To study the values, beliefs, and potential conflicts of interest that the Neck Pain Task Force brought to their deliberations. SUMMARY OF BACKGROUND DATA: Researchers' values and beliefs were studied to uncover areas of divergence and to develop guiding principles to assist decision making. METHODS: An observer used direct observation and survey of the Neck Pain Task Force, facilitated discussion, and developed a "disclosure tool" to collect information about relationships between researchers, funders, and others with a vested interest in the outcome. RESULTS: Clinicians and research methodologists brought different imperatives to the research process. Clinicians focused on offering useful advice, whereas methodologists guarded investigative rigor to ensure that evidence actually supported advice. Group conflict did not polarize along "clinical discipline lines." The Advisory Committee had greater impact when given a clear task and time to work as a group. The Neck Pain Task Force agreed on a set of "guiding principles," which became an overarching doctrine to guide their work. The disclosure questionnaires described relationships between Neck Pain Task Force members and other entities that might have had a financial interest in the topic. CONCLUSION: This study describes a process used to assess values, beliefs, and conflicts of interest among members of a scientific task force, and how this was used to create "guiding principles" to assist the research team in deliberations, particularly when conflict arose. Most members of the Neck Pain Task Force had potential conflicts of interest with various stakeholders, but there was marked diffusion of these potential conflicts and no evidence that any funder or other vested interest stakeholder was likely to have a significant impact on the deliberations or conclusions of the Neck Pain Task Force.

Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care?

Description of a workshop entitled "Sharing Guidelines for Low Back Pain Between Primary Health Care Providers: Toward a Common Message in Primary Care" that was held at the Fifth International Forum on Low Back Pain in Primary Care in Canada in May 2002. Despite a considerable degree of acceptance of current evidence-based guidelines, in practice, primary health care providers still do not share a common message. The objective of the workshop was to describe the outcomes of a workshop on the sharing of guidelines in primary care. The Fifth International Forum on Low Back Pain Research in Primary Care focused on relations between stakeholders in the primary care management of back pain. Participants in this workshop contributed to an open discussion on "how and why" evidence-based guidelines about back pain do or do not work in practice. Ways to minimise the factors that inhibit implementation were discussed in the light of whether guidelines are mono-disciplinary or multidisciplinary. Examples of potential issues for debate were contained in introductory presentations. The prospects for improving implementation and reducing barriers, and the priorities for future research, were then considered by an international group of researchers. This paper summarises the conclusions of three researcher subgroups that focused on the sharing of guidelines under the headings of: (1) the content, (2) the development process, and (3) implementation. How to share the evidence and make it meaningful to practice stakeholders is the main challenge of guideline implementation. There is a need to consider the balance between the strength of evidence in multidisciplinary guidelines and the utility/feasibility of mono-disciplinary guidelines. The usefulness of both mono-disciplinary and multidisciplinary guidelines was agreed on. However, in order to achieve consistent messages, mono-disciplinary guidelines should have a multidisciplinary parent. In other words, guidelines should be developed and monitored by a multidisciplinary team, but may be transferred to practice by mono-disciplinary messengers. Despite general agreement that multi-faceted interventions are most effective for implementing guidelines, the feasibility of doing this in busy clinical settings is questioned. Research is needed from local implementation pilots and quality monitoring studies to understand how to develop and deliver the contextual understanding required. This relates to processes of care as well as outcomes, and to social factors and policymaking as well as health care interventions. We commend these considerations to all who are interested in the challenges of achieving better-integrated, evidence-based care for people with back pain.