Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial.

BACKGROUND: Experts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs). OBJECTIVE: To develop, adapt and validate DECISION+ and estimate its impact on the decision of family physicians (FPs) and their patients on whether to use antibiotics for ARIs. DESIGN: Two-arm parallel clustered pilot randomized controlled trial. SETTING AND PARTICIPANTS: Four family medicine groups were randomized to immediate DECISION+ participation (the experimental group) or delayed DECISION+ participation (the control group). Thirty-three FPs and 459 patients participated. INTERVENTION: DECISION+ is a multiple-component, continuing professional development program in shared decision making that addresses the use of antibiotics for ARIs. MAIN OUTCOME MEASURES: Throughout the pilot trial, DECISION+ was adapted in response to participant feedback. After the consultation, patients and FPs independently self-reported the decision (immediate use, delayed use, or no use of antibiotics) and its quality. Agreement between their decisional conflict was assessed. Two weeks later, patients assessed their decisional regret and health status. RESULTS: Compared to the control group, the experimental group reduced its immediate use of antibiotics (49 vs. 33% absolute difference = 16%; P = 0.08). Decisional conflict agreement was stronger in the experimental group (absolute difference of Pearson's r = 0.26; P = 0.06). Decisional regret and perceptions of the quality of the decision and of health status in the two groups were similar. DISCUSSION AND CONCLUSIONS: DECISION+ was developed successfully and appears to reduce the use of antibiotics for ARIs without affecting patients' outcomes. A larger trial is needed to confirm this observation.

Learning and caring in communities of practice: using relationships and collective learning to improve primary care for patients with multimorbidity.

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Home environmental factors associated with poor asthma control in Montreal children: a population-based study.

BACKGROUND: Home environmental exposures may aggravate asthma. Few population-based studies have investigated the relationship between asthma control in children and home environmental exposures. OBJECTIVE: Identify home environmental exposures associated with poor control of asthma among asthmatic children less than 12 years of age in Montreal (Quebec, Canada). METHODS: This cross-sectional population-based study used data from a respiratory health survey of Montreal children aged 6 months to 12 years conducted in 2006 (n = 7980). Asthma control was assessed (n = 980) using an adaptation of the Canadian asthma consensus report clinical parameters. Using log-binomial regression models, prevalence ratios (PRs) with 95% confidence intervals (95% CIs) were estimated to explore the relationship between inadequate control of asthma and environmental home exposures, including allergens, irritants, mold, and dampness indicators. Subjects with acceptable asthma control were compared with those with inadequate disease control. RESULTS: Of 980 children with active asthma in the year prior to the survey, 36% met at least one of the five criteria as to poor control of their disease. The population's characteristics found to be related with a lack of asthma control were younger age, history of parental atopy, low maternal education level, foreign-born mothers, and tenant occupancy. After adjustments, children living along high-traffic density streets (PR, 1.35; 95% CI, 1.00-1.81) and those with their bedroom or residence at the basement level (PR, 1.30; 95% CI, 1.01-1.66) were found to be at increased risk of poor asthma control. CONCLUSIONS: Suboptimal asthma control appears to be mostly associated with traffic, along with mold and moisture conditions, the latter being a more frequent exposure and therefore having a greater public health impact.

Interprofessional learning in the trenches: fostering collective capability.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value--caring for patients--to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study.

OBJECTIVES: To assess the prevalence of neurologic and neuropsychological symptoms in the short-term and 1 year after an electric shock and to explore whether any of these were associated with risk factors. METHODS: Patients presenting to one of 21 EDs between October 2000 and November 2004 were eligible to be enrolled in a prospective observational study after an electric shock if they had risk factors for late arrhythmias. Telephone follow-up was done to evaluate the appearance of symptoms. RESULTS: A total of 30 (26%) of 114 patients complained of neurologic or neuropsychological symptoms at a median of 52 days post-electric shock. At 1 year, 24 (28%) of 86 patients complained of neurologic or neuropsychological symptoms. None of the risk factors evaluated were associated with the symptoms. CONCLUSION: The prevalence of the symptoms we observed should alarm all emergency physicians that the effect of electricity can cause late neurologic and neuropsychological manifestations.

Does training family physicians in shared decision making promote optimal use of antibiotics for acute respiratory infections? Study protocol of a pilot clustered randomised controlled trial.

BACKGROUND: In North America, although it varies according to the specific type of acute respiratory infections (ARI), use of antibiotics is estimated to be well above the expected prevalence of bacterial infections. The objective of this pilot clustered randomized controlled trial (RCT) is to assess the feasibility of a larger clustered RCT aiming at evaluating the impact of DECISION+, a continuing professional development (CPD) program in shared decision making, on the optimal use of antibiotics in the context of ARI. METHODS/DESIGN: This pilot study is a cluster RCT conducted with family physicians from Family Medicine Groups (FMG) in the Quebec City area, Canada. Participating FMG are randomised to an immediate DECISION+ group, a CPD program in shared decision making, (experimental group), or a delayed DECISION+ group (control group). Data collection involves recruiting five patients consulting for ARI per physician from both study groups before (Phase 1) and after (Phase 2) exposure of the experimental group to the DECISION+ program, and after exposure of the control group to the DECISION+ program (Phase 3). The primary outcome measures to assess the feasibility of a larger RCT include: 1) proportion of contacted FMG that agree to participate; 2) proportion of recruited physicians who participate in the DECISION+ program; 3) level of satisfaction of physicians regarding DECISION+; and 4) proportion of missing data in each data collection phase. Levels of agreement of the patient-physician dyad on the Decisional Conflict Scale and physicians' prescription profile for ARI are performed as secondary outcome measures. DISCUSSION: This study protocol is informative for researchers and clinicians interested in designing and/or conducting clustered RCT with FMG regarding training of physicians in shared decision making. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00354315.

Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study.

OBJECTIVE: To report our experience monitoring patients with previously identified theoretical risk factors of significant electrical injury. METHODS: Patients who presented to one of 21 emergency departments between October 2000 and November 2004 were eligible to be enrolled in a prospective observational cohort study if after an electric shock they had one of several risk factors (transthoracic current, tetany, loss of consciousness or voltage source > or =1000 V) and therefore needed cardiac monitoring. RESULTS: Of the 134 patients enrolled, most were monitored because of transthoracic current (n = 60), transthoracic current and tetany (n = 39), tetany (n = 10), or voltage > or =1000 V (n = 10). There were 15/134 (11%) patients with abnormal initial ECGs. No patient developed potentially lethal late arrhythmia during the 24 hours of cardiac monitoring. CONCLUSION: Although only patients deemed at risk of late arrhythmias were monitored, none developed potentially lethal late arrhythmias. Asymptomatic patients with transthoracic current and/or tetany and a normal initial ECG do not require cardiac monitoring after an electrical injury with voltage <1000 V and no loss of consciousness.

Canadian Pediatric Asthma Consensus guidelines, 2003 (updated to December 2004): introduction.

BACKGROUND: Although guidelines for the diagnosis and management of asthma have been published over the last 15 years, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian asthma consensus report, important new studies, particularly in children, have highlighted the need to incorporate this new information into asthma guidelines. OBJECTIVES: To review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the Canadian Asthma Consensus Report, 1999 and its 2001 update with a major focus on pediatric issues. METHODS: Diagnosis of asthma in young children, prevention strategies, pharmacotherapy, inhalation devices, immunotherapy and asthma education were selected for review by small expert resource groups. In June 2003, the reviews were discussed at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published up to December 2004 were subsequently reviewed by the individual expert resource groups. RESULTS: This report evaluates early life prevention strategies and focuses on treatment of asthma in children. Emphasis is placed on the importance of an early diagnosis and prevention therapy, the benefits of additional therapy and the essential role of asthma education. CONCLUSION: We generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This guide for asthma management is based on the best available published data and the opinion of health care professionals including asthma experts and educators.

Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents.

BACKGROUND: Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents' proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone. METHODS: Junior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions. RESULTS: After the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher's exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher's exact test p = 0.0055). CONCLUSIONS: Our study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Knowledge translation: the role and place of practice reflection.

Reflection is the mechanism by which we contemplate and try to understand relatively complex and sometimes troubling ideas for which there is no obvious solution. Reflection allows us to transform current ideas and experiences into new knowledge and action. Personal experiences and organizational feedback can trigger reflection, whereas a lack of time, available colleagues, and social networks detract from the ability professionals have to reflect. Educational programs can encourage reflection through the judicious use of case-based discussion, formal and informal needs assessments, and commitment to change exercises. Learning journals and personal learning projects are self-directed methods that facilitate reflection. In the workplace, critical incident techniques and debriefing of cases provide opportunities for thoughtful inquiry. Additional study is needed to understand how and why reflection works to transform surface learning into deep learning and change in practice; how reflection enhances the integration of reading, collegial interchange, and classroom discussion into practice; and how technology can enhance reflection.

Integrating clinical practice guidelines into daily practice: impact of an interactive workshop on drafting of a written action plan for asthma patients.

INTRODUCTION: Written action plans (WAPs) are instructions that enable asthmatics to manage their condition appropriately and are recommended by current asthma clinical practice guidelines (CPGs). However, general practitioners (GPs) rarely draft WAPs for their patients. An interactive, case-based workshop for asthma, combined with an objective structured clinical examination (OSCE), was developed to increase GPs' knowledge and use of WAPs in Québec. METHODS: The study compared 24 GPs receiving an OSCE preworkshop and 12 months post-workshop (group 1) with 16 GPs receiving an OSCE preworkshop and at 6 and 12 months post-workshop (group 2). Participants received no feedback on their OSCE performance. During the workshop, which presented a preformatted tool to aid drafting of the WAPs, all 40 GPs worked individually and in small groups to answer questions on a hypothetical clinical case and then discussed the responses with a facilitator and an asthma specialist. RESULTS: Only group 2 GPs showed a significant improvement in knowledge of WAPs 12 months post-workshop (p = .01). The likelihood of prescribing WAPs to patients increased in group 2 to a degree approaching statistical significance (p = .070), and there was a borderline nonsignificant trend for prescribing practice to improve more among group 2 GPs than among group 1 GPs (p = .052). There was also a nonsignificant trend for 6-month OSCE to increase attendance at the 12-month OSCE. DISCUSSION: An interactive workshop employing a preformatted WAP tool and a reinforcing OSCE at 6 months yielded improved knowledge of WAPs at 1 year. Although originally developed as a form of evaluation, the OSCE appears to have formative value even when correction is not provided and may increase the effectiveness of continuing medical education interventions to enhance CPG implementation.

Technology-enabled knowledge translation: frameworks to promote research and practice.

Knowledge translation articulates how new scientific insights can be implemented efficiently into clinical practice to reap maximal health benefits. Modern information and communication technologies can be effective tools to help in the collection, processing, and targeted distribution of information from which clinicians, researchers, administrators, policy makers in health, and the public can benefit. Effective implementation of knowledge translation through the use of information and communication technologies, or technology-enabled knowledge translation (TEKT), would benefit both the individual health professional and the health system. Successful TEKT in health requires cultivation and acceptance in the following key domains: Perceiving types of knowledge and ways in which clinicians acquire and apply knowledge in practice. Understanding the conceptual and contextual frameworks of information and communication technologies applied to health systems, particularly the push, pull, and exchange communication models. Comprehending essential issues in implementation of information and communication technologies and strategies to take advantage of emerging opportunities and overcome existing barriers. Establishing a common and widely acceptable evaluation framework in order that researchers can compare various methodologies in their rightful contexts in TEKT research and adoption. Achieving harmony and common understanding in these areas will go a long way in fostering a fertile and innovative environment to encourage research and advance understanding in this exciting domain of TEKT.

Using speed dating sessions to foster collaboration in continuing interdisciplinary education.

INTRODUCTION: There are numerous examples of care gaps that could be reduced through enhanced knowledge exchange and practice collaboration between medical specialist physicians. In this paper, we report preliminary results on using speed-dating sessions (SDSs) to stimulate the development of continuing interdisciplinary education (CIDE) activities. METHODS: In 2007, a 35-minute SDS was carried out during a 2-hour faculty development workshop to provide continuing medical education (CME) directors of Quebec's 35 medical specialist associations with a formal opportunity to quickly share clinical issues and goals. A post-workshop survey was used to assess participants' satisfaction and whether they had met new colleagues, learned about interdisciplinary issues, and discovered opportunities for collaboration. CME accreditation files were audited to assess the occurrence of CIDE activities in the year prior and the 2 years that followed the workshop. CME directors were called to assess whether the development of these activities was directly attributable to their participation in the SDS. RESULTS: CME directors of 26 specialist physician associations attended the faculty development workshop. The vast majority of survey respondents (n = 18/20) were satisfied with the SDS and believed that this method was a stimulating and efficient way to meet new colleagues, quickly share clinical issues and goals, learn about unexpected but important interdisciplinary issues, and identify opportunities for CIDE collaboration. Sixty percent (12/20) reported having identified at least 1 opportunity for collaboration that was worth pursuing in the near future, and 19% of attending CME directors (5/26) developed a CIDE activity within 2 years, as compared with none in the previous year and for the 9 nonparticipating associations. DISCUSSION: Results suggest that SDSs enhanced networking, knowledge exchange, and collaboration in continuing education among CME providers who participated in a faculty development activity on CIDE.

Development of PRIDe: a tool to assess physicians' preference of role in clinical decision making.

OBJECTIVE: To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM). METHODS: This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up. RESULTS: Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02). CONCLUSION: This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis. PRACTICE IMPLICATIONS: The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.

Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial.

BACKGROUND: The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care. METHODS: A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program. RESULTS: Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%. CONCLUSIONS: This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making. TRIAL REGISTRATION: Clinicaltrials.Gov NCT00354315.

Improved cardiovascular prevention using best CME practices: a randomized trial.

INTRODUCTION: It was hypothesized that after a continuing medical education (CME) event, practice enablers and reinforcers addressing main clinical barriers to preventive care would be more effective in improving general practitioners' (GPs) adherence to cardiovascular guidelines than a CME event only. METHODS: A cluster-randomized trial was conducted on a convenience sample of 122 GPs who were randomly assigned to either CME only (control group) or CME with practice enablers and reinforcers (PER group). In the PER group, nurses visited GPs' offices once a month to implement the clinical intervention on patients > or = 55 years old with a scheduled visit in the month following the nurse visit: (1) screening medical records for potentially undermanaged high-risk patients; (2) prompting physicians to reassess preventive care in these patients; (3) enclosing a checklist reporting most recent information relevant to guidelines' implementation; and (4) enclosing a summary of experts' recommendations in the form of a follow-up and treatment algorithm. RESULTS: A retrospective chart audit of 2344 consenting patients, potentially undermanaged at baseline, demonstrated that the PER intervention following CME significantly improved adherence to guidelines compared to CME alone (OR: 1.78, 95% CI: 1.32-2.41). DISCUSSION: The intervention was designed for self-implementation in primary care practices that have their own nursing staff. PER GPs were highly satisfied with the intervention; the majority said that they would implement it in their practice if someone trained their nurse, thus suggesting support for development of a multiprofessional CME program to disseminate this clinical approach to primary care practice groups.

Physicians' assessment of asthma control in low vs. high asthma-related morbidity regions.

OBJECTIVES: To analyze physician-assessed asthma control and care compared with current guidelines criteria, in a cohort of patients from a high (HMR) vs. low asthma-related morbidity region (LMR), as determined by a large-scale populational survey (asthma cartography). DESIGN: Analysis of questionnaires provided by 47 primary care physicians and asthmatic patients (HMR: 74; LMR: 73). RESULTS: Asthma control was often suboptimal in both regions. In both regions, asthma control, the pattern of prescriptions for asthma, patient compliance, and referral for asthma education were similar; 32% of patients had been referred for asthma education, whereas 65% wanted to know more about their asthma. CONCLUSIONS: Results of regional/local cohort studies differ from those of a "population cartography," the former probably more likely reflecting individual medical practices of physicians interested in taking part in such studies.

An integrated approach to improving appropriate use of anti-inflammatory medication in the treatment of osteoarthritis in Québec (Canada): the CURATA model.

CURATA is a multifaceted continuing medical education (CME) intervention, developed with input from 12 healthcare organizations to address the gap between current and recommended osteoarthritis (OA) treatment of general practitioners in Québec, Canada. Focusing on appropriate prescription of non-steroidal anti-inflammatory drugs, including cyclooxygenase-2 selective inhibitors (coxibs), the intervention comprised small-group, case-based workshops modelled after the Script Concordance test, and a decision tool reflecting current evidence-based clinical practice guidelines. A self-reported questionnaire measured knowledge of recommended OA treatment on an eight-point scale. Participants (n = 381) showed a mean 10.1% improvement in questionnaire score immediately following the workshop (15.2% improvement relative to mean pre-workshop score). Knowledge was maintained for three months post-workshop.