"In my age, we didn't have the computers": Using a complexity lens to understand uptake of diabetes eHealth innovations into primary care-A qualitative study.

BACKGROUND: Shared decision-making is a central component of person-centred care and can be facilitated with the use of patient decision aids (PtDA). Barriers and facilitators to shared decision-making and PtDA use have been identified, yet integration of PtDAs into clinical care is limited. We sought to understand why, using the concepts of complexity science. METHODS: We conducted 60-minute in-depth interviews with patients with diabetes, primary care physicians, nurses and dietitians who had participated in a randomized controlled trial examining the impact of MyDiabetesPlan (an online goal-setting PtDA). Relying on a qualitative description approach, we used a semi-structured interview guide to explore participants' experiences with using MyDiabetesPlan and how it was integrated into the clinical encounter and clinical care. Audiotapes were transcribed verbatim, then coded independently by two analysts. FINDINGS: 17 interviews were conducted (5 physicians, 3 nurses, 2 dietitians, 7 patients). Two themes were developed: (1) MyDiabetesPlan appeared to empower patients by providing tailored patient-important information which engaged them in decision-making and self-care. Patients' use of MyDiabetesPlan was however impacted by their competing medical conditions, other life priorities and socioeconomic context. (2) MyDiabetesPlan emphasized to clinicians a patient-centred approach that helped patients assume greater ownership for their care. Clinicians' use of MyDiabetesPlan was impacted by pre-existing clinical tools/workplans, workflow, technical issues, clinic administrative logistics and support, and time. How clinicians adapted to these barriers influenced the degree to which MyDiabetesPlan was integrated into care. CONCLUSIONS: A complexity lens (that considers relationships between multiple components of a complex system) may yield additional insights to optimize integration of PtDA into clinical care. A complexity lens recognizes that shared decision-making does not occur in the vacuum of a clinical dyad (patient and clinician), and will enable us to develop a family of interventions that address the whole process, rather than individual components. TRIAL REGISTRATION: ClinicalTrials.gov NCT02379078.

Developing a National Competency-Based Diabetes Curriculum in Undergraduate Medical Education: A Delphi Study.

OBJECTIVES: In recent years there has been an increased emphasis on competency-based medical education (CBME) in Canada and internationally, as can be seen with the implementation of competency-based curriculums for postgraduate medical education (PGME) through the Royal College of Physicians and Surgeons of Canada. Currently, no Canada-wide consensus exists on educational competencies relating to diabetes in undergraduate medical education (UGME). Our aim in this study was to develop a list of competencies and objectives for UGME in diabetes using a modified Delphi method. METHODS: Representatives involved in the development of the diabetes curriculum at all 17 medical schools across Canada were contacted. A draft list of competencies and objectives was developed by the research team using the existing curriculums at 9 Canadian medical schools and was organized using the CanMEDS framework. A Delphi method was used, with 2 iterations in order to reach consensus. RESULTS: Twelve of 17 medical schools agreed to participate. Of the 12 surveys sent in the first round, 8 responses were received (response rate 66.7%). The revised version was then resent to the 8 respondents and 7 responses were received (response rate 87.5%). A list of 9 competencies and 62 objectives was finalized. CONCLUSIONS: A competency-based consensus curriculum for diabetes education for undergraduate medical students was developed using a modified Delphi method. The final consensus syllabus will be disseminated across the country. This curriculum serves as a step in the transition to competency-based UGME and in ensuring that future medical school graduates are proficient in diabetes care.

Factors potentially linked with the occurrence of antimicrobial resistance in selected bacteria from cattle, chickens and pigs: A scoping review of publications for use in modelling of antimicrobial resistance (IAM.AMR Project).

Antimicrobial resistance is a complex issue with a large volume of published literature, and there is a need for synthesis of primary studies for an integrated understanding of this topic. Our research team aimed to have a more complete understanding of antimicrobial resistance in Canada (IAM.AMR Project) using multiple methods including the literature reviews and quantitative modelling. To accomplish this goal, qualitative features of publications (e.g., geographical location, study population) describing potential relationships between the occurrence of antimicrobial resistance and factors (e.g., antimicrobial use; management system) were of particular interest. The objectives of this review were to (a) describe the available peer-reviewed literature reporting potential relationships between factors and antimicrobial resistance; and (b) to highlight data gaps. A comprehensive literature search and screening were performed to identify studies investigating factors potentially linked with antimicrobial resistance in Campylobacter species, Escherichia coli and Salmonella enterica along the farm-to-fork pathway (farm, abattoir (slaughter houses) and retail meats) for the major Canadian livestock species (beef cattle, broiler chicken and pigs). The literature search returned 14,966 potentially relevant titles and abstracts. Following screening of titles, abstracts and full-text articles, the qualitative features of retained studies (n = 28) were extracted. The most common factors identified were antimicrobial use (n = 13 studies) and type of farm management system (e.g., antibiotic-free, organic; n = 8). Most studies were conducted outside of Canada and involved investigations at the farm level. Identified data gaps included the effect of vaccination, industry-specific factors (e.g., livestock density) and factors at sites other than farm along the agri-food chain. Further investigation of these factors and other relevant industry activities are needed for the development of quantitative models that aim to identify effective interventions to mitigate the occurrence of antimicrobial resistance along the agri-food chain.