Device-specific quality of life: Results from the ATLAS trial-Avoid Transvenous Leads in Appropriate Subjects.

AIM: Patient reported outcomes (PROs) provide important insights into patients' acceptance of their medical devices. ATLAS, a randomized, multi-center, open-label clinical trial, recently reported fewer perioperative complications in S-ICD compared to TV-ICD patients. This study reports PROs, including device-specific and generic quality of life (QOL) from the ATLAS trial. METHODS AND RESULTS: Device-specific QOL was the primary PRO using the Florida Patient Acceptance Survey (FPAS) at 1-and 6-months post-implantation. Secondary outcomes included generic QOL using the Medical Outcomes Survey (SF-36) pre-implant and 6-months post-implantation. FPAS and SF-36 were analyzed using ANCOVA. Pain measured using a Numeric Rating Scale, at 1-and 6-months, anesthetic, BMI and within/between differences were analyzed using descriptive statistics and mixed-effects linear models (MLM). Of the 503 patients randomized in ATLAS, 404 had complete FPAS data to include in this analysis. Participant characteristics were balanced. There were no significant differences between S-ICD and TV-ICD for FPAS or SF-36, across timepoints. Mean total FPAS scores increased from 73.73 (16.09) to 77.05 (16.13) and 74.43 (15.35) to 78.25 (15.88) for S-ICD and TV-ICD, respectively, (p <0.001). PROs suggested that both devices were associated with good QOL. CONCLUSION: Device-specific and generic QOL were similar between S-ICD and TV-ICD groups up to 6-months post-implantation indicating that regardless of device type, both groups reported good device specific QOL in ATLAS patients. S-ICD patients reported higher pain scores at implant, but pain decreased by 6 months. The findings offer evidence that can be included during shared decision-making. The inclusion of patient partners in ATLAS provided opportunity to measure PROs that were deemed important to patients.

Perceived value and benefits of the Community Paramedicine at Clinic (CP@clinic) programme: a descriptive qualitative study.

OBJECTIVES: Community Paramedicine (CP) is increasingly being used to provide chronic disease management for vulnerable populations in the community. CP@clinic took place in social housing buildings to support cardiovascular health and diabetes management for older adults. The purpose of this study was to examine participant perceptions of their experience with CP@clinic as well as potential ongoing programme benefits. DESIGN: This descriptive qualitative study used focus groups to understand resident experiences of the CP@clinic programme. Groups were facilitated by experienced moderators using a semistructured guide. An inductive coding approach was used with at least two researchers taking part in each step of the analysis process. SETTING: Community-based social housing buildings in Ontario, Canada. PARTICIPANTS: Forty-one participants from four CP@clinic sites took part in a focus group. Convenience sampling was used with anyone having taken part in a CP@clinic session being eligible to attend the focus group. RESULTS: Analysis yielded six themes across two broad areas: timely access to health information and services, support to achieve personal health goals, better understanding of healthcare system (Personal Benefits); and sense of community, comfortable and familiar place to talk about health, facilitated communication between healthcare professionals (Programme Structure). Participants experienced discernible health changes that motivated their participation. CP@clinic was viewed as a programme that created connections within the building and outside of it. Participants were enthusiastic for the continuation of the programme and appreciated the consistent support to meet their health goals. CONCLUSIONS: CP@clinic was successful in creating a supportive and friendly environment to facilitate health behavioural changes. Ongoing implementation of CP@clinic would allow residents to continue to build their chronic disease management knowledge and skills. TRIAL REGISTRATION NUMBER: Trial registration number: NCT02152891, Clinicaltrials.gov.

Adult newcomers' perceptions of access to care and differences in health systems after relocation from Syria.

BACKGROUND: In Canada, approximately 13% of the population lives with multiple chronic conditions. Newcomers, including refugees, have the same or higher risk of developing chronic diseases as their host population. In 2015-2016, Canada welcomed almost 40, 000 newcomers from Syria. This study aimed to (1) understand adult newcomer health needs for self-management of non-infectious chronic conditions; and (2) identify strategies to improve access to health care services to meet these needs. METHODS: This study used a qualitative descriptive design. Interviews and focus groups were conducted with consenting newcomers, service providers and community agency administrators. Interview guides were developed with input from community partners and snowball sampling was used. RESULTS: Participants included 22 Syrian newcomers and 8 service providers/administrators. Findings revealed the initial year of arrival as one of multiple adjustments, often rendering chronic disease management to a lower priority. Self-care and self-management were not routinely incorporated into newcomer lives though community health agencies were proactive in creating opportunities to learn self-management practices. Gaps in access to care were prevalent, including mental health services which typically were not well developed for trauma and post-traumatic stress disorder (PTSD), particularly for men. Newcomers expressed frustration with lengthy wait times and not being able to access specialists directly. Youth frequently played a key role in translation and disseminating information about services to their families. CONCLUSION: Chronic disease management was a low priority for newcomers who were focussed on resettlement issues such as learning English or finding work. Provision of practical supports such as bus tickets, translation, and information about the healthcare system were identified as means of improving access to care.

Validity of the Early Years Check-In (EYCI) in a Cross-Sectional Sample of Families.

Background: The objective of the present study was to develop and test the validity of the Early Years Check-In (EYCI), a new tool that measures parent and educator concerns regarding children's development. The study examined the EYCI's agreement with 3rd edition of the Bayley Scales of Infant and Toddler Development (BSID-III) an established measure of child development. Two possible thresholds were explored: one to identify children with a probable delay, and another to identify children at the borderline functioning threshold. Methods: Parents of children aged 18 to 42 months were recruited from childcare settings across Ontario, Canada. The study proceeded in two phases. Phase I, intended to pilot the measure, included 49 children. Phase II, a test of the validity of the final version, included 199 children. Parents and educators completed the EYCI for the child, while a blinded assessor completed the BSID-III. Results: The EYCI demonstrated good sensitivity and specificity (86 and 82%, respectively) as a parent-completed tool that identifies children with a probable delay. However, the positive predictive value (15%) suggests the EYCI is likely to over identify children. When identifying children who demonstrated borderline delay, the EYCI demonstrated good sensitivity (80%) but poor specificity (49%). Results from educator-completed EYCIs were poor for both probable and borderline delay. Conclusions: While further research is required, the EYCI shows promise as a parent-completed tool, particularly to identify more-severe cases of delay. Results with educators were poor overall. Future research investigating accuracy of educators in different types of early childcare centres is needed.

Preparing for patient partnership: A scoping review of patient partner engagement and evaluation in research.

BACKGROUND: Realizing patient partnership in research requires a shift from patient participation in ancillary roles to engagement as contributing members of research teams. While engaging patient partners is often discussed, impact is rarely measured. OBJECTIVE: Our primary aim was to conduct a scoping review of the impact of patient partnership on research outcomes. The secondary aim was to describe barriers and facilitators to realizing effective partnerships. SEARCH STRATEGY: A comprehensive bibliographic search was undertaken in EBSCO CINAHL, and Embase, MEDLINE and PsycINFO via Ovid. Reference lists of included articles were hand-searched. INCLUSION CRITERIA: Included studies were: (a) related to health care; (b) involved patients or proxies in the research process; and (c) reported results related to impact/evaluation of patient partnership on research outcomes. DATA EXTRACTION AND SYNTHESIS: Data were extracted from 14 studies meeting inclusion criteria using a narrative synthesis approach. MAIN RESULTS: Patient partners were involved in a range of research activities. Results highlight critical barriers and facilitators for researchers seeking to undertake patient partnerships to be aware of, such as power imbalances between patient partners and researchers, as well as valuing of patient partner roles. DISCUSSION: Addressing power dynamics in patient partner-researcher relationships and mitigating risks to patient partners through inclusive recruitment and training strategies may contribute towards effective engagement. Further guidance is needed to address evaluation strategies for patient partnerships across the continuum of patient partner involvement in research. CONCLUSIONS: Research teams can employ preparation strategies outlined in this review to support patient partnerships in their work.

Design Process and Utilization of a Novel Clinical Decision Support System for Neuropathic Pain in Primary Care: Mixed Methods Observational Study.

BACKGROUND: Computerized clinical decision support systems (CDSSs) have emerged as an approach to improve compliance of clinicians with clinical practice guidelines (CPGs). Research utilizing CDSS has primarily been conducted in clinical contexts with clear diagnostic criteria such as diabetes and cardiovascular diseases. In contrast, research on CDSS for pain management and more specifically neuropathic pain has been limited. A CDSS for neuropathic pain has the potential to enhance patient care as the challenge of diagnosing and treating neuropathic pain often leads to tension in clinician-patient relationships. OBJECTIVE: The aim of this study was to design and evaluate a CDSS aimed at improving the adherence of interprofessional primary care clinicians to CPG for managing neuropathic pain. METHODS: Recommendations from the Canadian CPGs informed the decision pathways. The development of the CDSS format and function involved participation of multiple stakeholders and end users in needs assessment and usability testing. Clinicians, including family medicine physicians, residents, and nurse practitioners, in three academic teaching clinics were trained in the use of the CDSS. Evaluation over one year included the measurement of utilization of the CDSS; change in reported awareness, agreement, and adoption of CPG recommendations; and change in the observed adherence to CPG recommendations. RESULTS: The usability testing of the CDSS was highly successful in the prototype environment. Deployment in the clinical setting was partially complete by the time of the study, with some limitations in the planned functionality. The study population had a high level of awareness, agreement, and adoption of guideline recommendations before implementation of CDSS. Nevertheless, there was a small and statistically significant improvement in the mean awareness and adoption scores over the year of observation (P=.01 for mean awareness scores at 6 and 12 months compared with baseline, for mean adoption scores at 6 months compared with baseline, and for mean adoption scores at 12 months). Documenting significant findings related to diagnosis of neuropathic pain increased significantly. Clinicians accessed CPG information more frequently than they utilized data entry functions. Nurse practitioners and first year family medicine trainees had higher utilization than physicians. CONCLUSIONS: We observed a small increase in the adherence to CPG recommendations for managing neuropathic pain. Clinicians utilized the CDSS more as a source of knowledge and as a training tool than as an ongoing dynamic decision support.

Health TAPESTRY: co-designing interprofessional primary care programs for older adults using the persona-scenario method.

BACKGROUND: Working with patients and health care providers to co-design health interventions is gaining global prominence. While co-design of interventions is important for all patients, it is particularly important for older adults who often experience multiple and complex chronic conditions. Persona-scenarios have been used by designers of technology applications. The purpose of this paper is to explore how a modified approach to the persona-scenario method was used to co-design a complex primary health care intervention (Health TAPESTRY) by and for older adults and providers and the value added of this approach. METHODS: The persona-scenario method involved patient and clinician participants from two academically-linked primary care practices. Local prospective volunteers and community service providers (e.g., home care services, support services) were also recruited. Persona-scenario workshops were facilitated by researchers experienced in qualitative methods. Working mostly in homogenous pairs, participants created a fictitious but authentic persona that represented people like themselves. Core components of the Health TAPESTRY intervention were described. Then, participants created a story (scenario) involving their persona and an aspect of the proposed Health TAPESTRY program (e.g., volunteer roles). Two stages of analysis involved descriptive identification of themes, followed by an interpretive phase to extract possible actions and products related to ideas in each theme. RESULTS: Fourteen persona-scenario workshops were held involving patients (n = 15), healthcare providers/community care providers (n = 29), community service providers (n = 12), and volunteers (n = 14). Fifty themes emerged under four Health TAPESTRY components and a fifth category - patient. Eight cross cutting themes highlighted areas integral to the intervention. In total, 414 actions were identified and 406 products were extracted under the themes, of which 44.8% of the products (n = 182) were novel. The remaining 224 had been considered by the research team. CONCLUSIONS: The persona-scenario method drew out feasible novel ideas from stakeholders, which expanded on the research team's original ideas and highlighted interactions among components and stakeholder groups. Many ideas were integrated into the Health TAPESTRY program's design and implementation. Persona-scenario method added significant value worthy of the added time it required. This method presents a promising alternative to active engagement of multiple stakeholders in the co-design of complex interventions.

Nursing perspectives on the confusion assessment method: a qualitative focus group study.

Background: the Confusion Assessment Method (CAM) is commonly used to detect delirium. Although accurate when administered by trained researchers, its sensitivity is low when performed by nurses in clinical practice. We aimed to understand the perspectives of nurses who used the CAM on orthopaedic wards. Design: qualitative focus group study. Setting: two academic hospitals in Hamilton, Ontario, Canada. Participants: forty-three nurses who worked on orthopaedic inpatient units and used the CAM daily participated in one of eight focus group sessions. Measurements: structured focus groups explored nurses' perception of delirium and the use of the CAM. Each transcript was coded and sampling continued until theme saturation. Results: the participants (84% female, mean age 40 years, mean years in practice 12.8) had mixed feelings about the CAM. Some nurses praised its simplicity, while others preferred a narrative description of the delirium episode. Only 35% recalled receiving training to administer the CAM. Across the groups, disorientation was inappropriately used to evaluate level of consciousness and inattention. Objective testing was reportedly rarely used for assessing inattention. Most nurses retrospectively completed the CAM at the end of their shift by extrapolating from earlier observations rather than formally administering the tool. Reported challenges included differentiating delirium from dementia, assessing non-verbal patients and those with language barriers, time constraints, discrepancy with physicians' assessments and pressure to diagnose delirium. Conclusion: despite its widespread use, the CAM was poorly understood by orthopaedic nurses at two academic institutions. The CAM may be difficult to implement in practice.

A Clinical Decision Support System for Chronic Pain Management in Primary Care: Usability testing and its relevance.

BACKGROUND: Clinical decision support systems (CDSSs) that are integrated into electronic medical records may be useful for encouraging practice change compliant with clinical practice guidelines. OBJECTIVE: To engage end users to inform early phase CDSS development through a process of usability testing. METHODS: A sequential exploratory mixed method approach was used. Interprofessional clinician participants (seven in iteration 1 and six in iteration 2) were asked to 'think aloud' while performing various tasks on the CDSS and then complete the System Usability Scale (SUS). Changes were made to the CDSS after each iteration.Results Barriers and facilitators were identified: systemic; user interface (most numerous barriers); content (most numerous facilitators) and technical. The mean SUS score was 81.1 (SD = 12.02) in iteration 1 and 70.40 (SD = 6.78) in iteration 2 (p > 0.05). CONCLUSIONS: Qualitative data from usability testing were valuable in the CDSS development process. SUS scores were of limited value at this development stage.

Minding the gap: Prioritization of care issues among nurse practitioners, family physicians and geriatricians when caring for the elderly.

Accumulating health problems of the elderly requires recognition of geriatric syndromes, while shifting away from a conventional disease-specific approach. We surveyed 179 practitioners representing Family Physicians (FPs), Nurse Practitioners (NPs) and geriatricians in Ontario, in order to quantify how they prioritize syndromes, diseases and conditions in the elderly. Identifying differences may inform opportunities for interprofessional sharing of expertise among professionals pursuing a common goal, which is expected to improve interprofessional collaboration. Our survey (response rate 36%) identifies that NP, FP and geriatrician respondents all recognize co-occurrence of "multiple morbidities" as one of the most frequently encountered issues when serving the elderly, however FPs and NPs place higher priority on managing individual chronic diseases than explicitly prioritizing geriatric syndromes. Our findings identify a need for a more clearly defined role for the geriatrician as syndrome-educator and implies further need for collaborative approaches to caring for seniors that values different professional's expertise.

Refinement of indicators and criteria in a quality tool for assessing quality in primary care in Canada: a Delphi panel study.

PURPOSE: Primary care is the cornerstone of the health care system and increasingly countries are developing indicators for assessing quality in primary care practices. The 'Quality Tool', developed in Ontario, Canada, provides a framework for assessing practices and consists of indicators and criteria. The purpose of this study was to validate the indicators and simplify the Quality Tool. METHODS: This study involved a systematic comparison of indicators in the Quality Tool with those in other local and international tools to determine common indicators to include as valid in the Quality Tool. A Delphi process was used to help reach consensus for inclusion of any indicators that were not included in the comparison exercise. SETTING: Primary care in Ontario, Canada. SUBJECTS: Key informants were those with known expertise and experience in quality assessment in primary care. MAIN OUTCOME: Validated set of indicators for inclusion in an updated Quality Tool. RESULTS: Twenty-three stakeholders participated in the Delphi panel. Forty-four indicators were included as valid after the systematic comparison of similar indicators in other assessment tools. Of the 63 indicators brought to the Delphi panel, 37 were included as valid, 15 were excluded and 11 became criteria for other included indicators. CONCLUSIONS: The study resulted in a set of 81 validated primary care indicators. The validation of the indicators provided a strong foundation for the next version of the Quality Tool and may be used for quality assessment in primary care.

Developing an institute of medicine-aligned framework for categorizing primary care indicators for quality assessment.

The Institute of Medicine (IOM) framework has been used frequently to assess and monitor quality in secondary and tertiary care, but not in primary care. This article describes and proposes a conceptual framework for categorizing primary care indicators that align with the IOM's six aims for quality in healthcare performance (Safe, Effective, Patient-Centred, Timely, Efficient and Equitable.) Using an iterative process, the authors developed and compared a primary care framework for categorizing indicators in the Quality in Family Practice Book of Tools (QBT) with the IOM aims and other local healthcare systems frameworks (Integrated and Continuous, Appropriate Practice Resources). They also compared, cross-matched and analyzed their QBT categories and indicators with other international primary care assessment tools. And they compared the QBT titles and descriptions of groups of indicators with those published in the international tools.

Interprofessional and integrated care of the elderly in a family health team.

PROBLEM ADDRESSED: Family physicians provide most of the care for the frail elderly population, but many challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services. OBJECTIVE OF PROGRAM: To improve the quality, efficiency, and coordination of care for the frail elderly living in the community and to enhance geriatric and interprofessional skills for providers and learners. PROGRAM DESCRIPTION: The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The feasibility of the program was evaluated through a pilot study conducted between November 2008 and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary aspects of care. The nurse practitioner's role was prominent in the program, while the geriatrician's clinical role was focused efficiently. CONCLUSION: The family health team is ideally positioned to deliver shared care for the frail elderly. Our model allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.

Impact of clinician judgement on formulary committees' recommendations in Canada.

OBJECTIVES: In formulary committee deliberations, evidence for the efficacy of medications is often based on changes in the scale scores of patient-reported outcome measures. Our aim was to examine whether clinician judgement about the efficacy of medications for Alzheimer's disease, when added to scale score evidence, affects formulary committee members' recommendations about providing these medications under public insurance. METHODS: The study was conducted using mixed methods. In a survey of formulary committee members in Canada, 32 participants were presented with scenarios that outlined different levels of efficacy for a medication. For each scenario, participants were asked to specify their likelihood of recommending that the medication be provided under public insurance. Of the 32 participants, 23 agreed to take part in an interview to explain the survey results. Content analysis was used to elicit recurrent themes across the interviews. RESULTS: When a medication was disease modifying, use of clinician judgement increased the mean likelihood of recommending that the medication be provided under public insurance. Despite this, some participants felt formulary committees should not use clinician judgement because of risks of subjectivity and bias. However, other participants believed the addition of clinician judgement would enhance the clinical relevance of evidence that might otherwise be based entirely on changes in scale score. CONCLUSIONS: Clinician judgement about the efficacy of medications can influence formulary committee recommendations. This suggests the need for a new approach to govern the consideration of expert evidence during formulary committee deliberations.

GPs' approach to insulin prescribing in older patients: a qualitative study.

BACKGROUND: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. DESIGN OF STUDY: Qualitative individual interviews using a grounded theory approach. SETTING: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. RESULTS: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. CONCLUSION: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.

It's all about relationships: a qualitative study of health researchers' perspectives of conducting interdisciplinary health research.

BACKGROUND: Interdisciplinary research has been promoted as an optimal research paradigm in the health sciences, yet little is known about how researchers experience interdisciplinarity in practice. This study sought to determine how interdisciplinary research was conceptualized and operationalized from the researcher's perspective and to better understand how best to facilitate interdisciplinary research success. METHODS: Key informant interviews were conducted with health researchers with expertise or experience in conducting interdisciplinary research. Interviews were completed either in person or over the telephone using a semi-structured interview guide. Data collection occurred simultaneously with data analysis so that emerging themes could be explored in subsequent interviews. A content analysis approach was used. RESULTS: Nineteen researchers took part in this study. Interdisciplinary research was conceptualized disparately between participants, and there was modest attention towards operationalization of interdisciplinary research. There was one overriding theme, "It's all about relationships", that emerged from the data. Within this theme, there were four related subthemes: 1) Involvement in interdisciplinary research; 2) Why do I do interdisciplinary research?; 3) Managing and fostering interdisciplinary relationships; and 4) The prickly side to interdisciplinary research. Together, these themes suggest that the choice to conduct interdisciplinary research, though often driven by the research question, is highly influenced by interpersonal and relationship-related factors. In addition, researchers preferred to engage in interdisciplinary research with those that they had already established relationships and where their role in the research process was clearly articulated. A focus on relationship building was seen as a strong facilitator of interdisciplinary success. CONCLUSION: Many health researchers experienced mixed reactions towards their involvement in interdisciplinary research. A well thought-out rationale for interdisciplinary research, and strategies to utilize the contribution of each researcher involved were seen as facilitators towards maximizing the benefits that could be derived from interdisciplinary research.

Do patients' expectations influence their use of medications? Qualitative study.

OBJECTIVE: To investigate whether patients' expectations influence how they take their medications by looking at the expectations patients have of their medications and the factors that affect these expectations. DESIGN: Qualitative study using in-depth interviews and a grounded-theory approach. SETTING: A large city in Ontario. PARTICIPANTS: A total of 18 community-dwelling adult patients taking medication for at least 6 months. METHOD: Both purposive and convenience sampling techniques were used. The initial strategy comprised stratified, maximum variation, and typical case sampling. The research team developed a semistructured interview guide after a preliminary review of the literature. Individual, face-to-face, in-depth interviews were conducted and audiotaped. At the end of the interviews, basic demographic information was collected. Interviewers were debriefed following each interview and their comments on relevant contextual information, general impressions of the interview, and possible changes to the interview guide were audiotaped. Audiotapes of each interview, including the debriefing, were transcribed verbatim, cleaned, and given a unique identifying number. At least 2 team members participated in analyzing the data using an operational code book that was modified to accommodate emerging themes as analysis continued. MAIN FINDINGS: Patients' expectations were more realistic than idealistic. Many participants acted on their expectations by changing their medication regimens on their own or by seeking additional information on their medications. Expectations were affected by patients' beliefs, past experiences with medications, relationships with their health care providers, other people's beliefs, and the cost of medication. Patients actively engaged in strategies to confirm or modify their expectations of their medications. CONCLUSION: A range of factors (most notably past experiences with medications and relationships with health care providers) influenced patients' expectations of their medications. More comprehensive discussion between patients and their health care providers about these factors could affect whether medications are used optimally.

Patients' adherence to osteoporosis therapy: exploring the perceptions of postmenopausal women.

OBJECTIVE: To explore the experiences and perceptions of postmenopausal women regarding strategies to improve adherence to osteoporosis therapy. DESIGN: Qualitative, mixed phenomenologic study using focus groups. SETTING: Family physicians' and specialists' practices and community pharmacies in Hamilton, Ont. PARTICIPANTS: A total of 37 postmenopausal women currently taking at least 1 prescription or over-the-counter medication for osteoporosis. METHOD: Focus groups were conducted using a semistructured interview guide consisting of 10 open-ended questions about patients' perceptions of their osteoporosis medications, their reasons for adherence and non-adherence to therapy, and the effectiveness of strategies they had tried to improve adherence. At least 2 research team members analyzed the data to find primary themes. MAIN FINDINGS: Analysis of data from the 7 focus groups found 6 main factors that influenced adherence to medications: belief in the importance of taking medications for osteoporosis, medication-specific factors, beliefs regarding medications and health, relationships with health care providers, information exchange, and strategies to improve adherence. Strategies that facilitated adherence to medications included having a system for taking medications, using cues or reminders, being well informed about the reasons for taking medications, and having regular follow-up by health care providers for support and monitoring after having been prescribed medications. CONCLUSION: Results of this study provide a better understanding of how patients' perceptions and experiences affect their adherence to osteoporosis medications. Because each patient's reasons for non-adherence might be different, depending on individual beliefs or circumstances, strategies to improve adherence to medications should be individualized accordingly.

"I take what I think works for me": a qualitative study to explore patient perception of diabetes treatment benefits and risks.

BACKGROUND: Diabetes is impacting more and more people each year. A key aspect of disease management is patient adherence to prescribed treatments. Treatment adherence is influenced by many factors, including the understanding of a treatment's benefits and risks. OBJECTIVE: This study sought to describe the experience of benefit and risk assessment for people with type 2 diabetes when making treatment decisions. METHODS: This study utilized qualitative research methods. Individual interviews were conducted using a semi-structured interview guide. Both purposeful and theoretical sampling was used. A grounded theory approach was employed to facilitate data collection and analysis. RESULTS: The 18 study participants were on varying treatment regimens for diabetes (diet therapy, oral medications, and insulin). Many people felt that they had not received enough information about the benefits and risks of treatment at the point of decision-making and later sought this information on their own. Participants did not seem to consciously assess treatment benefits and risks when treatments were prescribed or suggested, but rather continued to make decisions after the clinical encounter by means of experimentation or experience with treatments. In general, benefits and risks were conceptualized very broadly, and some people were not able to verbally articulate their perceptions of treatment benefits and risks. CONCLUSION: Patients' assessment of treatment benefits and risks is an ongoing, often unconscious process that requires continuous interaction with the health care system. Access to information and an opportunity to discuss treatment options with health care providers are important to people with diabetes when making treatment decisions.