Goals of Care Conversations in Long-Term Care during the First Wave of the COVID-19 Pandemic.

Goals of care discussions typically focus on decision maker preference and underemphasize prognosis and outcomes related to frailty, resulting in poorly informed decisions. Our objective was to determine whether navigated care planning with nursing home residents or their decision makers changed care plans during the first wave of the COVID-19 pandemic. The MED-LTC virtual consultation service, led by internal medicine specialists, conducted care planning conversations that balanced information-giving/physician guidance with resident autonomy. Consultation included (1) the assessment of co-morbidities, frailty, health trajectory, and capacity; (2) in-depth discussion with decision makers about health status and expected outcomes; and (3) co-development of a care plan. Non-parametric tests and logistic regression determined the significance and factors associated with a change in care plan. Sixty-three residents received virtual consultations to review care goals. Consultation resulted in less aggressive care decisions for 52 residents (83%), while 10 (16%) remained the same. One resident escalated their care plan after a mistaken diagnosis of dementia was corrected. Pre-consultation, 50 residents would have accepted intubation compared to 9 post-consultation. The de-escalation of care plans was associated with dementia, COVID-19 positive status, and advanced frailty. We conclude that during the COVID-19 pandemic, a specialist-led consultation service for frail nursing home residents significantly influenced decisions towards less aggressive care.

Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: questionable benefit and considerations for frailty.

BACKGROUND: Frail older adults are commonly prescribed antidepressants. Yet, there is little evidence to determine the efficacy and safety of antidepressants to treat depression with concomitant frailty. To better understand this issue, we examined the efficacy and safety of second-generation antidepressants for the treatment of older adults with depression and then considered implications for frailty. METHODS: Due to the absence of therapeutic studies of frail older adults with depression, we conducted a systematic review and meta-analysis of double-blind, randomized controlled trials that compared antidepressants versus placebo for adults with depression, age 65 years or older. We searched PubMed/MEDLINE, Cochrane Library, reference lists from meta-analyses/studies, hand searches of publication lists, and related articles on PubMed. Outcomes included rates of response, remission, and adverse events. After evaluating the data, we applied a frailty-informed framework to consider how the evidence could be applied to frailty. RESULTS: Nine trials were included in the meta-analysis (n = 2704). Subjects had moderate to severe depression. For older adults with depression, there was no statistically significant difference in response or remission to second-generation antidepressants compared to placebo. Response occurred in 45.3% of subjects receiving an antidepressant compared to 40.5% receiving placebo (RR 1.15, 95% CI: 0.96 - 1.37, p = 0.12, I2 = 71%). Remission occurred in 33.1% with antidepressant versus 31.3% with placebo (RR 1.10, 95% CI: 0.92 - 1.31, p = 0.30, I2 = 56%) (Figure 2 and 3). There were more withdrawals due to adverse events with antidepressants, 13% versus 5.8% (RR 2.30, 95% CI: 1.45-3.63; p < 0.001; I2 = 61%; NNH 14, 95% CI:10-28). IMPLICATIONS FOR FRAILTY: Subjects in the meta-analysis did not have obvious characteristics of frailty. Using framework questions to consider the implications of frailty, we hypothesize that, like older adults, frail individuals with depression may not respond to antidepressants. Further, observational studies suggest that those who are frail may be less responsive to antidepressants compared to the non-frail. Given the vulnerability of frailty, adverse events may be more burdensome. CONCLUSIONS: Second-generation antidepressants have uncertain benefit for older adults with depression and cause more adverse events compared to placebo. Until further research clarifies benefit, careful consideration of antidepressant prescribing with frailty is warranted.

Assessing Clinical Faculty Understanding of Statistical Terms Used to Measure Treatment Effects and Their Application to Teaching.

INTRODUCTION: Understanding of statistical terms used to measure treatment effect is important for evidence-informed medical teaching and practice. We explored knowledge of these terms among clinical faculty who instruct and mentor a continuum of medical learners to inform medical faculty learning needs. METHODS: This was a mixed methods study that used a questionnaire to measure a health professional's understanding of measures of treatment effect and a focus group to explore perspectives on learning, applying, and teaching these terms. We analyzed questionnaire data using descriptive statistics and focus group data using thematic analysis. RESULTS: We analyzed responses from clinical faculty who were physicians and completed all sections of the questionnaire (n = 137). Overall, approximately 55% were highly confident in their understanding of statistical terms; self-reported understanding was highest for number needed to treat (77%). Only 26% of respondents correctly responded to all comprehension questions; however, 80% correctly responded to at least one of these questions. There was a significant association among self-reported understanding and ability to correctly calculate terms. A focus group with clinical/medical faculty (n = 4) revealed themes of mentorship, support and resources, and beliefs about the value of statistical literacy. DISCUSSION: We found that half of clinical faculty members are highly confident in their understanding of relative and absolute terms. Despite the limitations of self-assessment data, our study provides some evidence that self-assessment can be reliable. Recognizing that faculty development is not mandatory for clinical faculty in many centers, and the notion that faculty may benefit from mentorship in critical appraisal topics, it may be appropriate to first engage and support influential clinical faculty rather than using a broad strategy to achieve universal statistical literacy. Second, senior leadership in medical education should support continuous learning by providing paid, protected time for faculty to incorporate evidence in their teaching.

Facilitated Reflective Performance Feedback: Developing an Evidence- and Theory-Based Model That Builds Relationship, Explores Reactions and Content, and Coaches for Performance Change (R2C2).

PURPOSE: To develop and conduct feasibility testing of an evidence-based and theory-informed model for facilitating performance feedback for physicians so as to enhance their acceptance and use of the feedback. METHOD: To develop the feedback model (2011-2013), the authors drew on earlier research which highlights not only the factors that influence giving, receiving, accepting, and using feedback but also the theoretical perspectives which enable the understanding of these influences. The authors undertook an iterative, multistage, qualitative study guided by two recognized research frameworks: the UK Medical Research Council guidelines for studying complex interventions and realist evaluation. Using these frameworks, they conducted the research in four stages: (1) modeling, (2) facilitator preparation, (3) model feasibility testing, and (4) model refinement. They analyzed data, using content and thematic analysis, and used the findings from each stage to inform the subsequent stage. RESULTS: Findings support the facilitated feedback model, its four phases-build relationship, explore reactions, explore content, coach for performance change (R2C2)-and the theoretical perspectives informing them. The findings contribute to understanding elements that enhance recipients' engagement with, acceptance of, and productive use of feedback. Facilitators reported that the model made sense and the phases generally flowed logically. Recipients reported that the feedback process was helpful and that they appreciated the reflection stimulated by the model and the coaching. CONCLUSIONS: The theory- and evidence-based reflective R2C2 Facilitated Feedback Model appears stable and helpful for physicians in facilitating their reflection on and use of formal performance assessment feedback.

An interprofessional approach to teaching communication skills.

INTRODUCTION: Recent research suggests that effective interprofessional communication and collaboration can positively influence patient satisfaction and outcomes. Health professional communication skills do not necessarily improve over time but can improve with formal communication skills training (CST). This article describes the development, evaluation, and lessons learned for a novel theater-based role-play CST program designed to improve community cancer care for patients and families by enhancing health care professionals' communication skills. INTERVENTION: Four 2-hour interprofessional communication skills workshops for Nova Scotia health professionals were developed. Topics were (1) Essential Communication Skills, (2) Delivering Difficult News and Providing Support, (3) When Patients and Families Are Angry, and (4) Managing Conflict in the Workplace. Strategies for enhancing communication skills based on the science (evidence-based practice and teaching) and the art (interactive theater) of communication skills were included. Facilitators included professional actors, communication skills facilitators, and trained health professionals. EVALUATION: We used a mixed-methods evaluation design assessing 4 levels of educational outcomes at 3 points: pre- and post-workshop and follow-up. RESULTS: Five hundred eighteen professionals representing over 20 health professions attended 17 workshops. Data showed the workshops were well received, despite some discomfort with role-playing. Pre/post paired t-tests of self-reported communication skills showed significant improvement after all workshops (p ≤ 0.05); 92% indicated intended changes to their communication practice immediately following the workshops. Of 68 respondents to the follow-up, 59 (87%) reported positive changes in the responses of their patients. DISCUSSION: Both positive and negative lessons learned are described.

Partnerships for knowledge translation and exchange in the context of continuing professional development.

Continuing professional development (CPD) is an important vehicle for knowledge translation (KT); however, selecting CPD strategies that will impact health professionals' behavior and improve patient outcomes is complex. In response, we, KT researchers and CPD knowledge users, have recently formed a partnership known as the National Network for Patient-Centered Evidence-Based Continuing Professional Development. The partnership was initiated in 2006 with a series of CIHR Knowledge Translation: Planning, Meetings and Dissemination grants. The objectives of these grants were to bring members of the CPD and KT communities together, determine their interest in working together, identify similarities and differences in the fields of CPD and KT, and develop working groups to inform larger collaborative initiatives to support knowledge translation and exchange. The vision for this partnership is to become a premiere knowledge translation collaboration and a cutting-edge implementation network that informs the provision of CPD across Canada and abroad. This paper reports on the development and outcomes of this network to date.

How do physicians assess their family physician colleagues' performance?: creating a rubric to inform assessment and feedback.

INTRODUCTION: The Colleges of Physicians and Surgeons of Alberta and Nova Scotia (CPSNS) use a standardized multisource feedback program, the Physician Achievement Review (PAR/NSPAR), to provide physicians with performance assessment data via questionnaires from medical colleagues, coworkers, and patients on 5 practice domains: consultation communication, patient interaction, professional self-management, clinical competence, and psychosocial management of patients. Physicians receive a confidential report; the intent is practice improvement. However, research indicates that feedback from medical colleagues appears to be less understood than that from coworkers or patients, due to a lack of specificity and concerns regarding feedback credibility. The purpose of this study was to determine how physicians make decisions about performance ratings for family physician (FP) colleagues in the 5 practice domains. METHODS: This was an exploratory qualitative study using focus groups-one with 11 family physicians and one with 12 specialists-who had served as NSPAR "medical colleague'' reviewers. We analyzed focus group transcripts using content analysis. RESULTS: Family and specialist physicians provided examples of behaviors indicative of both high- and low-scoring performance for items within the 5 practice domains. From these, an assessment rubric was created to inform both external reviewers and the physicians being reviewed of performance expectations. Reviewers reported using varied sources of information to make assessments, including shared patients, medical records, referral letters, feedback from others, and self-reference. DISCUSSION: The CPSNS has used the assessment rubric to create an online resource to inform medical colleague assessment and enhance the usefulness of their NSPAR scores. Further research will be required to determine its impact.

Presentation of evidence in continuing medical education programs: a mixed methods study.

INTRODUCTION: Clinical trial data can be presented in ways that exaggerate treatment effectiveness. Physicians consider therapy more effective, and may be more likely to make inappropriate practice changes, when data are presented in relative terms such as relative risk reduction rather than in absolute terms such as absolute risk reduction and number needed to treat. Our purpose was to determine (1) how frequently continuing medical education (CME) speakers present research data in relative terms compared to absolute terms; (2) how knowledgeable CME speakers and learners are about these terms; and (3) how CME learners want these terms presented. METHODS: Analysis of videotapes and PowerPoint slides of 26 CME presentations, questionnaire survey of CME speakers and learners, and focus groups with learners. RESULTS: Speakers presented data more frequently in relative than absolute terms, but most frequently in general terms such as frequencies, percentages, graphs, and P-values with no data. Of 1367 PowerPoint slides, 269 presented research data, and of these, 225 (84%) presented data in general terms, 50 (19%) in relative terms and 19 (7%) in absolute terms. CME speakers understood relative and absolute terms better than learners. Approximately 25-35% of speakers and 45-65% of learners could not correctly calculate relative risk reduction, absolute risk reduction, and number needed to treat. Learners wished to have these terms presented in CME programs in a consistent and easily understood format and requested a brief review of them at the beginning of CME programs. DISCUSSION: Presentation of research data in most CME programs is inadequate to allow learners to make fully informed therapeutic decisions. Speakers and learners need professional development to improve their presentation and understanding of research data.