Injury outcomes across Canadian trauma systems: a historical cohort study.

PURPOSE: Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS: In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS: The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS: Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

RéSUMé: OBJECTIF: La plupart des systèmes de traumatologie nord-américains disposent de centres de traumatologie (CT) désignés, y compris de niveau I (centres métropolitains ultraspécialisés à volume élevé), de niveau II (centres urbains spécialisés à volume moyen) et/ou de niveau III (centres semi-ruraux ou ruraux). La configuration des systèmes de traumatologie varie d'une province à l'autre et nous ne savons pas comment ces différences influent sur la répartition de la patientèle et sur les issues. Notre objectif était de comparer le mélange de cas des patient·es, le volume de cas et les issues ajustées en fonction du risque des adultes ayant subi un traumatisme majeur admis·es dans des CT désignés de niveaux I, II et III dans l'ensemble des systèmes de traumatologie canadiens. MéTHODE: Dans une étude de cohorte historique nationale, nous avons extrait des données des registres provinciaux canadiens de traumatologie sur les patient·es ayant subi un traumatisme majeur traité·es entre 2013 et 2018 dans tous les CT désignés de niveau I, II ou III en Colombie-Britannique, en Alberta, au Québec et en Nouvelle-Écosse, les CT de niveau I et II au Nouveau-Brunswick, et dans quatre CT en Ontario. Nous avons utilisé des modèles linéaires généralisés à plusieurs niveaux pour comparer la mortalité, les admissions en unité de soins intensifs (USI) et les modèles de risque compétitif pour la durée du séjour à l'hôpital et à l'USI. L'Ontario n'a pas pu être inclus dans les comparaisons des devenirs parce qu'il n'y avait pas de données démographiques pour cette province. RéSULTATS: L'échantillon de l'étude comptait 50 959 patient·es. La répartition des patient·es dans les CT de niveaux I et II était similaire d'une province à l'autre, mais nous avons observé des différences significatives dans le mélange des cas et les volumes pour les CT de niveau III. Il y avait une faible variation de la mortalité ajustée en fonction du risque et des durées de séjour entre les provinces et les CT, mais la variation interprovinciale et intercentre des admissions à l'USI ajustées en fonction du risque était élevée. CONCLUSION: Nos résultats suggèrent que les différences dans le rôle fonctionnel des CT selon leur niveau de désignation d'une province à l'autre entraînent des variations importantes dans la répartition des patient·es, le nombre de cas, l'utilisation des ressources et les issues cliniques. Ces résultats mettent en évidence les possibilités d'amélioration des soins de traumatologie au Canada et soulignent la nécessité de disposer de données normalisées sur les blessures dans la population pour appuyer les efforts nationaux d'amélioration de la qualité.

Developing a How-to-Guide for Health Technology Reassessment: "The HTR Playbook".

BACKGROUND: To develop a knowledge translation (KT) tool that will provide guidance to stakeholders actively planning or considering implementation of a health technology reassessment (HTR) initiative. METHODS: The KT tool is an international and collaborative endeavour between HTR researchers in Canada, Australia, and the United Kingdom. Evidence from a meta-review of documented international HTR experiences and approaches provided the conceptual framing for the KT tool. The purpose, audience, format, and overall scope and content of the tool were established through iterative discussions and consensus. An initial version of the KT tool was beta-tested with an international community of relevant stakeholders (i.e., potential users) at the Health Technology Assessment International 2018 annual meeting. RESULTS: An open access workbook, referred to as the HTR playbook, was developed. As a KT tool, the HTR playbook is intended to simplify the complex HTR planning process by navigating users step-by-step through 6 strategic domains: characteristics of the candidate health technology (The Stats and Projections), stakeholders to engage (The Team), potential facilitators and/or barriers within the policy context (The Playing Field), strategic use of different levers and tools (The Offensive Plays), unintended consequences (The Defensive Plays), and metrics and methods for monitoring and evaluation (Winning the Game). CONCLUSION: The HTR playbook is intended to enhance a user's ability to successfully complete a HTR by helping them systematically consider the different elements and approaches to achieve the right care for the patient population in question.

A collaborative pilot on current awareness alerts for disinvestment and horizon scanning.

OBJECTIVE: In 2019, members of the Health Technology Assessment international (HTAi) Interest Group for Disinvestment and Early Awareness (DEA-IG) and the HTAi Interest Group for Information Retrieval (IR-IG) agreed to produce quarterly current awareness alerts for members of the DEA-IG. The purpose was to pilot a predefined strategy for sharing new publications on methods and topical issues in this area. METHODS: Literature search strategies for PubMed and Google were developed. Retrieved citations were posted on the DEA-IG Web site. Members of the DEA-IG received an email notification when new alerts were available. An informal survey of the DEA-IG members was used to provide feedback after the pilot. RESULTS: Six alerts were issued during the pilot (June 2019-September 2020) with a total of 170 citations. The bulk of the information were 124 PubMed indexed citations, and of these, 96 were retrieved by the PubMed search strategies. Google searches were not found to be useful, but ongoing horizon scanning work at the Canadian Agency for Drugs and Technologies in Health (CADTH) provided additional information. Based on retrospective sorting, we considered thirty-five PubMed citations to be highly relevant for health technology assessment (HTA). The response rate to the survey was limited (seventeen respondents), but most respondents found the alerts useful for their work. CONCLUSIONS: The results of this pilot project can be used to revise search strategies and information sources, improve the relevance of the alerts, and plan for expanded dissemination strategies.

Identification of knowledge translation theories, models or frameworks suitable for health technology reassessment: a survey of international experts.

OBJECTIVE: Health technology reassessment (HTR) is a field focused on managing a technology throughout its life cycle for optimal use. The process results in one of four possible recommendations: increase use, decrease use, no change or complete withdrawal of the technology. However, implementation of these recommendations has been challenging. This paper explores knowledge translation (KT) theories, models and frameworks (TMFs) and their suitability for implementation of HTR recommendations. DESIGN: Cross-sectional survey. PARTICIPANTS: Purposeful sampling of international KT and HTR experts was administered between January and March 2019. METHODS: Sixteen full-spectrum KT TMFs were rated by the experts as 'yes', 'partially yes' or 'no' on six criteria: familiarity, logical consistency/plausibility, degree of specificity, accessibility, ease of use and HTR suitability. Consensus was determined as a rating of ≥70% responding 'yes'. Descriptive statistics and manifest content analysis were conducted on open-ended comments. RESULTS: Eleven HTR and 11 KT experts from Canada, USA, UK, Australia, Germany, Spain, Italy and Sweden participated. Of the 16 KT TMFs, none received ≥70% rating. When ratings of 'yes' and 'partially yes' were combined, the Consolidated Framework for Implementation Research was considered the most suitable KT TMF by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: Knowledge to Action framework. HTR experts selected two additional KT TMFs: Co-KT framework and Plan-Do-Study-Act cycle. Experts identified three key characteristics of a KT TMF that may be important to consider: practicality, guidance on implementation and KT TMF adaptability. CONCLUSIONS: Despite not reaching an overall ≥70% rating on any of the KT TMFs, experts identified four KT TMFs suitable for HTR. Users may apply these KT TMFs in the implementation of HTR recommendations. In addition, KT TMF characteristics relevant to the field of HTR need to be explored further.

Characteristics of knowledge translation theories, models and frameworks for health technology reassessment: expert perspectives through a qualitative exploration.

BACKGROUND: Health Technology Reassessment (HTR) is a process that systematically assesses technologies that are currently used in the health care system. The process results in four outputs: increase use or decrease use, no change, or de-adoption of a technology. Implementation of these outputs remains a challenge. The Knowledge Translation (KT) field enables to transfer/translate knowledge into practice. KT could help with implementation of HTR outputs. This study sought to identify which characteristics of KT theories, models, and frameworks could be useful, specifically for decreased use or de-adoption of a technology. METHODS: A qualitative descriptive approach was used to ascertain the perspectives of international KT and HTR experts on the characteristics of KT theories, models, and frameworks for decreased use or de-adoption of a technology. One-to-one semi-structured interviews were conducted from September to December 2019. Interviews were audio recorded and transcribed verbatim. Themes and sub-themes were deduced from the data through framework analysis using five distinctive steps: familiarization, identifying an analytic framework, indexing, charting, mapping and interpretation. Themes and sub-themes were also mapped to existing KT theories, models, and frameworks. RESULTS: Thirteen experts from Canada, United States, United Kingdom, Australia, Germany, Spain, and Sweden participated in the study. Three themes emerged that illustrated the ideal traits: principles that were foundational for HTR, levers of change, and steps for knowledge to action. Principles included evidence-based, high usability, patient-centered, and ability to apply to the micro, meso, macro levels. Levers of change were characterized as positive, neutral, or negative influences for changing behaviour for HTR. Steps for knowledge to action included: build the case for HTR, adapt research knowledge, assess context, select interventions, and assess impact. Of the KT theories, models, and frameworks that were mapped, the Consolidated Framework for Implementation Research had most of the characteristics, except ability to apply to micro, meso, macro levels. CONCLUSIONS: Characteristics that need to be considered within a KT theory, model, and framework for implementing HTR outputs have been identified. Consideration of these characteristics may guide users to select relevant KT theories, models, and frameworks to apply to HTR projects.

A scoping review of full-spectrum knowledge translation theories, models, and frameworks.

BACKGROUND: Application of knowledge translation (KT) theories, models, and frameworks (TMFs) is one method for successfully incorporating evidence into clinical care. However, there are multiple KT TMFs and little guidance on which to select. This study sought to identify and describe available full-spectrum KT TMFs to subsequently guide users. METHODS: A scoping review was completed. Articles were identified through searches within electronic databases, previous reviews, grey literature, and consultation with KT experts. Search terms included combinations of KT terms and theory-related terms. Included citations had to describe full-spectrum KT TMFs that had been applied or tested. Titles/abstracts and full-text articles were screened independently by two investigators. Each KT TMF was described by its characteristics including name, context, key components, how it was used, primary target audience, levels of use, and study outcomes. Each KT TMF was also categorized into theoretical approaches as process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. Within each category, KT TMFs were compared and contrasted to identify similarities and unique characteristics. RESULTS: Electronic searches yielded 7160 citations. Additional citations were identified from previous reviews (n = 41) and bibliographies of included full-text articles (n = 6). Thirty-six citations describing 36 full-spectrum were identified. In 24 KT TMFs, the primary target audience was multi-level including patients/public, professionals, organizational, and financial/regulatory. The majority of the KT TMFs were used within public health, followed by research (organizational, translation, health), or in multiple contexts. Twenty-six could be used at the individual, organization, or policy levels, five at the individual/organization levels, three at the individual level only, and two at the organizational/policy level. Categorization of the KT TMFs resulted in 18 process models, eight classic theories, three determinant frameworks, three evaluation frameworks, and four that fit more than one category. There were no KT TMFs that fit the implementation theory category. Within each category, similarities and unique characteristics emerged through comparison. CONCLUSIONS: A systematic compilation of existing full-spectrum KT TMFs, categorization into different approaches, and comparison has been provided in a user-friendly way. This list provides options for users to select from when designing KT projects and interventions. TRIAL REGISTRATION: A protocol outlining the methodology of this scoping review was developed and registered with PROSPERO (CRD42018088564).

Knowledge translation and health technology reassessment: identifying synergy.

BACKGROUND: Health Technology Reassessment (HTR) is an emerging field that shifts the focus from traditional methods of technology adoption to managing technology throughout its lifecycle. HTR is a mechanism to improve patient care and system efficiency through a reallocation of resources away from low-value care towards interventions and technologies that are high value. To achieve this, the outputs of HTR and its recommendations must be translated into practice. The evolving field of knowledge translation (KT) can provide guidance to improve the uptake of evidence-informed policies and recommendations resulting from the process of HTR. This paper argues how the theories, models and frameworks from KT could advance the HTR process. DISCUSSION: First, common KT theories, models and frameworks are presented. Second, facilitators and barriers to KT within the context of HTR are summarized from the literature. Facilitators and barriers to KT include ensuring a solid research evidence-base for the technology under reassessment, assessing the climate and context, understanding the social an political context, initiating linkage and exchange, having a structured HTR Process, adequate resources, and understanding the roles of researchers, knowledge users, and stakeholders can enhance knowledge translation of HTR outputs. Third, three case examples at the individual (micro), organizational (meso), and policy (macro) levels are used to illustrate to describe how a KT theory, model or framework could be applied to a HTR project. These case studies show how selecting and applying KT theories, models and frameworks can facilitate the implementation of HTR recommendations. CONCLUSION: HTR and KT are synergistic processes that can be used to optimize technology use throughout its lifecycle. We argue that the application of KT theories, models and frameworks, and the assessment of barriers and facilitators to KT can facilitate translation of HTR recommendations into practice.

UNTANGLING, UNBUNDLING, AND MOVING FORWARD: FRAMING HEALTH TECHNOLOGY REASSESSMENT IN THE CHANGING CONCEPTUAL LANDSCAPE.

OBJECTIVES: Health technology reassessment (HTR) is a policy process to manage health technologies throughout their lifecycle and ensure their ongoing optimal use. However, within an ever-evolving field, HTR is only one of many concepts associated with the optimization of health technologies. There is limited understanding of how other concepts and processes might differ and/or be interrelated. This study aims to describe the concepts underlying the various technology optimization processes and to reconcile their relationships within the HTR process. METHODS: A synthesis of the literature on approaches to HTR was completed. An inductive synthesis approach was completed to catalogue common concepts and themes. Expert stakeholders were consulted to develop a schematic to diagrammatically depict the relationships among concepts and frame them within the HTR process. RESULTS: A practical schematic was developed. Common concepts and themes were organized under six major domains that address the following discussion questions: (i) what is the value of the existing technology?; (ii) what is the current utilization gap?; (iii) what are the available tools and resources?; (iv) what are the levers for change?; (v) what is the desired outcome?; and (vi) who are the foundational actors? CONCLUSIONS: Using these six questions to frame the issues faced by HTR will advance the common understanding of HTR, as well as improve implementation of HTR initiatives. These questions will clearly identify the process required to move forward within a complex healthcare system.

Classification schemes for knowledge translation interventions: a practical resource for researchers.

BACKGROUND: As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme. METHODS: We abstracted the following information from each of the original 51 classification scheme articles: authors' objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not. RESULTS: Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination. CONCLUSIONS: Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science.

Back Schools for chronic non-specific low back pain.

BACKGROUND: Many people with low back pain (LBP) become frequent users of healthcare services in their attempt to find treatments that minimise the severity of their symptoms. Back School consists of a therapeutic programme given to groups of people that includes both education and exercise. However, the content of Back School has changed over time and appears to vary widely today. This review is an update of a Cochrane review of randomised controlled trials (RCTs) evaluating the effectiveness of Back School. We split the Cochrane review into two reviews, one focusing on acute and subacute LBP, and one on chronic LBP. OBJECTIVES: The objective of this systematic review was to determine the effect of Back School on pain and disability for adults with chronic non-specific LBP; we included adverse events as a secondary outcome. In trials that solely recruited workers, we also examined the effect on work status. SEARCH METHODS: We searched for trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, two other databases and two trials registers to 15 November 2016. We also searched the reference lists of eligible papers and consulted experts in the field of LBP management to identify any potentially relevant studies we may have missed. We placed no limitations on language or date of publication. SELECTION CRITERIA: We included only RCTs and quasi-RCTs evaluating pain, disability, and/or work status as outcomes. The primary outcomes for this update were pain and disability, and the secondary outcomes were work status and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently performed the 'Risk of bias' assessment of the included studies using the 'Risk of bias' assessment tool recommended by The Cochrane Collaboration. We summarised the results for the short-, intermediate-, and long-term follow-ups. We evaluated the overall quality of evidence using the GRADE approach. MAIN RESULTS: For the outcome pain, at short-term follow-up, we found very low-quality evidence that Back School is more effective than no treatment (mean difference (MD) -6.10, 95% confidence interval (CI) -10.18 to -2.01). However, we found very low-quality evidence that there is no significant difference between Back School and no treatment at intermediate-term (MD -4.34, 95% CI -14.37 to 5.68) or long-term follow-up (MD -12.16, 95% CI -29.14 to 4.83). There was very low-quality evidence that Back School reduces pain at short-term follow-up compared to medical care (MD -10.16, 95% CI -19.11 to -1.22). Very low-quality evidence showed there to be no significant difference between Back School and medical care at intermediate-term (MD -9.65, 95% CI -22.46 to 3.15) or long-term follow-up (MD -5.71, 95% CI -20.27 to 8.84). We found very low-quality evidence that Back School is no more effective than passive physiotherapy at short-term (MD 1.96, 95% CI -9.51 to 13.43), intermediate-term (MD -16.89, 95% CI -66.56 to 32.79), or long-term follow-up (MD -12.86, 95% CI -61.22 to 35.50). There was very low-quality evidence that Back School is no better than exercise at short- term follow-up (MD -2.06, 95% CI -14.58 to 10.45). There was low-quality evidence that Back School is no better than exercise at intermediate-term (MD -4.46, 95% CI -19.44 to 10.52) and long-term follow-up (MD 4.58, 95% CI -0.20 to 9.36).For the outcome disability, we found very low-quality evidence that Back School is no more effective than no treatment at intermediate-term (MD -5.92, 95% CI -12.08 to 0.23) and long-term follow-up (MD -7.36, 95% CI -22.05 to 7.34); medical care at short-term (MD -1.19, 95% CI -7.02 to 4.64) and long-term follow-up (MD -0.40, 95% CI -7.33 to 6.53); passive physiotherapy at short-term (MD 2.57, 95% CI -15.88 to 21.01) and intermediate-term follow-up (MD 6.88, 95% CI -4.86 to 18.63); and exercise at short-term (MD -1.65, 95% CI -8.66 to 5.37), intermediate-term (MD 1.57, 95% CI -3.86 to 7.00), and long-term follow-up (MD 4.54, 95% CI -4.44 to 13.52). We found very low-quality evidence of a small difference between Back School and no treatment at short-term follow-up (MD -3.38, 95% CI -6.70 to -0.05) and medical care at intermediate-term follow-up (MD -6.34, 95% CI -10.89 to -1.79). Still, at long-term follow-up there was very low-quality evidence that passive physiotherapy is better than Back School (MD 9.60, 95% CI 3.65 to 15.54).Few studies measured adverse effects. The results were reported as means without standard deviations or group size was not reported. Due to this lack of information, we were unable to statistically pool the adverse events data. Work status was not reported. AUTHORS' CONCLUSIONS: Due to the low- to very low-quality of the evidence for all treatment comparisons, outcomes, and follow-up periods investigated, it is uncertain if Back School is effective for chronic low back pain. Although the quality of the evidence was mostly very low, the results showed no difference or a trivial effect in favour of Back School. There are myriad potential variants on the Back School approach regarding the employment of different exercises and educational methods. While current evidence does not warrant their use, future variants on Back School may have different effects and will need to be studied in future RCTs and reviews.

A systematic review of the cost and cost-effectiveness of electronic discharge communications.

BACKGROUND: The transition between acute care and community care can be a vulnerable period in a patients' treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered. OBJECTIVE: To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider. METHODS: We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis. RESULTS: One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes. DISCUSSION: Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care.

Back schools for acute and subacute non-specific low-back pain.

BACKGROUND: Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating people with low-back pain (LBP). However, the content of back schools has changed and appears to vary widely today. In this review we defined back school as a therapeutic programme given to groups of people, which includes both education and exercise. This is an update of a Cochrane review first published in 1999, and updated in 2004. For this review update, we split the review into two distinct reviews which separated acute from chronic LBP. OBJECTIVES: To assess the effectiveness of back schools on pain and disability for people with acute or subacute non-specific LBP. We also examined the effect on work status and adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, PubMed and two clinical trials registers up to 4 August 2015. We also checked the reference lists of articles and contacted experts in the field of research on LBP. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that reported on back school for acute or subacute non-specific LBP. The primary outcomes were pain and disability. The secondary outcomes were work status and adverse events. Back school had to be compared with another treatment, a placebo (or sham or attention control) or no treatment. DATA COLLECTION AND ANALYSIS: We used the 2009 updated method guidelines for this Cochrane review. Two review authors independently screened the references, assessed the quality of the trials and extracted the data. We set the threshold for low risk of bias, a priori, as six or more of 13 internal validity criteria and no serious flaws (e.g. large drop-out rate). We classified the quality of the evidence into one of four levels (high, moderate, low or very low) using the adapted Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We contacted study authors for additional information. We collected adverse effects information from the trials. MAIN RESULTS: The search update identified 273 new references, of which none fulfilled our inclusion criteria. We included four studies (643 participants) in this updated review, which were all included in the previous (2004) update. The quality of the evidence was very low for all outcomes. As data were too clinically heterogeneous to be pooled, we described individual trial results. The results indicate that there is very low quality evidence that back schools are no more effective than a placebo (or sham or attention control) or another treatment (physical therapies, myofascial therapy, joint manipulations, advice) on pain, disability, work status and adverse events at short-term, intermediate-term and long-term follow-up. There is very low quality evidence that shows a statistically significant difference between back schools and a placebo (or sham or attention control) for return to work at short-term follow-up in favour of back school. Very low quality evidence suggests that back school added to a back care programme is more effective than a back care programme alone for disability at short-term follow-up. Very low quality evidence also indicates that there is no difference in terms of adverse events between back school and myofascial therapy, joint manipulation and combined myofascial therapy and joint manipulation. AUTHORS' CONCLUSIONS: It is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available. While large well-conducted studies will likely provide more conclusive findings, back schools are not widely used interventions for acute and subacute LBP and further research into this area may not be a priority.

An integrated, population-based framework for knowledge management for cancer control.

Cancer control organizations commonly refer to the critical role of clinical practice guidelines to support the best possible cancer care. But how can a cancer care program ensure the systematic implementation of those guidelines? The goals of this article are to describe the process of developing a cancer control system driven by knowledge management, to highlight the key elements of this system and to foster discussion on the implementation of such frameworks. In order to promote best cancer practices within an expanded radiation service model for the province of Alberta, we developed an integrated conceptual framework for knowledge management. We identified six key elements of a knowledge management framework for the cancer program: evidence-based provincial guidelines, funding decisions, harmonized care pathways, targeted knowledge transfer projects, performance measurement and feedback to the system. We are establishing a process to characterize the explicit linkages and accountabilities between each of these elements as part of a broader cancer care quality agenda. We will implement the framework to support the start-up of the first of three new radiation treatment services in the province. The basic elements of a guidelines-supported cancer care system are not in doubt; how to unambiguously engage them within an integrated care system remains an area of intense interest.

Prevention of ventilator-associated pneumonia in the calgary health region: a Canadian success story!

This article describes the experiences of a Canadian multidisciplinary critical care team striving to reduce the incidence of ventilator-associated pneumonia (VAP). Several interventions, including a VAP bundle, were used and applied across a health region. Our regional VAP rate has seen a steady decline over the past 12 months and has been largely under our goal of 9.8 cases per 1,000 ventilator-days. The team's success in lowering VAP has provided the momentum for sustained improvement, which has spread to other areas.

Is your patient ready for transport? Developing an ICU patient transport decision scorecard.

Transport of patients from the intensive care unit (ICU) to another area of the hospital can pose serious risks if the patient has not been assessed prior to transport. Recently, the Department of Critical Care Medicine, Calgary Health Region, experienced two adverse events during transport. A subgroup of the Department's Patient Safety and Adverse Events team developed an ICU patient transport decision scorecard. This tool was tested through Plan-Do-Study-Act cycles and further revised using human factors principles. Staff, especially novice nurses, found the tool extremely useful in determining patient preparedness for transport.

Using Healthcare Failure Mode and Effect Analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate.

During the spring of 2004, in the Calgary Health Region (CHR) two critical incidents occurred involving patients receiving continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The outcome of these events resulted in the sudden death of both patients. The Department of Critical Care Medicine's Patient Safety and Adverse Events Team (PSAT), utilized the Healthcare Failure Mode and Effect Analysis (HFMEA) tool to review the process and conditions surrounding the ordering and administration of potassium chloride (KCI) and potassium phosphate (KPO4) in our ICUs. The HFMEA tool and the multidisciplinary team structure provided a solid framework for systematic analysis and prioritization of areas for improvement regarding the use of intravenous, high-concentration KCL and KPO4 in the ICU.

Quality improvement in the ICU. A Canadian perspective.

This article will provide an overview of the quality improvement initiatives of the Department of Critical Care Medicine, Calgary Health Region. The Department has a Quality Council that is responsible for its quality improvement activities. The FOCUS-PDSA model is used for various projects including the development of guidelines and protocols. The Department has also participated in two collaboratives which use the Improvement Model methodology. It has 7 projects completed with 10 projects currently underway.

The role of high-dose chemotherapy and stem-cell transplantation in patients with multiple myeloma: a practice guideline of the Cancer Care Ontario Practice Guidelines Initiative.

The Hematology Disease Site Group of the Cancer Care Ontario Practice Guidelines Initiative has systematically reviewed the published literature and, through a consensus process, developed an evidence-based practice guideline assessing the role of stem-cell transplantation in patients with multiple myeloma. The conclusions were validated by solicited feedback from 221 practitioners across Ontario, Canada. The guideline comprises six recommendations: 1) Autologous transplantation is recommended for patients with stage II or III myeloma and good performance status. Evidence of benefit is strongest for patients who are younger than 55 years of age and have a serum creatinine level less than 150 micromol/L (<1.7 mg/dL). Physicians must use clinical judgment in recommending transplantation to other patients. 2) Allogeneic transplantation is not recommended as routine therapy. 3) Patients potentially eligible for transplantation should be referred for assessment early after diagnosis and should not be extensively exposed to alkylating agents before collection of stem cells. 4) Autologous peripheral blood stem cells should be harvested early in the patient's treatment course. The best available data suggest that transplantation is most advantageous when performed as part of initial therapy. 5) The comparative data addressing the specifics of the transplantation process are insufficient to allow definitive recommendations. In the absence of such data, a single transplant with high-dose melphalan, with or without total-body irradiation, is suggested for patients undergoing transplantation outside a clinical trial. 6) At this time, no conclusions can be reached about the role of interferon therapy after transplantation.

Chemotherapy for older patients with newly diagnosed, advanced-stage, aggressive-histology non-Hodgkin lymphoma: a systematic review.

PURPOSE: To conduct a systematic review assessing chemotherapeutic regimens in patients at least 60 years of age with previously untreated, advanced-stage, aggressive-histology non-Hodgkin lymphoma. DATA SOURCES: Computerized databases were searched for reports from 1966 to April 2000. Relevant journals, textbooks, and reference lists of published articles were hand searched. Abstract reports were not considered. STUDY SELECTION: Randomized trials comparing different chemotherapy regimens were selected. Two independent assessors, who were blinded to authors, institution, and results of the report, reviewed the retrieved citations. DATA EXTRACTION: One author abstracted data on patient characteristics, study quality score, survival, disease response and control, toxicity, and quality of life; pooling was not done because of study heterogeneity. DATA SYNTHESIS: 12 randomized trials that compared chemotherapeutic regimens were reviewed. Progression-free and overall survival were improved when anthracycline-containing regimens, such as CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or CTVP (cyclophosphamide, pirarubicin, vincristine, and prednisone), were compared with other regimens. CONCLUSIONS: For treatment of older patients with advanced-stage, aggressive-histology lymphoma who do not have significant comorbid illnesses, an anthracycline-containing regimen, such as CHOP, given in standard doses and schedule, provides for superior outcomes compared with other regimens.