Cancer care pathways mapping and dissemination toolkit: lessons learnt from cancer services in NSW, Australia.

OBJECTIVE: Gaps and complexities exist in cancer referral and diagnosis in Australia, leading to delays in cancer treatments. Developing evidence-based referral pathways is important for promoting better and more timely cancer diagnosis and care. Type of program or service: This paper describes a toolkit endorsed by the Cancer Institute NSW as a guide for promoting best practice in localising cancer referral and diagnosis pathways in line with the national Optimal Care Pathways. Use of toolkit: Employing methods in the toolkit yielded an increased understanding of cancer care pathways, strengthened collaboration between tertiary and primary sector stakeholders, and enhanced the project skills of Cancer System Innovation Managers. The toolkit has become a valuable guide for consolidating referral pathways for various cancers in the NSW local health districts and could apply to cancer services in other jurisdictions. LESSONS LEARNT: The pilot project showed that the toolkit is useful in developing referral pathways and reflects best stakeholder engagement practices. Local evidence should be generated to support systematic change and should include the perspectives of cancer patients and clinicians. NSW local health districts continue to use the toolkit methods to optimise care to improve outcomes for people living with cancer.

Education messages and strategies to inform the public, potential screening candidates and healthcare providers about lung cancer screening: A systematic review.

International lung cancer screening (LCS) trials, using low-dose computed tomography, have demonstrated clinical effectiveness in reducing mortality from lung cancer. This systematic review aims to synthesise the key messages and strategies that could be successful in increasing awareness and knowledge of LCS, and ultimately increase uptake of screening. Studies were identified via relevant database searches up to January 2022. Two authors evaluated eligible studies, extracted and crosschecked data, and assessed quality. Results were synthesised narratively. Of 3205 titles identified, 116 full text articles were reviewed and 22 studies met the inclusion criteria. Twenty studies were conducted in the United States. While the study findings were heterogenous, key messages mentioned across multiple studies were about: provision of information on LCS and the recommendations for LCS (n = 8); benefits and harms of LCS (n = 6); cost of LCS and insurance coverage for participants (n = 6) and eligibility criteria (n = 5). To increase knowledge and awareness, evidence from awareness campaigns suggests that presenting information about eligibility and the benefits and harms of screening, may increase screening intention and uptake. Evidence from behavioural studies suggests that campaigns supporting engagement with platforms such as educational videos and digital awareness campaigns might be most effective. Group based learning appears to be most suited to increasing health professionals' knowledge. This systematic review found a lack of consistent evidence to demonstrate which strategies are most effective for increasing participant healthcare professional and community awareness and education about LCS.

Use of Established Guidelines When Reporting on Interprofessional Team-Based Learning in Health Professions Student Education: A Systematic Review.

PURPOSE: Team-based learning (TBL) has gained popularity across the health professions, including in interprofessional contexts. The authors conducted this systematic review to summarize the published evidence regarding the extent, design, and practice of interprofessional TBL within health professions (including medical) degree programs to inform interprofessional education (IPE) educators and curricula designers. METHOD: In June 2020, the authors searched PubMed Central, CINAHL, Web of Science, and ERIC for original research articles describing TBL programs with student representation from multiple health professions degree programs that were published between January 2010 and June 2020. Included articles underwent data extraction for study characteristics (e.g., country of origin, topics covered, class descriptors) and the 7 core design elements of TBL: team formation, readiness assurance, immediate feedback, sequencing of in-class problem solving, the 4 Ss (significant problem, same problem, specific choice, and simultaneous reporting), incentive structure, and peer review. RESULTS: Twelve articles were included. Significant variability was noted in the application and reporting of the 7 core design elements of TBL, which highlighted challenges to the implementation of interprofessional TBL. CONCLUSIONS: Although the structured format of TBL provides a suitable pedagogy for IPE, this review identified challenges associated with the effective integration of IPE into TBL, including: the unequal distribution of students to teams as a result of there being multiple disciplines from different programs; varied levels of student experience with the pedagogy of TBL; a lack of resources required for large groups of students; timetabling requirements for multiple disciplines from different programs; inability to provide more than 1 TBL session; design of patient cases that suit multiple disciplines; alignment of topics within the curricula of multiple disciplines, programs, and universities; inequities in grading for different students within the same TBL program; and limited opportunity for peer review.

Supportive Care Interventions for People With Cancer Assisted by Digital Technology: Systematic Review.

BACKGROUND: Although relatively new, digital health interventions are demonstrating rapid growth because of their ability to facilitate access and overcome issues of location, time, health status, and most recently, the impact of a major pandemic. With the increased uptake of digital technologies, digital health has the potential to improve the provision of supportive cancer care. OBJECTIVE: This systematic review aims to evaluate digital health interventions for supportive cancer care. METHODS: Published literature between 2000 and 2020 was systematically searched in MEDLINE, PubMed, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and Scopus. Eligible publications were randomized controlled trials of clinician-led digital health interventions to support adult cancer patients. The interventions included were determined by applying a digital health conceptual model. Studies were appraised for quality using the revised Cochrane risk of bias tool. RESULTS: Twenty randomized controlled trials met the inclusion criteria for the analysis. Interventions varied by duration, frequency, degree of technology use, and applied outcome measures. Interventions targeting a single tumor stream, predominantly breast cancer, and studies involving the implementation of remote symptom monitoring have dominated the results. In most studies, digital intervention resulted in significant positive outcomes in patient-reported symptoms, levels of fatigue and pain, health-related quality of life, functional capacity, and depression levels compared with the control. CONCLUSIONS: Digital health interventions are helpful and effective for supportive care of patients with cancer. There is a need for high-quality research. Future endeavors could focus on the use of valid, standardized outcome measures, maintenance of methodological rigor, and strategies to improve patient and health professional engagement in the design and delivery of supportive digital health interventions. TRIAL REGISTRATION: PROSPERO CRD42020149730; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149730.

Mapping eHealth Education: Review of eHealth Content in Health and Medical Degrees at a Metropolitan Tertiary Institute in Australia.

BACKGROUND: With the increasing use of digital technology in society, there is a greater need for health professionals to engage in eHealth-enabled clinical practice. For this, higher education institutions need to suitably prepare graduates of health professional degrees with the capabilities required to practice in eHealth contexts. OBJECTIVE: This study aims to understand how eHealth is taught at a major Australian university and the challenges and suggestions for integrating eHealth into allied health, nursing, and medical university curricula. METHODS: Cross-disciplinary subject unit outlines (N=77) were reviewed for eHealth-related content, and interviews and focus groups were conducted with the corresponding subject unit coordinators (n=26). Content analysis was used to identify themes around challenges and opportunities for embedding eHealth in teaching. RESULTS: There was no evidence of a standardized approach to eHealth teaching across any of the health degrees at the university. Where eHealth content existed, it tended to focus on clinical applications rather than systems and policies, data analysis and knowledge creation, or system and technology implementation. Despite identifying numerous challenges to embedding eHealth in their subjects, unit coordinators expressed enthusiasm for eHealth teaching and were keen to adjust content and learning activities. CONCLUSIONS: Explicit strategies are required to address how eHealth capabilities can be embedded across clinical health degrees. Unit coordinators require support, including access to relevant information, teaching resources, and curriculum mapping, which clearly articulates eHealth capabilities for students across their degrees. Degree-wide conversations and collaboration are required between professional bodes, clinical practice, and universities to overcome the practical and perceived challenges of integrating eHealth in health curricula.

Developing and testing a mobile application for breastfeeding support: The Milky Way application.

BACKGROUND: Supporting women to continue breastfeeding is a global challenge. The Milky Way Program is an effective face to face intervention to increase breastfeeding rates up to six months postpartum. The sustainability and access to the Milky Way Program could be enhanced by transforming it into a mobile application allowing women to access relevant information from their own place at a convenient time. AIM: To explore the process of transforming the Milky Way Program into an acceptable and usable mobile health application. METHOD: Stakeholders including multidisciplinary researchers and end-users designed the application based on the Milky Way Program by using Persuasive System Design principles. A mixed-method approach was used in the development and evaluation process. Seven women were recruited through convenience sampling to pilot test the application. The women's feedback was collected through an online survey six weeks after birth and individual interviews at four months postpartum. FINDINGS: Women in the pilot study reported that the breastfeeding application was well designed, easy to use, interactive, reassuring and evidence-based with credible sources of information. CONCLUSION: The Persuasive System Design model combined with end-user engagement can feasibly inform the development of an acceptable and usable mobile health application for breastfeeding based on a proven clinical intervention. Further rigorous testing is required to evaluate the effectiveness of the application on breastfeeding initiation and duration.

Peer teacher training for health professional students: a systematic review of formal programs.

BACKGROUND: Skills in peer teaching, assessment and feedback are documented internationally as required graduate attributes for health professional students, placing emphasis on universities to prepare health professional graduates with teaching skills. The aim of this systematic review was to determine the rational, design, content and evaluation of student peer teacher training skills programs across the health professions. METHODS: In October 2017, a search was conducted of five databases (Pubmed, Embase, CINAHL, ERIC and Cochrane Collection) using combinations of key search terms: 'Student as teacher', 'near-peer teaching', 'student teacher', 'peer teacher', 'peer-to-peer', 'undergraduate', 'medical education', 'curriculum', 'program', 'training', 'allied health', 'health science', 'pharmacy', 'nurse', and 'medicine', with results restricted to articles published in English within the decade. Articles were excluded if they were not original research, focused on a teaching approach other than peer assisted learning or teaching, did not adequately describe a student teacher training component of at least 3 hrs duration, or addressed only clinical skills training and not teaching skills training. RESULTS: The two authors independently assessed 42 full-text articles for eligibility, with 19 articles satisfying criteria for inclusion. Dominating results were uni-disciplinary, faculty-led, non-mandated programs, targeting participants in senior years of training. Medicine was the dominant profession, with an obvious underrepresentation of the other health professions. Common program content included the foundations of education theory, teaching methods and techniques, and providing feedback. Summary and comparison of program design is restricted by gaps and inconsistencies in reporting, while the evaluation of programs remains largely subjective. CONCLUSIONS: Teaching is increasingly recognised as a core professional skill across the health workforce, with expectations to teach peers and colleagues, within and across professional disciplines, as well as to educate patients. Students, faculty and institutes may benefit from training programs being designed for implementation in any health profession; and further to this, implemented within an interprofessionally context. Consistent reporting of teacher training programs, and objective methods of evaluation would enable more in-depth investigation.

Defining success factors to describe coordinated care in cancer.

Providing coordinated care remains a challenge for cancer services globally. There is a lack of consensus in the literature about what constitutes successful coordinated care. This study aimed to define and prioritize a set of consensus-driven success factors that can lead to coordinated care. A mixed-methods approach was used that included literature review, a broad call for submissions from relevant stakeholders, and a priority-setting process based on a modified nominal group technique. Thirty articles that related to success factors in coordinated care were identified in the literature. Twenty submissions were received from a broad range of stakeholders. From these sources, a set of 20 success factors was derived. Seventy stakeholders attended a series of workshops across New South Wales, Australia, to review and prioritize these 20 success factors against significance and measurability. Clear consensus was reached on prioritizing two success factors linked to improving coordinated care from first presentation to diagnosis and ensuring that patients are routinely screened for physical and supportive care needs. Other highly ranked factors included the need for a comprehensive care plan and the identification of patients at higher risk for disjointed care. This study defines and prioritizes a set of success factors related to coordinated care in cancer. These success factors will be used to guide the development of interventions that target improving coordinated care as well as supporting the development of new funding models based on performance indicators derived from these factors.

An eHealth Capabilities Framework for Graduates and Health Professionals: Mixed-Methods Study.

BACKGROUND: The demand for an eHealth-ready and adaptable workforce is placing increasing pressure on universities to deliver eHealth education. At present, eHealth education is largely focused on components of eHealth rather than considering a curriculum-wide approach. OBJECTIVE: This study aimed to develop a framework that could be used to guide health curriculum design based on current evidence, and stakeholder perceptions of eHealth capabilities expected of tertiary health graduates. METHODS: A 3-phase, mixed-methods approach incorporated the results of a literature review, focus groups, and a Delphi process to develop a framework of eHealth capability statements. RESULTS: Participants (N=39) with expertise or experience in eHealth education, practice, or policy provided feedback on the proposed framework, and following the fourth iteration of this process, consensus was achieved. The final framework consisted of 4 higher-level capability statements that describe the learning outcomes expected of university graduates across the domains of (1) digital health technologies, systems, and policies; (2) clinical practice; (3) data analysis and knowledge creation; and (4) technology implementation and codesign. Across the capability statements are 40 performance cues that provide examples of how these capabilities might be demonstrated. CONCLUSIONS: The results of this study inform a cross-faculty eHealth curriculum that aligns with workforce expectations. There is a need for educational curriculum to reinforce existing eHealth capabilities, adapt existing capabilities to make them transferable to novel eHealth contexts, and introduce new learning opportunities for interactions with technologies within education and practice encounters. As such, the capability framework developed may assist in the application of eHealth by emerging and existing health care professionals. Future research needs to explore the potential for integration of findings into workforce development programs.

What is eHealth (6)? Development of a Conceptual Model for eHealth: Qualitative Study with Key Informants.

BACKGROUND: Despite rapid growth in eHealth research, there remains a lack of consistency in defining and using terms related to eHealth. More widely cited definitions provide broad understanding of eHealth but lack sufficient conceptual clarity to operationalize eHealth and enable its implementation in health care practice, research, education, and policy. Definitions that are more detailed are often context or discipline specific, limiting ease of translation of these definitions across the breadth of eHealth perspectives and situations. A conceptual model of eHealth that adequately captures its complexity and potential overlaps is required. This model must also be sufficiently detailed to enable eHealth operationalization and hypothesis testing. OBJECTIVE: This study aimed to develop a conceptual practice-based model of eHealth to support health professionals in applying eHealth to their particular professional or discipline contexts. METHODS: We conducted semistructured interviews with key informants (N=25) from organizations involved in health care delivery, research, education, practice, governance, and policy to explore their perspectives on and experiences with eHealth. We used purposeful sampling for maximum diversity. Interviews were coded and thematically analyzed for emergent domains. RESULTS: Thematic analyses revealed 3 prominent but overlapping domains of eHealth: (1) health in our hands (using eHealth technologies to monitor, track, and inform health), (2) interacting for health (using digital technologies to enable health communication among practitioners and between health professionals and clients or patients), and (3) data enabling health (collecting, managing, and using health data). These domains formed a model of eHealth that addresses the need for clear definitions and a taxonomy of eHealth while acknowledging the fluidity of this area and the strengths of initiatives that span multiple eHealth domains. CONCLUSIONS: This model extends current understanding of eHealth by providing clearly defined domains of eHealth while highlighting the benefits of using digital technologies in ways that cross several domains. It provides the depth of perspectives and examples of eHealth use that are lacking in previous research. On the basis of this model, we suggest that eHealth initiatives that are most impactful would include elements from all 3 domains.

Preparing E-Health Ready Graduates: A Qualitative Focus Group Study.

BACKGROUND: Well documented demand for an e-health ready workforce is placing increasing pressure on universities to deliver essential e-health education. AIM: We aimed to explore stakeholders' perceptions of e-health knowledge and skills anticipated of workforce-ready tertiary graduates from clinical health degree programs. METHOD: A qualitative research study of a purposively selected sample of 23 key informants with expertise and/or experience in e-health education, practice and/or policy was conducted. Data collection involved focus group interviews that were recorded, transcribed verbatim and underwent thematic analysis. FINDINGS: Three primary themes about e-health education and preparation of health graduates emerged from the analyses: 1) Reinforce fundamental competencies, 2) Acknowledge and adapt existing competencies, and 3) Introduce and provide opportunities for new learning. CONCLUSIONS AND IMPLICATIONS: This study will inform the articulation of a consensus driven set of core competencies for a cross-faculty e-health curriculum that aligns with workforce expectations. There is also potential for vertical integration of findings into workforce development programs.

Pathways to Lung Cancer Diagnosis: A Qualitative Study of Patients and General Practitioners about Diagnostic and Pretreatment Intervals.

RATIONALE: Pathways to lung cancer diagnosis and treatment are complex. International evidence shows significant variations in pathways. Qualitative research investigating pathways to lung cancer diagnosis rarely considers both patient and general practitioner views simultaneously. OBJECTIVES: To describe the lung cancer diagnostic pathway, focusing on the perspective of patients and general practitioners about diagnostic and pretreatment intervals. METHODS: This qualitative study of patients with lung cancer and general practitioners in Australia used qualitative interviews or a focus group in which participants responded to a semistructured questionnaire designed to explore experiences of the diagnostic pathway. The Model of Pathways to Treatment (the Model) was used as a framework for analysis, with data organized into (1) events, (2) processes, and (3) contributing factors for variations in diagnostic and pretreatment intervals. RESULTS: Thirty participants (19 patients with lung cancer and 11 general practitioners) took part. Nine themes were identified during analysis. For the diagnostic interval, these were: (1) taking patient concerns seriously, (2) a sense of urgency, (3) advocacy that is doctor-driven or self-motivated, and (4) referral: "knowing who to refer to." For the pretreatment interval, themes were: (5) uncertainty, (6) psychosocial support for the patient and family before treatment, and (7) communication among the multidisciplinary team and general practitioners. Two cross-cutting themes were: (8) coordination of care and "handing over" the patient, and (9) general practitioner knowledge about lung cancer. Events were perceived as complex, with diagnosis often being revealed over time, rather than as a single event. Contributing factors at patient, system, and disease levels are described for both intervals. CONCLUSIONS: Patients and general practitioners expressed similar themes across the diagnostic and pretreatment intervals. Significant improvements could be made to health systems to facilitate better patient and general practitioner experiences of the diagnostic pathway. This novel presentation of patient and general practitioner perspectives indicates that systemic interventions have a role in timely and appropriate referrals to specialist care and coordination of investigations. Systemic interventions may alleviate concerns about urgency of diagnostic workup, communication, and coordination of care as patients transition from primary to specialist care.

Closing evidence-practice gaps in lung cancer: Results from multi-methods priority setting in the clinical context.

AIM: To establish priorities for implementation research to reduce evidence-practice gaps in lung cancer care. METHODS: A modified Nominal Group Technique was used to prioritize evidence-practice gaps in lung cancer care with oncology professionals at three clinical study sites: one rural and two metropolitan. A multimethods design was used to gather quantitative and qualitative data. Quantitative data were analyzed with descriptive statistics, while qualitative data were thematically analyzed. RESULTS: Forty-two health professionals participated, representing a multidisciplinary spread across the care trajectory. A standout priority was identified: reducing the time from first presentation of symptoms to diagnosis and referral for treatment (gap 1), as well as significant focus on a number of presented priorities, including: utilization of active treatments; timely referral to palliative care services; screening as a potential diagnostic tool; and focusing on the care needs of our vulnerable population groups. We describe emerging themes from the qualitative analysis, including: patient help-seeking behavior, provider knowledge about lung cancer, service factors, patient and provider factors in not receiving treatment, the "flow on" effect of variations from optimal care, vulnerable populations of patients, psychosocial needs and early referral to palliative care services. CONCLUSION: This study is an example of a priority setting partnership between clinicians and health researchers. The priorities highlighted by this study guide future decision making for collaborative implementation of research in lung cancer care.

Adapting the nominal group technique for priority setting of evidence-practice gaps in implementation science.

BACKGROUND: There are a variety of methods for priority setting in health research but few studies have addressed how to prioritise the gaps that exist between research evidence and clinical practice. This study aimed to build a suite of robust, evidence based techniques and tools for use in implementation science projects. We applied the priority setting methodology in lung cancer care as an example. METHODS: We reviewed existing techniques and tools for priority setting in health research and the criteria used to prioritise items. An expert interdisciplinary consensus group comprised of health service, cancer and nursing researchers iteratively reviewed and adapted the techniques and tools. We tested these on evidence-practice gaps identified for lung cancer. The tools were pilot tested and finalised. A brief process evaluation was conducted. RESULTS: We based our priority setting on the Nominal Group Technique (NGT). The adapted tools included a matrix for individuals to privately rate priority gaps; the same matrix was used for group discussion and reaching consensus. An investment exercise was used to validate allocation of priorities across the gaps. We describe the NGT process, criteria and tool adaptations and process evaluation results. CONCLUSIONS: The modified NGT process, criteria and tools contribute to building a suite of methods that can be applied in prioritising evidence-practice gaps. These methods could be adapted for other health settings within the broader context of implementation science projects.

Collaborative research networks in health: a pragmatic scoping study for the development of an imaging network.

BACKGROUND: Collaborative research networks are often touted as a solution for enhancing the translation of knowledge, but questions remain about how to evaluate their impact on health service delivery. This pragmatic scoping study explored the enabling factors for developing and supporting a collaborative imaging network in a metropolitan university in Australia. METHODS: An advisory group was established to provide governance and to identify key informants and participants. Focus group discussions (n = 2) and semi-structured interviews (n = 22) were facilitated with representatives from a broad range of disciplines. In addition, a survey, a review of relevant websites (n = 15) and a broad review of the literature were undertaken to elicit information on collaborative research networks and perceived needs and factors that would support their involvement in a multi-disciplinary collaborative research network. Findings were de-identified and broad themes were identified. RESULTS: Participants identified human factors as having priority for developing and sustaining a collaborative research network. In particular, leadership, a shared vision and a communication plan that includes social media were identified as crucial for sustaining an imaging network in health research. It is important to develop metrics that map relationships between network members and the role that communication tools can contribute to this process. CONCLUSIONS: This study confirms that human factors remain significant across a range of collaborative endeavours. The use of focus group discussions, interviews, and literature and website reviews means we can now strongly recommend the primacy of human factors. More work is needed to identify how the network operates and what specific indicators or metrics help build the capacity of clinicians and scientists to participate in translational research.

Using the Knowledge, Process, Practice (KPP) model for driving the design and development of online postgraduate medical education.

BACKGROUND: Online learning is a primary delivery method for continuing health education programs. It is critical that programs have curricula objectives linked to educational models that support learning. Using a proven educational modelling process ensures that curricula objectives are met and a solid basis for learning and assessment is achieved. AIM: To develop an educational design model that produces an educationally sound program development plan for use by anyone involved in online course development. METHODS: We have described the development of a generic educational model designed for continuing health education programs. The Knowledge, Process, Practice (KPP) model is founded on recognised educational theory and online education practice. This paper presents a step-by-step guide on using this model for program development that encases reliable learning and evaluation. RESULTS: The model supports a three-step approach, KPP, based on learning outcomes and supporting appropriate assessment activities. It provides a program structure for online or blended learning that is explicit, educationally defensible, and supports multiple assessment points for health professionals. CONCLUSION: The KPP model is based on best practice educational design using a structure that can be adapted for a variety of online or flexibly delivered postgraduate medical education programs.

Medical students as peer tutors: a systematic review.

BACKGROUND: While Peer Assisted Learning (PAL) has long occurred informally in medical education, in the past ten years, there has been increasing international interest in formally organised PAL, with many benefits for both the students and institutions. We conducted a systematic review of the literature to establish why and how PAL has been implemented, focussing on the recruitment and training process for peer tutors, the benefits for peer tutors, and the competency of peer tutors. METHOD: A literature search was conducted in three electronic databases. Selection of titles and abstracts were made based on pre-determined eligibility criteria. We utilized the 'AMEE Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30' to assist us in establishing the review aims in a systematic review of the literature between 2002 and 2012. Six key questions were developed and used in our analysis of particular aspects of PAL programs within medical degree programs. RESULTS: We found nineteen articles that satisfied our inclusion criteria. The PAL activities fell into three broad categories of teacher training, peer teaching and peer assessment. Variability was found in the reporting of tutor recruitment and training processes, tutor outcomes, and tutor competencies. CONCLUSION: Results from this review suggest that there are many perceived learning benefits for student tutors. However, there were mixed results regarding the accuracy of peer assessment and feedback, and no substantial evidence to conclude that participation as a peer tutor improves one's own examination performance. Further research into PAL in medicine is required if we are to better understand the relative impact and benefits for student tutors.

Applying established guidelines to team-based learning programs in medical schools: a systematic review.

PURPOSE: Team-based learning (TBL), a structured form of small-group learning, has gained popularity in medical education in recent years. A growing number of medical schools have adopted TBL in a variety of combinations and permutations across a diversity of settings, learners, and content areas. The authors conducted this systematic review to establish the extent, design, and practice of TBL programs within medical schools to inform curriculum planners and education designers. METHOD: The authors searched the MEDLINE, PubMed, Web of Knowledge, and ERIC databases for articles on TBL in undergraduate medical education published between 2002 and 2012. They selected and reviewed articles that included original research on TBL programs and assessed the articles according to the seven core TBL design elements (team formation, readiness assurance, immediate feedback, sequencing of in-class problem solving, the four S's [significant problem, same problem, specific choice, and simultaneous reporting], incentive structure, and peer review) described in established guidelines. RESULTS: The authors identified 20 articles that satisfied the inclusion criteria. They found significant variability across the articles in terms of the application of the seven core design elements and the depth with which they were described. The majority of the articles, however, reported that TBL provided a positive learning experience for students. CONCLUSIONS: In the future, faculty should adhere to a standardized TBL framework to better understand the impact and relative merits of each feature of their program.