Measurement without management: qualitative evaluation of a voluntary audit & feedback intervention for primary care teams.

BACKGROUND: The use of clinical performance feedback to support quality improvement (QI) activities is based on the sound rationale that measurement is necessary to improve quality of care. However, concerns persist about the reliability of this strategy, known as Audit and Feedback (A&F) to support QI. If successfully implemented, A&F should reflect an iterative, self-regulating QI process. Whether and how real-world A&F initiatives result in this type of feedback loop are scarcely reported. This study aimed to identify barriers or facilitators to implementation in a team-based primary care context. METHODS: Semi-structured interviews were conducted with key informants from team-based primary care practices in Ontario, Canada. At the time of data collection, practices could have received up to three iterations of the voluntary A&F initiative. Interviews explored whether, how, and why practices used the feedback to guide their QI activities. The Consolidated Framework for Implementation Research was used to code transcripts and the resulting frameworks were analyzed inductively to generate key themes. RESULTS: Twenty-five individuals representing 18 primary care teams participated in the study. Analysis of how the A&F intervention was used revealed that implementation reflected an incomplete feedback loop. Participation was facilitated by the reliance on an external resource to facilitate the practice audit. The frequency of feedback, concerns with data validity, the design of the feedback report, the resource requirements to participate, and the team relationship were all identified as barriers to implementation of A&F. CONCLUSIONS: The implementation of a real-world, voluntary A&F initiative did not lead to desired QI activities despite substantial investments in performance measurement. In small primary care teams, it may take long periods of time to develop capacity for QI and future evaluations may reveal shifts in the implementation state of the initiative. Findings from the present study demonstrate that the potential mechanism of action of A&F may be deceptively clear; in practice, moving from measurement to action can be complex.

Beyond quality improvement: exploring why primary care teams engage in a voluntary audit and feedback program.

BACKGROUND: Despite its popularity, the effectiveness of audit and feedback in support quality improvement efforts is mixed. While audit and feedback-related research efforts have investigated issues relating to feedback design and delivery, little attention has been directed towards factors which motivate interest and engagement with feedback interventions. This study explored the motivating factors that drove primary care teams to participate in a voluntary audit and feedback initiative. METHODS: Interviews were conducted with leaders of primary care teams who had participated in at least one iteration of the audit and feedback program. This intervention was developed by an organization which advocates for high-quality, team-based primary care in Ontario, Canada. Interview transcripts were coded using the Consolidated Framework for Implementation Research and the resulting framework was analyzed inductively to generate key themes. RESULTS: Interviews were completed with 25 individuals from 18 primary care teams across Ontario. The majority were Executive Directors (14), Physician leaders (3) and support staff for Quality Improvement (4). A range of motivations for participating in the audit and feedback program beyond quality improvement were emphasized. Primarily, informants believed that the program would eventually become a best-in-class audit and feedback initiative. This reflected concerns regarding existing initiatives in terms of the intervention components and intentions as well as the perception that an initiative by primary care, for primary care would better reflect their own goals and better support desired patient outcomes. Key enablers included perceived obligations to engage and provision of support for the work involved. No teams cited an evidence base for A&F as a motivating factor for participation. CONCLUSIONS: A range of motivating factors, beyond quality improvement, contributed to participation in the audit and feedback program. Findings from this study highlight that efforts to understand how and when the intervention works best cannot be limited to factors within developers' control. Clinical teams may more readily engage with initiatives with the potential to address their own long-term system goals. Aligning motivations for participation with the goals of the audit and feedback initiative may facilitate both engagement and impact.

Modified Low-Flow Arthroscopic Sandwich Technique for Complex Osteochondral Lesions of the Talus.

Treatment of osteochondral lesions of the talus proves to be challenging given the unique anatomy of the intra-articular surface and associated complexity of larger lesions. Simple bone marrow-stimulating procedures for large complex lesions often lead to poor results with increased risk of lesion progression, refractory pain, and associated functional limitations. Other methods of osteochondral autografts or allografts often require osteotomies, bone windows, or fibrin glue, which are associated with donor pain and nonunion. Thus, for larger and cystic lesions, we report our experience using a modified low-flow arthroscopic sandwich technique consisting of autologous cancellous bone graft, followed by a viable cryopreserved cartilage fiber, cartilage allograft matrix putty.

A Cadaveric Comparison of Approaches for Exposure of the Volar Distal Radius: Is There a Utilitarian Approach?

BACKGROUND: It remains unclear whether exposure for planned fixation of distal radius fractrues is superior with any given approach, and whether a single utilitarian approach exists that permits reliable complete exposure of the volar distal radius. METHODS: A cadaveric study was performed using 10 matched specimens. Group 1 consisted of 3 radially based approaches (standard flexor carpi radialis [FCR], standard FCR with radial retraction of FCR and flexor pollicis longus [FPL] tendons, extended FCR). Group 2 consisted of 2 ulnarly based approaches (volar ulnar, extended carpal tunnel). The primary outcome was total width of exposed distal radius at the watershed line. Mann-Whitney U and Wilcoxon rank testing was used to identify differences. RESULTS: The standard FCR approach exposed 29 mm (90%), leaving on average 3 mm (10%) of the ulnar corner unexposed. Retracting the FCR and FPL tendons radially allows for an extra 1 mm of volar ulnar corner exposure. Finally, converting to an extended FCR approach provided 100% exposure in all specimens. The volar ulnar exposure however provided exposure to only 9 mm (37%), leaving 20 mm (62.5%) left unexposed radially. The extended carpal tunnel provided exposure to 21 mm (65%), leaving 11 mm (35%) radially unexposed. Differences between each group were statistically significant (P < .05). CONCLUSIONS: The extended FCR approach exposed 100% of the volar distal radius in our study and may serve as a utilitarian volar surgical approach for exposure and fixation of distal radius fractures. Additional knowledge of the limitations of alternative approaches can be helpful in surgical planning.

Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures.

Background: With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs. Methods: A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery. Results: 56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication. Conclusions: Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients. Level of Evidence: Prognostic, Level III.

Evidence synthesis - A systematized literature review on the associations between neighbourhood built characteristics and walking among Canadian adults. / Synthèse des données probantes - Associations entre les caractéristiques de l'environnement bâti du quartier et la marche chez les adultes canadiens : une revue systématisée de la littérature.

INTRODUCTION: Evidence to date suggests that the built environment has the potential to facilitate and even discourage physical activity. A limitation of previous reviews is that they have typically not been country-specific. We conducted a systematized literature review of quantitative studies that estimated associations between the built environment-which were objectively measured-and walking among Canadian adults. METHODS: Five scientific databases were searched for peer-reviewed studies published in all years up to December 31, 2016, that estimated the association between the built environment (i.e. objectively measured using audits and Geographic Information Systems [GIS]) and physical activity among a sample of Canadian adults. The database searches, title and abstract screen, full-text review and data extraction were undertaken by two reviewers. RESULTS: Of 4140 articles identified, 25 met the inclusion criteria. Most studies included data from a single Canadian province. All but two studies were cross-sectional. Most studies captured self-reported walking for transportation and walking for any purpose. Overall walkability and land use were consistently associated with walking for transportation, while proximity to destinations was associated with walking for any purpose. CONCLUSION: Our review findings suggest that the built environment is potentially important for supporting adult walking. Overall walkability, land use and proximity to destinations appear to be important given their association with transportation walking and walking for any purpose.

INTRODUCTION: Les données récentes semblent indiquer que l'environnement bâti peut faciliter comme décourager l'activité physique. Les revues de la littérature disponibles ont en général comme limite de ne pas être spécifiques à un pays. Nous avons effectué une revue systématisée des études quantitatives qui analysent les associations, mesurées objectivement, entre l'environnement bâti et la marche chez les adultes canadiens. MÉTHODOLOGIE: Nous avons effectué une recherche dans cinq bases de données scientifiques pour sélectionner les études évaluées par les pairs et publiées jusqu'au 31 décembre 2016 ayant analysé l'association entre l'environnement bâti (mesuré objectivement grâce à des vérifications et à un système d'information géographique [SIG]) et l'activité physique chez un échantillon d'adultes canadiens. Deux chercheurs ont effectué les recherches dans les bases de données, ont filtré les articles par titre et résumé, ont revu l'intégralité des textes sélectionnés et en ont extrait les données. RÉSULTATS: Parmi les 4 140 articles recensés, 25 respectaient nos critères d'inclusion. La plupart des études contenaient des données sur une seule province canadienne. Toutes les études sauf deux étaient transversales. La plupart des études disposaient d'information autodéclarée sur la marche comme mode de déplacement et la marche sans but spécifié. Le potentiel piétonnier global et l'occupation des sols ont été systématiquement associés à la marche comme mode de déplacement, alors que la proximité de la destination a été associée à la marche sans but spécifié. CONCLUSION: Les résultats de notre revue de littérature suggèrent que l'environnement bâti possède un fort potentiel susceptible d'encourager la marche chez les adultes. Ce sont surtout le potentiel piétonnier global, l'occupation des sols et la proximité de la destination qui sont importants, si l'on se fie à leur association à la marche comme mode de déplacement et à la marche sans but spécifié.

An Alternative Approach to Scoring the MTA-SNAP-IV to Guide Attention-Deficit/Hyperactivity Disorder Medication Treatment Titration towards Symptom Remission: A Preliminary Consideration.

OBJECTIVE: The Multimodal Treatment Study for Attention-Deficit/Hyperactivity Disorder Swanson, Nolan, and Pelham, Version IV (MTA-SNAP-IV) is a common rating scale to measure attention-deficit/hyperactivity disorder (ADHD) symptoms during medication treatment. Relying on the traditional scoring approach for this instrument to identify symptom remission, however, may leave a child with significant residual symptoms. The objective of this study was to examine an alternative scoring approach for this instrument to identify the extent of residual symptoms for children completing ADHD medication treatment. METHODS: Parent and teacher ratings on the ADHD symptom component of the MTA-SNAP-IV were extracted from medical records of 80 children completing medication treatment at a specialty clinic in Canada. Data were scored in two ways. 1) Traditional scoring based on assigning a value ranging from 0 to 3 for response options: "Not at all," "Just a little," "Pretty much," or "Very much," for each symptom and then determining a mean across items, and 2) alternative scoring based on assigning values of 0, 0, 0.5, and 1 across the same response options and summing the total across items. Symptom remission based on the former is defined as a mean value ≤ 1, and for the latter it is defined as a summed value equal to 0. RESULTS: Children were significantly less likely to be classified as symptom remitted under the alternative scoring method based on parent, teacher, and combined parent-teacher ratings. Using the alternative scoring approach, residual symptoms were identified for 25%, 39%, and 70% of children classified as symptom remitted (under traditional scoring rules) by parents, teachers, and parents/teachers combined, respectively. CONCLUSIONS: Potential "residual" ADHD symptoms were identified in many children attaining symptom remission using the traditional scoring approach; however, further scrutiny of this alternative scoring approach is required. Although it may improve the ability to detect residual symptoms that could signal the need for further intervention to achieve symptom remission, it may increase the risk of over treatment.

Comparative desiccation tolerance of two Sphagnum mosses.

Sphagnum fallax (Klinggr.) Klinggr., a moss growing in hollows close to the water table, is more desiccation tolerant than S. nemoreum Scop., a hummock former distributed high above the hollows. Sphagnum fallax recovered to a greater proportion of its predesiccation photosynthetic rate after one and five days of tissue dryness. Further, a greater percentage of S. fallax plants survived five and ten day periods at low tissue water contents. Longer desiccated periods and lower water contents during these periods decreased both photosynthetic recovery and survival.Water contents measured in Bloomingdale Bog (Adirondack Mountains, NY, USA) showed that S. fallax probably dries more frequently and for longer periods than S. nemoreum. These results support previous findings that the greater ability of S. nemoreum to remain moist in the field is the most important character in its success as a hummock former. Greater tolerance of desiccation helps S. fallax to compensate for its greater tendency to become dry, and is a key physiological feature enabling it to dominate hollows.

Treatment receipt and outcomes from a clinic employing the attention-deficit/hyperactivity disorder treatment guideline of the children's medication algorithm project.

OBJECTIVE: Little is known about the pattern of service receipt and outcomes from clinics implementing best practice guidelines in child mental health. This study aimed to determine these variables for a clinic that implemented an attention-deficit/hyperactivity disorder (ADHD) treatment guideline proposed by the Children's Medication Algorithm Project (CMAP). METHODS: Secondary analyses of medical record extracts were conducted for children who received treatment from 2007 to 2012 in a specialty clinic linked to a public children's hospital in Canada. Patterns of medication selection and dosing were compared with CMAP guidelines. Outcomes were based on parent and teacher ratings on the ADHD portion of the Multimodal Treatment Study for ADHD (MTA)- Swanson, Nolan, and Pelham, Version IV (SNAP-IV). RESULTS: Data were available for 132 children (ages 5-14), 81.8% of whom had no previous ADHD medication exposure, and 97.0% of whom had started at least one medication. Methylphenidate was used first for 59.8% of children, whereas 33.3% started with an amphetamine product. Of the 47.0% of children who progressed to a second medication trial, 88.7% tried a stimulant from a second class. In total, 19.7% tried atomoxetine, which was typically used as a third stage choice (i.e., after two different stimulant exposures). Stage four to six medications were rarely used, rather stimulants were retried after atomoxetine and/or medication combinations were tried. Symptomatic remission at the end of treatment was achieved by 70.4% and 82.4%, according to parents and teachers respectively, for those with outcome data and who completed treatment. Outcomes for those further along the treatment algorithm were similar to discharges at the beginning of the algorithm. CONCLUSIONS: The high rates of symptomatic remission observed within this clinical service may be a function of adherence to CMAP recommendations. However, the lack of a comparison group or experimental design prevents determination of causality. Additional investigations of the impacts of implementing evidence-based guidelines are critically needed, with proposed benchmarks to inform outcome evaluations.

Identification of a region of the Arabidopsis AtAOX1a promoter necessary for mitochondrial retrograde regulation of expression.

Chemical inhibition of the mitochondrial electron transport chain (mtETC) by antimycin A (AA) or the TCA cycle by monofluoroacetate (MFA) causes increased expression of nucleus-encoded alternative oxidase (AOX) genes in plants. In order to better understand the mechanisms of this mitochondrial retrograde regulation (MRR) of gene expression, constructs containing deleted and mutated versions of a promoter region of the Arabidopsis thaliana AOX1a gene (AtAOX1a) controlling expression of the coding region of the enhanced firefly luciferase gene were employed to identify regions of the AtAOX1a promoter important for induction in response to mtETC or TCA cycle inhibition. Transient transformation coupled with in vitro and in vivo assays as well as plants containing transgenes with truncated promoter regions were used to identify a 93 base pair portion of the promoter, termed the MRR region, that was necessary for induction. Further mutational analyses showed that most of the 93 bp MRR region is important for both AA and MFA induction. Sub-regions within the MRR region that are especially important for strong induction by both AA or MFA were identified. Specific mutations in a W-box and Dof motifs in the MRR region indicate that these specific motifs are not important for induction. Recent evidence suggests that MRR of AOX genes following inhibition of the mtETC is via a separate signaling pathway from MRR resulting from metabolic shifts, such as those that result from MFA treatment. Our data suggest that these signaling pathways share regulatory regions in the AtAOX1a promoter. Arabidopsis proteins interacted specifically with a probe containing the MRR region, as shown by electrophoretic mobility shift assays and Southwestern blotting. These interactions were eliminated under reducing conditions.