Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial.

BACKGROUND: Experts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs). OBJECTIVE: To develop, adapt and validate DECISION+ and estimate its impact on the decision of family physicians (FPs) and their patients on whether to use antibiotics for ARIs. DESIGN: Two-arm parallel clustered pilot randomized controlled trial. SETTING AND PARTICIPANTS: Four family medicine groups were randomized to immediate DECISION+ participation (the experimental group) or delayed DECISION+ participation (the control group). Thirty-three FPs and 459 patients participated. INTERVENTION: DECISION+ is a multiple-component, continuing professional development program in shared decision making that addresses the use of antibiotics for ARIs. MAIN OUTCOME MEASURES: Throughout the pilot trial, DECISION+ was adapted in response to participant feedback. After the consultation, patients and FPs independently self-reported the decision (immediate use, delayed use, or no use of antibiotics) and its quality. Agreement between their decisional conflict was assessed. Two weeks later, patients assessed their decisional regret and health status. RESULTS: Compared to the control group, the experimental group reduced its immediate use of antibiotics (49 vs. 33% absolute difference = 16%; P = 0.08). Decisional conflict agreement was stronger in the experimental group (absolute difference of Pearson's r = 0.26; P = 0.06). Decisional regret and perceptions of the quality of the decision and of health status in the two groups were similar. DISCUSSION AND CONCLUSIONS: DECISION+ was developed successfully and appears to reduce the use of antibiotics for ARIs without affecting patients' outcomes. A larger trial is needed to confirm this observation.

Home environmental factors associated with poor asthma control in Montreal children: a population-based study.

BACKGROUND: Home environmental exposures may aggravate asthma. Few population-based studies have investigated the relationship between asthma control in children and home environmental exposures. OBJECTIVE: Identify home environmental exposures associated with poor control of asthma among asthmatic children less than 12 years of age in Montreal (Quebec, Canada). METHODS: This cross-sectional population-based study used data from a respiratory health survey of Montreal children aged 6 months to 12 years conducted in 2006 (n = 7980). Asthma control was assessed (n = 980) using an adaptation of the Canadian asthma consensus report clinical parameters. Using log-binomial regression models, prevalence ratios (PRs) with 95% confidence intervals (95% CIs) were estimated to explore the relationship between inadequate control of asthma and environmental home exposures, including allergens, irritants, mold, and dampness indicators. Subjects with acceptable asthma control were compared with those with inadequate disease control. RESULTS: Of 980 children with active asthma in the year prior to the survey, 36% met at least one of the five criteria as to poor control of their disease. The population's characteristics found to be related with a lack of asthma control were younger age, history of parental atopy, low maternal education level, foreign-born mothers, and tenant occupancy. After adjustments, children living along high-traffic density streets (PR, 1.35; 95% CI, 1.00-1.81) and those with their bedroom or residence at the basement level (PR, 1.30; 95% CI, 1.01-1.66) were found to be at increased risk of poor asthma control. CONCLUSIONS: Suboptimal asthma control appears to be mostly associated with traffic, along with mold and moisture conditions, the latter being a more frequent exposure and therefore having a greater public health impact.

Interprofessional learning in the trenches: fostering collective capability.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value--caring for patients--to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

Neurologic and neuropsychological symptoms during the first year after an electric shock: results of a prospective multicenter study.

OBJECTIVES: To assess the prevalence of neurologic and neuropsychological symptoms in the short-term and 1 year after an electric shock and to explore whether any of these were associated with risk factors. METHODS: Patients presenting to one of 21 EDs between October 2000 and November 2004 were eligible to be enrolled in a prospective observational study after an electric shock if they had risk factors for late arrhythmias. Telephone follow-up was done to evaluate the appearance of symptoms. RESULTS: A total of 30 (26%) of 114 patients complained of neurologic or neuropsychological symptoms at a median of 52 days post-electric shock. At 1 year, 24 (28%) of 86 patients complained of neurologic or neuropsychological symptoms. None of the risk factors evaluated were associated with the symptoms. CONCLUSION: The prevalence of the symptoms we observed should alarm all emergency physicians that the effect of electricity can cause late neurologic and neuropsychological manifestations.

Cardiac monitoring of high-risk patients after an electrical injury: a prospective multicentre study.

OBJECTIVE: To report our experience monitoring patients with previously identified theoretical risk factors of significant electrical injury. METHODS: Patients who presented to one of 21 emergency departments between October 2000 and November 2004 were eligible to be enrolled in a prospective observational cohort study if after an electric shock they had one of several risk factors (transthoracic current, tetany, loss of consciousness or voltage source > or =1000 V) and therefore needed cardiac monitoring. RESULTS: Of the 134 patients enrolled, most were monitored because of transthoracic current (n = 60), transthoracic current and tetany (n = 39), tetany (n = 10), or voltage > or =1000 V (n = 10). There were 15/134 (11%) patients with abnormal initial ECGs. No patient developed potentially lethal late arrhythmia during the 24 hours of cardiac monitoring. CONCLUSION: Although only patients deemed at risk of late arrhythmias were monitored, none developed potentially lethal late arrhythmias. Asymptomatic patients with transthoracic current and/or tetany and a normal initial ECG do not require cardiac monitoring after an electrical injury with voltage <1000 V and no loss of consciousness.

Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents.

BACKGROUND: Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents' proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone. METHODS: Junior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions. RESULTS: After the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher's exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher's exact test p = 0.0055). CONCLUSIONS: Our study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Knowledge translation: the role and place of practice reflection.

Reflection is the mechanism by which we contemplate and try to understand relatively complex and sometimes troubling ideas for which there is no obvious solution. Reflection allows us to transform current ideas and experiences into new knowledge and action. Personal experiences and organizational feedback can trigger reflection, whereas a lack of time, available colleagues, and social networks detract from the ability professionals have to reflect. Educational programs can encourage reflection through the judicious use of case-based discussion, formal and informal needs assessments, and commitment to change exercises. Learning journals and personal learning projects are self-directed methods that facilitate reflection. In the workplace, critical incident techniques and debriefing of cases provide opportunities for thoughtful inquiry. Additional study is needed to understand how and why reflection works to transform surface learning into deep learning and change in practice; how reflection enhances the integration of reading, collegial interchange, and classroom discussion into practice; and how technology can enhance reflection.

Integrating clinical practice guidelines into daily practice: impact of an interactive workshop on drafting of a written action plan for asthma patients.

INTRODUCTION: Written action plans (WAPs) are instructions that enable asthmatics to manage their condition appropriately and are recommended by current asthma clinical practice guidelines (CPGs). However, general practitioners (GPs) rarely draft WAPs for their patients. An interactive, case-based workshop for asthma, combined with an objective structured clinical examination (OSCE), was developed to increase GPs' knowledge and use of WAPs in Québec. METHODS: The study compared 24 GPs receiving an OSCE preworkshop and 12 months post-workshop (group 1) with 16 GPs receiving an OSCE preworkshop and at 6 and 12 months post-workshop (group 2). Participants received no feedback on their OSCE performance. During the workshop, which presented a preformatted tool to aid drafting of the WAPs, all 40 GPs worked individually and in small groups to answer questions on a hypothetical clinical case and then discussed the responses with a facilitator and an asthma specialist. RESULTS: Only group 2 GPs showed a significant improvement in knowledge of WAPs 12 months post-workshop (p = .01). The likelihood of prescribing WAPs to patients increased in group 2 to a degree approaching statistical significance (p = .070), and there was a borderline nonsignificant trend for prescribing practice to improve more among group 2 GPs than among group 1 GPs (p = .052). There was also a nonsignificant trend for 6-month OSCE to increase attendance at the 12-month OSCE. DISCUSSION: An interactive workshop employing a preformatted WAP tool and a reinforcing OSCE at 6 months yielded improved knowledge of WAPs at 1 year. Although originally developed as a form of evaluation, the OSCE appears to have formative value even when correction is not provided and may increase the effectiveness of continuing medical education interventions to enhance CPG implementation.

Using speed dating sessions to foster collaboration in continuing interdisciplinary education.

INTRODUCTION: There are numerous examples of care gaps that could be reduced through enhanced knowledge exchange and practice collaboration between medical specialist physicians. In this paper, we report preliminary results on using speed-dating sessions (SDSs) to stimulate the development of continuing interdisciplinary education (CIDE) activities. METHODS: In 2007, a 35-minute SDS was carried out during a 2-hour faculty development workshop to provide continuing medical education (CME) directors of Quebec's 35 medical specialist associations with a formal opportunity to quickly share clinical issues and goals. A post-workshop survey was used to assess participants' satisfaction and whether they had met new colleagues, learned about interdisciplinary issues, and discovered opportunities for collaboration. CME accreditation files were audited to assess the occurrence of CIDE activities in the year prior and the 2 years that followed the workshop. CME directors were called to assess whether the development of these activities was directly attributable to their participation in the SDS. RESULTS: CME directors of 26 specialist physician associations attended the faculty development workshop. The vast majority of survey respondents (n = 18/20) were satisfied with the SDS and believed that this method was a stimulating and efficient way to meet new colleagues, quickly share clinical issues and goals, learn about unexpected but important interdisciplinary issues, and identify opportunities for CIDE collaboration. Sixty percent (12/20) reported having identified at least 1 opportunity for collaboration that was worth pursuing in the near future, and 19% of attending CME directors (5/26) developed a CIDE activity within 2 years, as compared with none in the previous year and for the 9 nonparticipating associations. DISCUSSION: Results suggest that SDSs enhanced networking, knowledge exchange, and collaboration in continuing education among CME providers who participated in a faculty development activity on CIDE.

Physicians' assessment of asthma control in low vs. high asthma-related morbidity regions.

OBJECTIVES: To analyze physician-assessed asthma control and care compared with current guidelines criteria, in a cohort of patients from a high (HMR) vs. low asthma-related morbidity region (LMR), as determined by a large-scale populational survey (asthma cartography). DESIGN: Analysis of questionnaires provided by 47 primary care physicians and asthmatic patients (HMR: 74; LMR: 73). RESULTS: Asthma control was often suboptimal in both regions. In both regions, asthma control, the pattern of prescriptions for asthma, patient compliance, and referral for asthma education were similar; 32% of patients had been referred for asthma education, whereas 65% wanted to know more about their asthma. CONCLUSIONS: Results of regional/local cohort studies differ from those of a "population cartography," the former probably more likely reflecting individual medical practices of physicians interested in taking part in such studies.

An integrated approach to improving appropriate use of anti-inflammatory medication in the treatment of osteoarthritis in Québec (Canada): the CURATA model.

CURATA is a multifaceted continuing medical education (CME) intervention, developed with input from 12 healthcare organizations to address the gap between current and recommended osteoarthritis (OA) treatment of general practitioners in Québec, Canada. Focusing on appropriate prescription of non-steroidal anti-inflammatory drugs, including cyclooxygenase-2 selective inhibitors (coxibs), the intervention comprised small-group, case-based workshops modelled after the Script Concordance test, and a decision tool reflecting current evidence-based clinical practice guidelines. A self-reported questionnaire measured knowledge of recommended OA treatment on an eight-point scale. Participants (n = 381) showed a mean 10.1% improvement in questionnaire score immediately following the workshop (15.2% improvement relative to mean pre-workshop score). Knowledge was maintained for three months post-workshop.

Towards excellence in asthma management (TEAM): a populational disease-management model.

Asthma management is not always optimal, and deficiencies such as inadequate treatment and insufficient patient education are often reported. Towards Excellence in Asthma Management (TEAM) is a four-phase disease management program of the Quebec Asthma Education Network (QAEN), to be carried out over a 5-year period. The program aims to achieve a continuous improvement of asthma management by caregivers and patients. The first phase, completed in January 2000, consisted of determining the actual level of asthma-associated morbidity and mortality in various Quebec regions. The second phase, which began in September 1999, included three parts: 1. Definition of the burden of asthma, taking into account the socioeconomic consequences of the disease and the quality of life of the patients, 2. Comparison of current medical practices with the Canadian Asthma Consensus Guidelines for adult and pediatric populations, 3. Evaluation of the level of compliance with medical treatment and with the environmental changes recommended to asthmatic patients. This phase is carried out via a cohort study of physicians, mainly general practitioners and pediatricians, generating a patient cohort study, in addition to substudies evaluating specific aspects of asthma care. Once the care gap is identified, it will be possible to define, apply, and evaluate a series of interventions for physicians, other health professionals, and patients. The interventions will be particularly targeted at regions where asthma incidence and morbidity are higher. We hope that this model of disease management will progressively reduce the burden associated with asthma, and potentially other chronic diseases, and will result in the more effective use of health services.