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Ian D Graham

Publications and source records attributed to Ian D Graham.

At least 37 records · Page 2Linked to original sources
PubMed2005

Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians' transfusion practices.

BACKGROUND: Transfusion services have used various techniques to reduce blood product utilization. Given the potential adverse effects of transfusions and the resources consumed in implementing strategies to reduce transfusions, there is a need to understand their effectiveness. Therefore, we performed a systematic review of the literature to examine the effectiveness of behavioral interventions to reduce blood product utilization. METHODS: We identified all relevant articles through the use of electronic searches of MEDLINE and EMBASE, as well as hand searches of review articles and personal files. The electronic searches included articles published between January 1966 and May 2003. The searches included the terms blood transfusion, plasma exchange, guidelines, education, practice patterns, and professional practice. The outcomes of interest were the number of units transfused and the proportion of patients who received transfusions. RESULTS: Nineteen studies examining the effectiveness of single (guidelines, prospective audits, retrospective audits, and reminders) or multifaceted interventions in reducing red blood cell, platelet, plasma, cryoprecipitate, and albumin transfusions met the inclusion criteria. Eighteen studies demonstrated a relative reduction in the number of units given (range, 9%-77%) or the proportion of patients receiving transfusions (range, 17%-79%). The reported reductions were qualitatively similar for the different blood products studied. No particular intervention or combination of interventions appeared more effective in reducing utilization. CONCLUSIONS: Behavioral interventions, including simple interventions, appear to be effective in changing physician transfusion practices and reducing blood utilization. Appropriately designed clinical trials are still needed to determine the relative effectiveness of different interventions to change practices.

Behavior↗
PubMed2005

Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines.

BACKGROUND: The AGREE instrument has been validated for evaluating Clinical Practice Guidelines (CPG) pertaining to medical care. This study evaluated the reliability and validity of physical therapists using the AGREE to assess quality of CPGs relevant to physical therapy practice. METHODS: A total of 69 physical therapists participated and were classified as generalists, specialist or researchers. Pairs of appraisers within each category evaluated independently, a set of 6 CPG selected at random from a pool of 55 CPGs. RESULTS: Reliability between pairs of appraisers indicated low to high reliability depending on the domain and number of appraisers (0.17-0.81 for single appraiser; 0.30-0.96 when score averaged across a pair of appraisers). The highest reliability was achieved for Rigour of Development, which exceeded ICC> 0.79, if scores from pairs of appraisers were pooled. Adding more than 3 appraisers did not consistently improve reliability. Appraiser type did not determine reliability scores. End-users, including study participants and a separate sample of 102 physical therapy students, found the AGREE useful to guide critical appraisal. The construct validity of the AGREE was supported in that expected differences on Rigour of Development domains were observed between expert panels versus those with no/uncertain expertise (differences of 10-21% p = 0.09-0.001). Factor analysis with varimax rotation, produced a 4-factor solution that was similar, although not in exact agreement with the AGREE Domains. Validity was also supported by the correlation observed (Kendall-tao = 0.69) between Overall Assessment and the Rigour of Development domain. CONCLUSION: These findings suggest that the AGREE instrument is reliable and valid when used by physiotherapists to assess the quality of CPG pertaining to physical therapy health services.

Cardiology↗
PubMed2005

Evaluation of a decision aid for making choices about intubation and mechanical ventilation in chronic obstructive pulmonary disease.

To assist patients with chronic obstructive pulmonary disease (COPD) in advance planning for life-threatening exacerbations, we developed a structured decision aid that describes the process, risks, and outcomes of intubation and mechanical ventilation (MV). Thirty-three patients with severe COPD took part in a before-after evaluation study. At baseline, only two participants (6%) reported that they had already made an advance decision about MV. After reviewing the decision aid, 31 participants (94%) reported that they had made a choice, which in 23 cases (74% of those deciding) was to forego MV. These choices were associated with more accurate expectations of MV outcome, and reduced decisional conflict. Qualitatively, participants who would accept MV emphasized their wish to prolong life, whereas those who would forego MV were more influenced by the burdens of treatment and the perception of a poor long-term outcome. However, there was evidence that 24% of participants did not completely comprehend the decision aid and 27% found the experience to be stressful. These findings indicate that a decision aid for MV helps patients plan for life-threatening exacerbations, and may be a useful adjunct to counseling for some patients with severe COPD.

Adult↗
PubMed2005

Revisiting transfusion practices in critically ill patients.

OBJECTIVE: The objective of this study was to characterize contemporary red cell transfusion practice in the critically ill and to examine changes in practice over time. STUDY DESIGN: The authors conducted a scenario-based national survey. STUDY POPULATION: This study consisted of Canadian critical care practitioners. OUTCOME MEASURE: The authors evaluated transfusion thresholds in four hypothetical scenarios. RESULTS: Of 343 eligible Canadian critical care physicians, 235 (68.5%) responded to the survey. Most respondents were general internists (57%) who had been in practice for an average of 11.1 (+/-7.1) yrs and worked most often in combined medical/surgical intensive care units. Transfusion thresholds differed significantly among the four scenarios (p < .0001). The proportion of respondents adopting a threshold of 70 g/L was 63% and 70% in the hypothetical scenarios of trauma and septic shock compared with 16% and 3% who adopted the same threshold for scenarios involving patients with stable gastrointestinal hemorrhage and postoperative myocardial infarction, respectively. Fifteen percent of respondents identified transfusion thresholds exceeding 100 g/L for the postoperative myocardial infarction scenario, and 7% identified this threshold for the gastrointestinal hemorrhage scenario. Only 0.4% of respondents adopted a 100-g/L threshold for the two remaining scenarios. There was a significant decrease in transfusion thresholds in all four scenarios (p < .001) since the administration of a previous survey in 1993. The reported use of single-unit transfusions was 56% in 2002 vs. 10% in 1993. Eighty-five percent of physicians stated that they had modified their approach to transfusion, primarily in response to the publication of a major Canadian clinical trial and institutional guidelines. CONCLUSIONS: Canadian physicians appear to have adopted lower transfusion triggers and an increase in the use of single-unit red cell transfusion.

APACHE↗
PubMed2005

Episiotomy rates around the world: an update.

UNLABELLED: Episiotomy, the unkindest cut of all, persists despite clinical practice guidelines recommending its restrictive use. The purpose of this paper was to compile international statistics on the use of this practice and examine whether current guidance on the restrictive use of episiotomy was being followed. METHODS: We searched government websites and the Internet, contacted colleagues for references, and checked the references of retrieved citations. RESULTS: Statistics from around the world revealed overall high rates of episiotomy with a decreasing trend in some countries. Considerable variation occurs in the use of the operation by country, within countries, and even within the same professional provider group. CONCLUSIONS: Greater efforts are needed than currently in place to reduce the episiotomy rate, particularly in the developing world.

Episiotomy↗
PubMed2005

Barriers and facilitators influencing call center nurses' decision support for callers facing values-sensitive decisions: a mixed methods study.

BACKGROUND: Call center nurses triage symptoms and provide health information. However, information alone is not adequate for people facing values-sensitive health decisions. For these decisions, effective interventions are evidence-based patient decision aids and in-person nurse coaching using a structured process. Little is known about the quality of decision support provided by call center nurses. AIMS: To identify the barriers and facilitators influencing the provision of decision support by call center nurses to callers facing values-sensitive health decisions at a Canadian province-wide health call center. METHODS: A mixed qualitative and quantitative descriptive study from December 2003 to January 2004 using key informant interviews (n= 4), two focus groups (n= 7), a barriers assessment survey (n= 57), and analysis of simulated patient calls (n= 38) were carried out. Triangulation of these data was conducted using a conceptual content analysis method. RESULTS: Participants indicated positive attitudes toward call center nurses preparing callers facing values-sensitive decisions. Facilitators included decision support resources, nurses' ability to recognize callers having difficulty, and having a supportive organizational infrastructure. The most frequently identified barriers were (a) limited usability of patient decision aids via telephone; (b) lack of a structured process to guide nurses during these types of calls; (c) nurses' inadequate knowledge, skills, and confidence in providing values-sensitive decision support; (d) unclear program direction; (e) organizational pressure to minimize call length; and (f) low public awareness of the services. CONCLUSIONS AND IMPLICATIONS: Despite call center nurses having positive attitudes, several modifiable barriers were interfering with nurses' current approaches to supporting callers facing values-sensitive decisions. Nurses wanted educational opportunities to further develop their decision support knowledge and skills, and decision support resources that are easier to use via telephone. As well, changes to organizational policies that address identified barriers could further facilitate the provision of decision support.

Attitude of Health Personnel↗
PubMed2005

Methodological issues encountered in a study of hospitalized COPD patients.

A study with hospitalized chronic obstructive pulmonary disease (COPD) patients determined the feasibility of providing and evaluating a tailored education program. This article describes two methodological issues encountered. Issues included recruitment and retention, and selection of outcome measures. The COPD Self-Efficacy Scale (CSES) and Dartmouth Functional Health Status (FHS) charts provided data on evaluation and outcome measurements. Of 67 patients, 55% met eligibility criteria, 73% (n = 27) agreed to participate, and 74% (n = 20) completed the study. Results revealed acceptance and satisfaction with the educational intervention. The median CSES score, significantly (z = 3.51,p = .004) improved from 53% to 82%. In FHS, a 20% improvement occurred in all except social support. Methodological concerns with the CSES reinforced the need for further investigation of the reliability and validity for hospitalized COPD patients. Researchers' observations may assist in planning educational interventions and program evaluations with hospitalized COPD patients.

Attitude to Health↗
PubMed2005

Celiac disease: evaluation of the diagnosis and dietary compliance in Canadian children.

OBJECTIVES: We sought to characterize the clinical features at presentation as well as the associated disorders, family history, and evaluation of compliance with a gluten-free diet in children with celiac disease from across Canada. STUDY DESIGN: All members (n = 5240) of the Canadian Celiac Association were surveyed with a questionnaire. Of the 2849 respondents with biopsy-confirmed celiac disease, 168 who were < 16 years old provided the data reported here. RESULTS: The mean age when surveyed was 9.1 +/- 4.1 years, and 58% were female. Median age at diagnosis was 3.0 years with a range of 1 to 15 years. Presenting symptoms included abdominal pain (90%), weight loss (71%), diarrhea (65%), weakness (64%), nausea/vomiting (53%), anemia (40%), mood swings (37%), and constipation (30%). Almost one third of families consulted > or = 2 pediatricians before confirmation of the diagnosis. Before the recognition of celiac disease, other diagnoses received by these children included anemia (15%), irritable bowel syndrome (11%), gastroesophageal reflux (8%), stress (8%), and peptic ulcer disease (4%). A serological test was performed to screen for celiac disease in 70% of those in this population. Eight percent had either type 1 diabetes mellitus or a first-degree relative with celiac disease. Almost all respondents (95%) reported strict adherence to a gluten-free diet, and 89% noted improved health. Reactions after accidental gluten ingestion developed in 54% of the children between 0.5 and 60 hours after ingestion with a median of 2.0 hours. Reactions included abdominal discomfort (87%), diarrhea (64%), bloating (57%), fatigue (37%), headache (24%), and constipation (8%), and most displayed > 1 symptom. Although most adjusted well to their disease and diet, 10% to 20% reported major disruptions in lifestyle. Twenty-three percent felt angry all or most of the time about following a gluten-free diet. Only 15% avoided traveling all or most of the time, and during travel, 83% brought gluten-free food with them all of the time. More than half of the families avoided restaurants all or most of the time. Twenty-eight percent of the respondents found it extremely difficult to locate stores with gluten-free foods, and 27% reported extreme difficulty in finding gluten-free foods or determining if foods were free of gluten. Sixty-three percent of the respondents felt that the information supplied by the Canadian Celiac Association was excellent. Gastroenterologists provided excellent information to 44%, dietitians to 36%, and the family physician to 11.5%. When asked to select 2 items that would improve their quality of life, better labeling of gluten-containing ingredients was selected by 63%, more gluten-free foods in the supermarket by 49%, gluten-free choices on restaurant menus by 49%, earlier diagnosis of celiac disease by 34%, and better dietary counseling by 7%. CONCLUSIONS: In Canada, children with celiac disease present at all ages with a variety of symptoms and associated conditions. Delays in diagnosis are common. Most children are compliant with a gluten-free diet. A minority of these children experience difficulties in modifying their lifestyles, and gluten-free foods remain difficult to obtain.

Adolescent↗
PubMed2004

Family physicians' perspectives on practice guidelines related to cancer control.

BACKGROUND: Family physicians (FPs) play an important role in cancer control. While FPs' attitudes towards, and use of guidelines in general have been explored, no study has looked at the needs of FPs with respect to guidelines for the continuum of cancer control. The objective of this study was to understand which guideline topics FPs consider important. METHODS: Five group interviews were conducted by telephone with FPs from across Ontario, Canada. Transcripts were analyzed inductively. Content analysis identified emergent themes. Themes are illustrated by representative quotes taken from the transcripts. RESULTS: The main areas where FPs felt guidelines were needed most included screening - a traditional area of responsibility for FPs - and treatment and follow-up - areas where they felt they lacked the knowledge to best support patients. Confusion over best practice when faced with conflicting guidelines varied according to disease site. FPs defined good guideline formats; the most often cited forms of presentation were tear-off sheets to use interactively with patients, or a binder. Computer-based dissemination was acknowledged as the best way of widely distributing material that needs frequent updates. However, until computer use is a common aspect of practice, mail was considered the most viable method of dissemination. Guidelines designed for use by patients were supported by FPs. CONCLUSIONS: Preferred guideline topics, format, dissemination methods and role of patient guidelines identified by FPs in this study reflect the nature of their practice situations. Guideline developers and those supporting use of evidence-based guidelines (e.g., Canadian Strategy for Cancer Control) have a responsibility to ensure that FPs are provided with the resources they identify as important, and to provide them in a format that will best support their use.

Adult↗
PubMed2004

Clinicians' assessments of practice guidelines in oncology: the CAPGO survey.

OBJECTIVES: Promoting the adoption of clinical practice guidelines is a challenging task. Research shows that adopters' beliefs about guidelines and the process of their development are important predictors of guideline use. Our objective is to report on the development and refinement of an instrument designed to measure oncologists' assessments of guidelines in oncology. METHOD: A theoretically derived instrument was drafted. Oncologists were asked to complete a questionnaire for each draft guideline they were asked to review. Factor analyses and multilevel modeling techniques were undertaken to explore the properties of the instrument and refine it. RESULTS: A total of 488 Ontario clinicians were sent 1494 new questionnaires regarding 34 clinical practice guidelines produced between 1999 and 2002. A refined eighteen-item questionnaire with four stable factors that predicted 60 percent of the variance emerged. The factors are interpreted as guideline quality, applicability, acceptability, and comparative value. The four factors predicted oncologists' endorsements of draft guidelines and, with the exception of quality, predicted their intentions to use the guidelines. As expected, variation in the factor scores could be attributed more to the differences among the oncologist who completed the survey than to the differences among the guidelines themselves. CONCLUSIONS: An instrument composed of four stable and theoretically relevant factors emerged. The findings support the hypothesis that beliefs about guideline attributes and development attributes relate to oncologists' endorsement of and intentions to use guidelines. Our next step is to link the responses of the survey with actual clinical behavior.

Attitude of Health Personnel↗
PubMed2004

Changing the use of electronic fetal monitoring and labor support: a case study of barriers and facilitators.

BACKGROUND: Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline. METHODS: This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals. RESULTS: Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use. CONCLUSIONS: When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

Communication Barriers↗
PubMed2004

Enhancing research use through online action research.

BACKGROUND: Many health professionals, including occupational therapists, have difficulty utilizing research findings in daily practice. PURPOSE: To determine if an online action research project could enhance research use among occupational therapists working in similar practice areas. METHODS: Four groups of 12-14 occupational therapists met online for approximately one year. They discussed barriers and facilitators to research utilization, defined practice questions, and attempted to search for, synthesize and apply relevant research findings. Online communications and post-group interviews were thematically analyzed. RESULTS: Only half of the participants who began the project were still online with the research project at completion. These participants believed that their involvement in the group led to increased personal awareness, motivation and confidence regarding the use of research evidence in practice and knowledge to be used in practice. Time to review, critique and synthesize research evidence continued to be a major barrier to enhanced research utilization. PRACTICE IMPLICATIONS: Online meetings designed to enhance research use among occupational therapists appear to hold some promise, but refinements are needed to ensure their ultimate success.

Biomedical Research↗
PubMed2004

Structured interview assessment of symptoms and concerns in palliative care.

OBJECTIVE: Assessment in palliative care requires a multidimensional review of physical symptoms and psychosocial concerns in a format appropriate for patients with advanced illness. In this study, we describe the initial development and validation of a structured interview for assessing common symptoms and concerns faced by terminally ill individuals. METHOD: We constructed a 13-item Structured Interview for Symptoms and Concerns (SISC) based on a review of end-of-life issues and administered it to 69 patients receiving palliative care for advanced cancer. Along with the interview, each participant completed visual analog scales (VAS) addressing the same constructs. Test-retest and interrater reliability were determined, as was the concordance between interview ratings and VAS scores. RESULTS: Overall, the interview items had excellent interrater reliability (intraclass correlations were > 0.90) and at least moderate temporal stability (test-retest correlations ranged from 0.50 to 0.90). Concurrent validity was evident in the good concordance between interview items and VAS measures (correlations were > 0.70). The SISC was also sensitive to individual differences between subgroups of participants who did or did not meet diagnostic criteria for anxiety or depressive disorders. CONCLUSIONS: This study demonstrates that structured interviews provide a reliable and valid approach to assessment in palliative care and may be an appropriate alternative for some research applications.

Anxiety↗
PubMed2004

Understanding venous leg ulcer pain: results of a longitudinal study.

Venous leg ulcer pain experienced during compression bandaging is poorly understood. A prospective, pilot cohort study was initiated to determine the feasibility of conducting a large-scale, repeated measures cohort study of venous leg ulcer pain and to document and describe the venous leg ulcer pain experience during the first 5 weeks of treatment with compression bandages. Eligible individuals admitted to a nurse-led community leg ulcer service in one Canadian community were recruited for the 5-week study. Pain assessment tools (ie, numerical rating scale and short form McGill Pain Questionnaire) were evaluated by 20 venous ulcer patients (mean age = 73.7 years) and their nurses for ease of use during one baseline and five weekly follow-up visits. Health-related quality of life (HRQL) information was obtained. Nurses reported on ease of integrating pain data collection into regular clinical care. Each pain assessment tool was audited for completion. Most participants found the pain assessment tools easy to use, but nurses reported lengthened visit times with some participants as a result of tool administration difficulties, particularly the visual analogue scale (VAS). Overall completeness of pain assessment tools ranged from 85.0% (visual analogue scale) to 96.3% (present pain intensity and word descriptor list). The vast majority of patients (18) reported ulcer pain at baseline. Total mean scores for all pain assessment tools used decreased over time, but most patients reported pain throughout the study. The most common pain descriptors used were "aching," "stabbing," "sharp," "tender," and "tiring." Health-related quality of life was low and did not change during the 5-week study. The results of this study suggest that the vast majority of venous ulcer patients experience pain and that it is feasible to examine this pain in individuals receiving care in the community over time.

Activities of Daily Living↗
PubMed2004

Innovations in knowledge transfer and continuity of care.

In summary, the transfer of continuity-of-care innovations to practice is a complex process. Knowledge transfer is complex in and of itself, and in the case of continuity-of-care innovations this complexity is compounded by the need to simultaneously target multiple sectors, settings, agencies, and providers. Although there are a number of knowledge transfer theories/models, their use in guiding implementation activities is not yet commonplace. If the health-care system and patients/clients are to benefit from continuity-of-care research, researchers and implementers will need to become better versed in the knowledge transfer literature, experiment with these frameworks when implementing innovations, and test their usefulness with different innovations in different contexts.

Continuity of Patient Care↗
PubMed2003

The Canadian celiac health survey--the Ottawa chapter pilot.

BACKGROUND: Celiac disease may manifest with a variety of symptoms which can result in delays in diagnosis. Celiac disease is associated with a number of other medical conditions. The last national survey of members of the Canadian Celiac Association (CCA) was in 1989. Our objective was to determine the feasibility of surveying over 5,000 members of the CCA, in addition to obtaining more health related information about celiac disease. METHODS: The Professional Advisory Board of the CCA in collaboration with the University of Ottawa developed a comprehensive questionnaire on celiac disease. The questionnaire was pre-tested and then a pilot survey was conducted on members of the Ottawa Chapter of the CCA using a Modified Dillmans' Total Design method for mail surveys. RESULTS: We had a 76% response to the first mailout of the questionnaire. The mean age of participants was 55.5 years and the mean age at diagnosis was 45 years. The majority of respondents presented with abdominal pain, diarrhea, fatigue or weight loss. Prior to diagnosis, 30% of respondents consulted four or more family doctors. Thirty seven percent of individuals were told they had either osteoporosis or osteopenia. Regarding the impact of the gluten-free diet (GFD), 45% of individuals reported that they found following a GFD was very or moderately difficult. The quality of life of individuals with celiac disease was comparable to the mean quality of life of Canadians. CONCLUSION: On the basis of our results, we concluded that a nationwide survey is feasible and this is in progress. Important concerns included delays in the diagnosis of celiac disease and the awareness of associated medical conditions. Other issues include awareness of celiac disease by health professionals and the impact of the GFD on quality of life. These issues will be addressed further in the national survey.

Celiac Disease↗