Biomedical subjects

Ian D Graham

Publications and source records attributed to Ian D Graham.

At least 55 records · Page 3Linked to original sources

PubMed2003

The effect of decision aids on the agreement between women's and physicians' decisional conflict about hormone replacement therapy.

The aim of this secondary analysis was to compare the effects of a tailored decision aid (DA) with those of a pamphlet on the agreement between women's and physicians' decisional conflict about hormone replacement therapy (HRT). A total of 40 physicians and 184 women provided data. The agreement between women's and physicians' decisional conflict scores was measured using the intraclass correlation coefficient (ICC). The ICC was higher for dyads in the DA group (ICC=0.44; 95% confidence interval (CI)=0.25-0.59) compared to the pamphlet group (ICC=0.28; 95% CI=0.06-0.47). When the average score of decisional conflict of women nested within a physician and of each physician were used, the ICC for the DA group and the pamphlet group was 0.41 (95% CI=-0.04 to 0.72) and 0.06 (95% CI=-0.41 to 0.49), respectively. Compared to pamphlets, DAs appear to improve the agreement between women's and physicians' decisional conflict about HRT.

Adult↗

PubMed2003

Validation of a tool to assess health practitioners' decision support and communication skills.

As patients become more involved in decisions affecting their health, it is important to monitor and improve the support clinicians provide to facilitate shared decision making. The Decision Support Analysis Tool (DSAT) was developed as a research tool to evaluate practitioners' use of decision support and related communication skills during a clinical encounter. The DSAT, consisting of six categories of decision support skills and four categories of communication skills, was tested with 34 actual transcripts of patient-physician dialogue. The patients were prepared for the clinical encounter with either a detailed decision aid plus worksheet (n=16) or a pamphlet (n=18). Pairs of raters, blinded to the intervention allocation, coded each transcript independently. The overall inter-rater agreement and kappa coefficients were, respectively 75% and 0.59 for the decision support skills and 76% and 0.68 for the communication skills categories. The frequency of DSAT skills coded: (a) were significantly correlated with three out of six patient and physician outcome measures (r>0.30, P<0.05); and (b) showed significant discrimination (P=0.05) or trends (P<0.15) in discrimination between the decision aid and pamphlet groups. The DSAT shows promise as a reliable and valid evaluation tool but requires further testing with larger samples.

Communication↗

PubMed2003

A qualitative study of physicians' perceptions of three decision aids.

The study objective was to investigate physicians' perceptions of three patient decision aids (DA). Semi-structured telephone interviews were conducted with 20 family physicians and 12 gynecologists about a DA for women considering long-term hormone replacement therapy; with 16 respirologists about a DA for the use of intubation and mechanical ventilation for patients with severe chronic obstructive pulmonary disease; and with 19 physicians (geriatricians, gastroenterologists, internists) about a DA for long-term placement of feeding tubes in the elderly. Participants were identified by a snowball sampling technique. The interviews were analyzed using standard qualitative methods. Most participants (81%) indicated some willingness to use the DAs. The characteristics of the DA viewed positively included it being: balanced, well organized, a useful tool, evidence-based, improves decision making process and multimedia. Some of the negative characteristics were stated as: too complex, the cost, the availability, only appropriate for certain groups of patients, and time consuming. The DAs were acceptable to most participants. Perceived positive and negative factors were similar for all DAs. Uptake of decision aids may be facilitated if physicians have an opportunity to examine and try them, and if they can have unfettered access to them for distribution purposes.

Attitude of Health Personnel↗

PubMed2003

The state of the science and art of practice guidelines development, dissemination and evaluation in Canada.

The Canadian Medical Association (CMA) maintains a database of clinical practice guidelines (CPGs) developed or endorsed by Canadian organizations. The study purpose was to describe how these guidelines were developed, disseminated and evaluated. A survey was mailed to the developer of each CPG registered in the CMA Infobase between June 1996 and December 1999. Data were received for 730 unique guidelines (response rate of 70%) developed by 75 organizations. Of these, 72% were developed by committees that had a formal process for selecting their members. The scientific literature was reviewed for all of the guidelines, a computerized search undertaken for 88% and the search strategy included 34% of CPG documents. An attempt was made to grade the quality of the evidence underpinning 54% of the guidelines. For most guidelines, consensus about values or judgements was reached by expert opinion through open discussion (78% of guidelines). The most common strategies used to disseminate the guidelines were direct mailing of guidelines to members of the developing organization (80% of all guidelines), publishing guidelines in newsletters/journals (76%), direct mailing to others (73%), electronic dissemination (62%), educational or continuing medical education activities (50%), and providing information about guidelines to patients/consumers (47%). Overall, 5% of the guidelines have been evaluated to determine their impact on health outcomes. During the 5-year study period (1994-99), the more recent guidelines were more likely to use multidisciplinary development panels, report the literature search strategies and grade the quality of the evidence. The CPG development process in Canada is becoming more rigorous and reproducible, but there is still considerable room for improvement. In addition to encouraging Canadian guideline developers to use more rigorous and transparent methods, considerably more attention must be focused on using and identifying effective and cost-effective strategies to promote and facilitate the uptake of guidelines by practitioners and to evaluate the impact of guidelines on patient outcomes.

Canada↗

PubMed2003

What factors are associated with a woman's decision to take hormone replacement therapy? Evaluated in the context of a decision aid.

OBJECTIVES: To understand the factors associated with a post-menopausal woman deciding to take hormone replacement therapy (HRT) after reviewing a decision aid (DA) and having a counselling visit with her physician as well as the factors associated with the act of taking HRT 2 months after the counselling interview. DESIGN: A secondary analysis of data collected for a randomized controlled trial evaluating two DAs. MAIN OUTCOME RESULTS: Although 28% of women were uncertain regarding their decision after the counselling interview, only 2.4% of women, at the assessment at 2 months, had not made a decision. The most significant factor associated with the decision to take HRT, after the physician visit, was the physician preference (OR: 62, 95% CI: 13.3, 289.7). Physician preference (OR: 78, 95% CI: 6.2, 975) remained the most significant factor for taking HRT 2 months after the counselling interview followed by low uncertainty about the decision (OR: 0.4, 95% CI: 0.2, 0.7). CONCLUSION: Physician preference was the factor that was most associated with the woman's decision following counselling and 2 months later. Qualitative evaluation of the interview process involving the patient and physician would determine whether the patient and physician are reaching a shared decision or is the physician preference influencing the patient.

Canada↗

PubMed2003

Factors associated with the difference in score between women's and doctors' decisional conflict about hormone therapy: a multilevel regression analysis.

OBJECTIVE: To explore factors associated with the difference in score between women's and doctors' decisional conflict about hormone therapy (HT). DESIGN: Secondary analysis. SETTING AND PARTICIPANTS: family doctors were randomized to prepare women for counselling about HT using either a decision aid or a pamphlet. MAIN VARIABLES STUDIED: After each counselling session, decisional conflict was assessed in women and doctors using the Decisional Conflict Scale (DCS) and the Provider Decision Process Assessment Instrument (PDPAI), respectively. The difference in score between the DCS and PDPAI was computed and entered as the dependent variable in a multilevel regression analysis. MAIN OUTCOME RESULTS: A total of 40 doctors and 167 women were included in the analysis. The intra-doctor correlation coefficient was 0.25. Factors associated with women experiencing higher decisional conflict than their doctor were: age of doctor >45 years, women who were undecided about the best choice after the counselling session, women with a university degree and women who said that their doctor usually does not give them control over treatment decision. Factors associated with doctors experiencing more decisional conflict than women were: doctors who were undecided about the quality of the decision, length of visit <30 min and women who thought that the decision was shared with their doctor. CONCLUSION: In order to reduce the disparities between women's and doctors' decisional conflict about HT, interventions aimed at raising awareness of doctors about shared decision-making should be encouraged.

Canada↗

PubMed2003

A continuing medical education initiative for canadian primary care physicians: the driving and dementia toolkit: a pre- and postevaluation of knowledge, confidence gained, and satisfaction.

This study examined the effect of the Driving and Dementia Toolkit on physician knowledge and confidence gained and the anticipated change in patient assessment and evaluated the extent to which physicians found the material to be useful. Before receiving the driving toolkit, 301 randomly selected primary care physicians received a copy of the pretest questionnaire; 145 responded and met the eligibility criteria. This group was then sent the toolkit, a satisfaction a survey, and a posttest questionnaire. Physicians were faxed the questionnaires (with up to three reminders) and telephoned if necessary. Changes in pre- and posttest results were analyzed using the McNemar test and Wilcoxon signed rank test nonparametric procedures included in SPSS, Version 10.0, and paired-samples t test. Pre- and posttest data were available and could be matched for 86 physicians (59.3%) response. Knowledge and confidence increased significantly (P</=.05) for most of the toolkit content questions. There was also a clear intent on the part of study participants to begin including additional pertinent questions in the patient/caregivers interview when assessing a patient's fitness to drive. On a scale from 1 (low) to 10 (high), overall satisfaction with the toolkit rated an average of 8.4. Use of the toolkit resulted in a clear improvement in physicians' reported knowledge of and confidence in dealing with dementia and driving. Future applications of similar innovative continuing education models can be used for other areas such as disclosure of dementia diagnosis, capacity assessments, or end-of life issues.

Attitude of Health Personnel↗

PubMed2003

Venous leg ulcer care: how evidence-based is nursing practice?

OBJECTIVES: The objectives of this study were to (1) determine how congruent community-provided leg ulcer care was with best practice for venous leg ulcers and (2) identify organizational and clinical factors associated with the provision of best practice for venous leg ulcers. DESIGN: The practice variation study group was an audit of nursing agency client records to determine the provision of care. SETTING AND SUBJECTS: The study population was a home care cohort of persons with venous leg ulcers (n = 66) who received care from one Ontario home care nursing agency between March 1999 and November 1999. INSTRUMENT: The audit tool was developed with a checklist reflecting the common recommendations from 3 international practice guidelines, as well as organizational and clinical factors that may influence or reflect best practice. RESULTS: Half of client records (35/66) included an identified etiology of the leg ulcer. An Ankle Brachial Pressure Index score was documented prior to the initiation of compression on fewer than half of the records (21/44). Regular ulcer measurement was done for 11% of the clients (7/64). Two thirds of the clients (44/66) were treated with compression. More than 60% of the clients (40/66) had been seen by either a dermatologist or a vascular surgeon. Topical antibiotics were prescribed for two thirds of clients (44/64). Fifteen percent of clients (10/66) were assessed for pain, and 17% (11/66) received some form of pain management. Documentation of client education specific to the leg ulcer was present on 3% of records (2/66). The mean number of different nurses providing leg ulcer care to each client was 19. A registered practical nurse was the classification of nurse assigned to 43.8% (29/66) of the clients. CONCLUSION: Several gaps were identified in the care provided. A standardized approach to care is needed that includes a comprehensive leg ulcer assessment to determine the ulcer etiology, determination of an Ankle Brachial Pressure Index score to screen for the presence of arterial disease, and compression for all clients who meet the criteria for venous disease. A reorganization of services is required, which includes an increased role for community nurses in leg ulcer assessment and management. Organizational and clinical factors influencing the delivery of best practice need to be identified and addressed.

Clinical Competence↗

PubMed2003

Prevalence of lower-limb ulceration: a systematic review of prevalence studies.

OBJECTIVE: To determine the prevalence of leg ulcers reported in the literature. DESIGN: A systematic review of prevalence studies of lower-limb ulceration in the adult population was conducted. Critical appraisal of the research papers was guided by published standards for methodologic review of prevalence studies, which were modified to address the issues related to leg ulcers. MAIN RESULTS: Twenty-two reports of prevalence studies were identified. Eight population-based prevalence studies used clinical validation and reported prevalence rates of open ulcers ranging from 0.12% to 1.1% of the population; the prevalence rate of open or healed ulcers was reported to be 1.8%. Seven population-based studies without clinical validation reported prevalence rates of open ulcers ranging from 0.12% to 0.32% of the population. Differences in the populations studied, study design, ulcer definition, ulcer etiology, inclusion of foot ulcers, method of clinical assessment, and clinical validation of ulcer cases indicate that it is inappropriate to pool the estimates of prevalence. In most studies that considered age and sex, the prevalence of ulcers increased with age and was higher for women. CONCLUSIONS: Better-quality prevalence studies are needed. These studies should clearly define the populations being studied, include large numbers of individuals and total populations, provide a clear definition of an ulcer, describe case identification procedures, and clinically confirm the presence of ulcers.

Age Distribution↗

PubMed2003

Multidisciplinary cross-national studies: a commentary on issues of collaboration, methodology, analysis, and publication.

Although multicenter studies proliferate in quantitative health and medical studies, few examples of similar multidisciplinary cross-national qualitative studies exist. In this article, the authors present a commentary on this type of study based on their involvement with two international projects. Issues include maintaining coinvestigators' participation in an international qualitative project with limited funding; difficulties in promoting collaboration in protocol development; factors inhibiting interest and enthusiasm; ethical concerns; issues of data recording, language, coding, and analysis; and implications for write-up and publication. Despite the difficulties and challenges posed at each stage of the process, the authors remain convinced of the value of these projects and provide recommendations for facilitating future multidisciplinary cross-national qualitative health projects.

Blood Loss, Surgical↗

PubMed2003

Assessing venous ulcer population characteristics and practices in a home care community.

To plan for a new community leg ulcer service in one Ontario region, venous ulcer population characteristics and current community care practices were obtained from a home care cohort of people with venous ulcers. A secondary analysis was conducted on the venous ulcer cohort using data collected during a Regional Prevalence and Profile Study. Patients were identified based on the clinical syndrome for venous disease criteria described in the Royal College of Nurses clinical practice guidelines and by the presence of an ankle-brachial pressure index 0.8. The Regional Prevalence and Profile Study identified 263 people with leg ulcers for a rate of 2.0 per 1,000 people >25 years of age. One hundred, seven ulcers (41%) were the result of venous disease; of these, 83 (78% of cases) were associated with a single nursing agency and formed the study cohort. Most patients (51, 61%) were female and 65 years old. Thirty-eight (46%) had 4 comorbid conditions, 63 spoke English, 29 lived alone, 38 did not require physical aids or assistance for mobility, and 81 (98%) were able to travel outside of their home. The current ulcer had been present for an average of 15 months (median 6 months), 51 participants had a previous leg ulcer, and 22 had episodes of ulceration for > 5 years. Of the 121 ulcers in the study, 48 (41%) were located at the ankle, and the majority (85%) were > 1 cm2. General practitioners were the main medical care providers for 48 participants, and 52 (62%) had seen a specialist physician for their current ulcer. These findings are similar to large studies conducted in other industrialized countries and confirm that venous ulcers are a chronic problem in a population with complex health needs.

Adult↗

PubMed2003

Knowledge and attitudes regarding care of leg ulcers. Survey of family physicians.

OBJECTIVE: To determine family physicians' perceptions of and attitudes toward leg ulcer care and awareness of effective treatments for venous leg ulcers. DESIGN: Self-administered, cross-sectional faxed and mailed survey. SETTING: Ottawa-Carleton, Ont. PARTICIPANTS: All physicians in the region who were members of the College of Family Physicians of Canada. RESULTS: Response rate was 62%. During 1 month, 107 physicians reported having 226 patients with leg ulcers; only a few patients had had ultrasound assessment. Few physicians (16%) were confident about managing leg ulcers; 61% reported not knowing enough about wound-care products. More than 50% were unaware that compression is effective treatment for venous ulcers. Problems reported were lack of evidence-based clinical practice guidelines for leg ulcer care (82%); absence of evidence-based protocols in home-care agencies (72%); lack of access to wound-care products (69%) and wound-care centres (66%); and poor communication among health care workers (60%). CONCLUSION: Better access to diagnostic assessments and use of compression therapy for venous leg ulcers would improve care.

Bandages↗

PubMed2002

Current home care expenditures for persons with leg ulcers.

OBJECTIVE: The purpose of this study was to gain a better understanding of the home care expenditures incurred in providing care to the population with leg ulcers. DESIGN: The study was designed as a descriptive survey and was conducted over a 4-week period during March 1999. SETTING AND SUBJECTS: Persons in a large Ontario urban center with an ulcer below the knee, including the foot, who were receiving nursing services in the home, were eligible for inclusion in the study. INSTRUMENTS: A leg assessment tool, a supply usage form, and a visiting nurses log (all developed by the researchers for the study) were used to collect data. METHODS: Home care nurses visited all clients and completed an in-depth assessment of their social, medical, and leg ulcer history. Legs were inspected, an ankle brachial pressure index score was determined, and ulcers were examined and measured. For each nursing visit, supply usage, travel and treatment times, and mileage were tracked. RESULTS: During the study period, 2270 visits were made (mean treatment time = 26 minutes, mean travel time = 17 minutes) costing $80.62 (Canadian dollars). Supply costs were $21.06. The regional annual home care expenditures were conservatively estimated to be $1.3 million. CONCLUSION: Costs could potentially be reduced by cutting the 40% visit time attributed to travel, decreasing the visit frequency to clients with minimal drainage, and attention to "best practice."

Cohort Studies↗

PubMed2002

Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition.

BACKGROUND: The growing number of patients with congestive heart failure has increased both the pressure on hospital resources and the need for community management of the condition. Improving hospital-to-home transition for this population is a logical step in responding to current practice guidelines' recommendations for coordination and education. Positive outcomes have been reported from trials evaluating multiple interventions, enhanced hospital discharge, and follow-up through the addition of a case management role. The question remains if similar gains could be achieved working with usual hospital and community nurses. METHODS: A 12-week, prospective, randomized controlled trial was conducted of the effect of transitional care on health-related quality of life (disease-specific and generic measures), rates of readmission, and emergency room use. The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management 2 weeks after hospital discharge. RESULTS: At 6 weeks after hospital discharge, the overall Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was better among the Transitional Care patients (27.2 +/- 19.1 SD) than among the Usual Care patients (37.5 +/- 20.3 SD; P = 0.002). Similar results were found at 12 weeks postdischarge for the overall MLHFQ and at 6- and 12-weeks postdischarge for the MLHFQ's Physical Dimension and Emotional Dimension subscales. Differences in generic quality life, as assessed by the SF-36 Physical component, Mental Component, and General Health subscales, were not significantly different between the Transition and Usual Care groups. At 12 weeks postdischarge, 31% of the Usual Care patients had been readmitted compared with 23% of the Transitional Care patients (P = 0.26), and 46% of the Usual Care group visited the emergency department compared with 29% in the Transitional Care group (chi2 = 4.86, df 1, P = 0.03). CONCLUSIONS: There were significant improvements in health-related quality of life (HRQL) associated with Transitional Care and less use of emergency rooms.

Adult↗

PubMed2002

Factors influencing the adoption of blood alternatives to minimize allogeneic transfusion: the perspective of eight Ontario hospitals.

OBJECTIVE: To identify and describe the factors influencing the use and nonuse of blood-sparing methods such as preoperative autologous donation, acute normovolemic hemodilution, and the use of cell salvage devices, hemostatic agents and erythropoietin. DESIGN: An interview survey. SETTING: Eight Ontario hospitals. METHOD: Interviews were conducted with chiefs of surgery, orthopedics, cardiac surgery and anesthesia, and with heads of transfusion medicine and pharmacy. Hospitals were selected using the qualitative sampling strategy of maximum variation based on their use of the methods (as reported in a previous mail survey). RESULTS: Use of blood-sparing methods was influenced by diverse factors often operating simultaneously. These included the following: characteristics of the method (e.g., evidence of its effectiveness, ease of use, cost); perceptions and experiences of the potential adopters (experience with the method, perception of the current safety of allogeneic blood, perceived convenience or inconvenience of using the method); aspects of the practice setting (inability to move resources between hospital departments, presence of a local clinical champion); and the external environment (patient and public expectations, funding of the blood system, blood shortages). INTERPRETATION: More rational and evidence-based use of blood-sparing methods could be promoted by the adoption of an interdisciplinary, comprehensive, coordinated approach tailored to each patient's needs.

Blood Transfusion↗

PubMed2002

The process of developing best practice guidelines for nurses in Ontario: risk assessment and prevention of pressure ulcers.

Linking practice to current evidence-based wound care guidelines is a challenge for healthcare professionals, especially because of the quantity of wound care guidelines available. In 1999, the Registered Nurses Association of Ontario, Canada, with funding from the Province of Ontario's Ministry of Health and Long Term Care, established a process for the development and implementation of 17 best practice guidelines to support nurses using evidence-based practice. Four of the 17 guidelines pertain to wound care. The consensus development, pilot testing, and evaluation process of one of the guidelines, Risk Assessment and Prevention of Pressure Ulcers in Adults, is described. Following a comprehensive and systematic search for existing guidelines, a formal quality appraisal of five selected guidelines, decisions for adoption and/or adaptation of best practice recommendations, and stakeholder feedback on the draft guidelines, a pilot implementation testing of the guidelines was conducted. In early 2002, the nursing best practice guideline was disseminated through conferences, publications, and the Registered Nurses Association of Ontario website www.rnao.org.

Benchmarking↗

PubMedDate not supplied

The measurement of leg ulcer pain: identification and appraisal of pain assessment tools.

OBJECTIVE: To identify and compare the psychometric, clinical sensibility, and pain-specific properties of leg ulcer pain assessment tools for use as a guide for clinicians and researchers. DESIGN: Pain assessment tools were selected for appraisal based on 4 inclusion criteria: (1) designed specifically to measure either quality and/or intensity of pain, (2) used in at least 2 different diseases and/or pain-inducing interventions in adults, (3) generic, and (4) patient self-reporting. The tools were appraised against psychometric properties, clinical sensibility attributes, and pain-specific issues. Two reviewers independently reviewed each abstract, with a third reviewer resolving any disagreements. Then the first 2 reviewers independently assessed the selected tools using the predetermined appraisal criteria. RESULTS: Of 54 identified pain assessment tools, 5 (the pain ruler, the numerical rating scale, the visual analogue scale, the verbal descriptor scale, and the short-form McGill Pain Questionnaire) met the inclusion criteria. Each tool met the appraisal criteria to varying degrees. CONCLUSIONS: The use of a pain assessment tool to measure leg ulcer pain is recommended. Clinicians must decide independently which factors are most important when selecting a tool. Although a specific pain assessment approach cannot yet be recommended, a 2-step pain assessment process is most practical. To optimize pain management, further study is needed to ensure that leg ulcer pain is accurately and reliably assessed.

Humans↗

PubMedDate not supplied

Adapting national and international leg ulcer practice guidelines for local use: the Ontario Leg Ulcer Community Care Protocol.

BACKGROUND: Because of growing resources devoted to individuals requiring community care for leg ulcers, the authority responsible for home care in Ottawa, Ontario, Canada, established and evaluated a demonstration leg ulcer service. In an effort to provide current and evidence-based care, existing leg ulcer clinical practice guidelines were identified and appraised for quality and suitability to the new service. PROCESS: The Practice Guideline Evaluation and Adaptation Cycle guided development of a local protocol for leg ulcer care, which included: (1) systematically searching for practice guidelines, (2) appraising the quality of identified guidelines using a validated guideline appraisal instrument, (3) conducting a content analysis of guideline recommendations, (4) selecting recommendations to include in the local protocol, and (5) obtaining practitioner and external expert feedback on the proposed protocol. Updating the protocol followed a similar process. RESULTS: Of 19 identified leg ulcer practice guidelines, 14 were not evaluated because they did not meet the criteria (ie, treatment-focused guidelines, written in English and developed after 1998). Of the 5 remaining guidelines, 3 were fairly well developed and made similar recommendations. The level of evidence supporting specific recommendations ranged from randomized clinical trial evidence to expert opinion. By comparing the methodologic quality and content of the guidelines, the Task Force reached consensus regarding recommendations appropriate for local application. Two additional guidelines were subsequently identified and incorporated into the local protocol during a scheduled update. CONCLUSIONS: Local adaptation of international and national guidelines is feasible following facilitation of the Practice Guidelines Evaluation and Adaptation Cycle.

Community Health Services↗