Snakes and ladders: A qualitative study understanding the active ingredients of social interaction around the use of audit and feedback.

Explore characteristics of the facilitator, group, and interaction that influence whether a group discussion about data leads to the identification of a clearly specified action plan. Peer-facilitated group discussions among primary care physicians were carried out and recorded. A follow-up focus group was conducted with peer facilitators to explore which aspects of the discussion promoted action planning. Qualitative data was analyzed using an inductive-deductive thematic analysis approach using the conceptual model developed by Cooke et al. Group discussions were coded case-specifically and then analyzed to identify which themes influenced action planning as it relates to performance improvement. Physicians were more likely to interact with practice-level data and explore actions for performance improvement when the group facilitator focused the discussion on action planning. Only one of the three sites (Site C) converged on an action plan following the peer-facilitated group discussion. At Site A, physicians shared skepticism of the data, were defensive about performance, and explained performance as a product of factors beyond their control. Site B identified several potential actions but had trouble focusing on a single indicator or deciding between physician- and group-level actions. None of the groups discussed variation in physician-level performance indicators, or how physician actions might contribute to the reported outcomes. Peer facilitators can support data interpretation and practice change; however their success depends on their personal beliefs about the data and their ability to identify and leverage change cues that arise in conversation. Further research is needed to understand how to create a psychologically safe environment that welcomes open discussion of physician variation.

Family doctors have access to a lot of data on their practice. However, doctors report difficulties in thinking of ways to use this data to improve their practice. Group discussions among doctors may be one way to support practice improvements. This study analyzed discussions among three groups of doctors to see which aspects of the discussions helped the doctors come up with new ways to improve their practices. The ability of the person leading the discussion to continually re-focus the conversation on the goal of making a change was key to whether the group made any progress. The first group was skeptical of the data and felt that its findings were beyond their control; the second group had trouble focusing on a single outcome; and the third group successfully identified an action. None of the groups discussed how their actions might contribute to the outcomes.

How the Novel Person-Centered Primary Care Measure Performs in Canada.

BACKGROUND: The Person-Centered Primary Care Measure (PCPCM) is a relatively new and concise yet comprehensive measure of primary care quality. The objectives of this study are to administer the PCPCM in Canada and to understand whether there is an association between the PCPCM and sociodemographic and patient experience measures. METHODS: The PCPCM was added to the routine patient experience survey administered at a multi-site academic primary care practice in Toronto, Canada. The survey was administered to patients with an e-mail on file and included questions on demographics, timely access, patient-centeredness, care continuity, and the PCPCM. Descriptive statistics were used to summarize the PCPCM. We used 1-way analysis of variance to determine whether there was an association between the PCPCM and patient demographics and patient experience measures at the team level. RESULTS: We analyzed 2581 survey responses. The mean PCPCM score was 3.47. The PCPCM was higher for people with better health status (P < .001), those born in Canada (P = .036), those with higher educational attainment (P = .003), and those who knew their provider for longer (P < .001). There was no significant association between PCPCM and income quintile (P = .417). The PCPCM was significantly associated with all 9 patient experience measures related to access, patient-centeredness, and care continuity (P < .001). CONCLUSIONS: The 11-item PCPCM is a feasible and meaningful measure that reflects patient-reported access, continuity, and patient-centeredness and can be incorporated into primary care patient experience surveys to evaluate and improve quality of care.

Sociodemographic differences in patient experience with primary care during COVID-19: results from a cross-sectional survey in Ontario, Canada.

PURPOSE: We sought to understand patients' care-seeking behaviours early in the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors. METHODS: We conducted a multisite cross-sectional patient experience survey at 13 academic primary care teaching practices between May and June 2020. An anonymised link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using χ2 tests. RESULTS: In total, 7532 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic. CONCLUSIONS: Our study suggests that newcomers, people living with a lower income and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.

Unpacking the intention to action gap: a qualitative study understanding how physicians engage with audit and feedback.

BACKGROUND: Audit and feedback (A&F) often successfully enhances health professionals' intentions to improve quality of care but does not consistently lead to practice changes. Recipients often cite data credibility and limited resources as barriers impeding their ability to act upon A&F, suggesting the intention-to-action gap manifests while recipients are interacting with their data. While attention has been paid to the role feedback and contextual variables play in contributing to (or impeding) success, we lack a nuanced understanding of how healthcare professionals interact with and process clinical performance data. METHODS: We used qualitative, semi-structured interviews guided by Normalization Process Theory (NPT). Questions explored the role of data in quality improvement, experiences with the A&F report, perceptions of the data, and interpretations and reflections. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using a combination of inductive and deductive strategies using reflexive thematic analysis informed by a constructivist paradigm. RESULTS: Healthcare professional characteristics (individual quality improvement capabilities and beliefs about data) seem to influence engagement with A&F to a greater degree than feedback variables (i.e., delivered by peers) and observed contextual factors (i.e., strong quality improvement culture). Most participants lacked the capabilities to interpret practice-level data in an actionable way despite a motivation to engage meaningfully. Reasons for the intention-to-action gap included challenges interpreting longitudinal data, appreciating the nuances of common data sources, understanding how aggregate data provides insights into individualized care, and identifying practice-level actions to improve quality. These factors limited effective cognitive participation and collective action, as outlined in NPT. CONCLUSIONS: A well-designed A&F intervention is necessary but not sufficient to inform practice changes. A&F initiatives must include co-interventions to address recipient characteristics (i.e., beliefs and capabilities) and context to optimize impact. Effective strategies to overcome the intention-to-action gap may include modelling how to use A&F to inform practice change, providing opportunities for social interaction relating to the A&F, and circulating examples of effective actions taken in response to A&F. More broadly, undergraduate medical education and post-graduate training must ensure physicians are equipped with QI capabilities, with an emphasis on the skills required to interpret and act on practice-level data.

Ten tips for advancing a culture of improvement in primary care.

Embracing practice-based quality improvement (QI) represents one way for clinicians to improve the care they provide to patients while also improving their own professional satisfaction. But engaging in care redesign is challenging for clinicians. In this article, we describe our experience over the last 7 years transforming the care delivered in our large primary care practice. We reflect on our journey and offer 10 tips to healthcare leaders seeking to advance a culture of improvement. Our organisation has developed a cadre of QI leaders, tracks a range of performance measures and has demonstrated sustained improvements in important areas of patient care. Success has required deep engagement with both patients and clinicians, a long-term vision, and requisite patience.

Collaborative Care Transitions Symposium: Insights from Participants.

BACKGROUND/PURPOSE: There are promising signs that interprofessional collaborative practice is associated with quality care transitions and improved access to patient-centred healthcare. A one-day symposium was held to increase awareness and capacity to deliver quality collaborative care transitions to interprofessional health disciplines and service users. METHOD: A mixed methods study was used that included a pre-post survey design and interviews to examine the impact of the symposium on knowledge, attitudes and practice change towards care transitions and collaborative practice with symposium participants. DISCUSSION: Our survey results revealed a statistically significant increase in only a few of the scores towards care transitions and collaborative practice among post-survey respondents. Three key themes emerged from the qualitative analysis, including: (1) engaging the patient at the heart of interprofessional collaboration and co-design of care transitions; (2) having time to reach out, share and learn from each other; and (3) reflecting, reinforcing and revising practice. CONCLUSION: Further efforts that engage inter-organizational learning by exchanging knowledge and evaluating these forums are warranted.

Receptor for advanced glycation end products (RAGEs) and experimental diabetic neuropathy.

OBJECTIVE: Heightened expression of the receptor for advanced glycation end products (RAGE) contributes to development of systemic diabetic complications, but its contribution to diabetic neuropathy is uncertain. We studied experimental diabetic neuropathy and its relationship with RAGE expression using streptozotocin-induced diabetic mice including a RAGE(-/-) cohort exposed to long-term diabetes compared with littermates without diabetes. RESEARCH DESIGN AND METHODS: Structural indexes of neuropathy were addressed with serial (1, 3, 5, and 9 months of experimental diabetes) electrophysiological and quantitative morphometric analysis of dorsal root ganglia (DRG), peripheral nerve, and epidermal innervation. RAGE protein and mRNA levels in DRG, peripheral nerve, and epidermal terminals were assessed in WT and RAGE(-/-) mice, with and without diabetes. The correlation of RAGE activation with nuclear factor (NF)-kappaB and protein kinase C beta II (PKC beta II) protein and mRNA expression was also determined. RESULTS: Diabetic peripheral epidermal axons, sural axons, Schwann cells, and sensory neurons within ganglia developed dramatic and cumulative rises in RAGE mRNA and protein along with progressive electrophysiological and structural abnormalities. RAGE(-/-) mice had attenuated structural features of neuropathy after 5 months of diabetes. RAGE-mediated signaling pathway activation for NF-kappaB and PKC beta II pathways was most evident among Schwann cells in the DRG and peripheral nerve. CONCLUSIONS: In a long-term model of experimental diabetes resembling human diabetic peripheral neuropathy, RAGE expression in the peripheral nervous system rises cumulatively and relates to progressive pathological changes. Mice lacking RAGE have attenuated features of neuropathy and limited activation of potentially detrimental signaling pathways.

Does diabetes mellitus target motor neurons?

A pattern of peripheral neurodegeneration occurs in chronic diabetes mellitus in which an early, but selective retraction of distal axons may occur prior to any irretrievable neuronal loss. Clinical observations suggest that sensory systems undergo damage before those of motor neurons. In this work, we examined the fate of the spinal motor neuron in a long-term chronic model of experimental (streptozotocin-induced) diabetes already known to be associated with substantial loss of sensory neurons. The integrity, physiological function, and critical forms of protein expression of the full motor neuron tree was examined in mice exposed to 8 months of diabetes. Motor neurons developed progressive features of distal loss of axonal terminals but without perikaryal dropout, indicating distal axon retraction. While numbers and caliber of motor neuron perikarya and their nerve trunk axons were preserved, axons developed conduction velocity slowing, loss of motor units and neuromuscular junctions, and compensatory single motor unit action potential enlargement. Four critical proteins directly linked to diabetic complications were altered in motor neurons of diabetic mice: an elevated perikaryal expression of RAGE and PARP, molecules associated with cellular stress, along with concurrent rises in HSP-27 and pAKT, molecules alternatively identified with neuroprotective survival. Moreover, Akt mRNA was increased in diabetic lumbar spinal cords. Overall these findings indicate that although motor neurons are resistant to irretrievable dropout, they are targeted nonetheless by diabetes and gradually withdraw their terminals from distal innervation.

Two TTX-resistant Na+ currents in mouse colonic dorsal root ganglia neurons and their role in colitis-induced hyperexcitability.

The composition of Na+ currents in dorsal root ganglia (DRG) neurons depends on their neuronal phenotype and innervation target. Two TTX-resistant (TTX-R) Na+ currents [voltage-gated Na channels (Nav)] have been described in small DRG neurons; one with slow inactivation kinetics (Nav1.8) and the other with persistent kinetics (Nav1.9), and their modulation has been implicated in inflammatory pain. This has not been studied in neurons projecting to the colon. This study examined the relative importance of these currents in inflammation-induced changes in a mouse model of inflammatory bowel disease. Colonic sensory neurons were retrogradely labeled, and colitis was induced by instillation of trinitrobenzenesulfonic acid (TNBS) into the lumen of the distal colon. Seven to ten days later, immunohistochemical properties were characterized in controls, and whole cell recordings were obtained from small (<40 pF) labeled DRG neurons from control and TNBS animals. Most neurons exhibited both fast TTX-sensitive (TTX-S)- and slow TTX-R-inactivating Na+ currents, but persistent TTX-R currents were uncommon (<15%). Most labeled neurons were CGRP (79%), tyrosine kinase A (trkA) (84%) immunoreactive, but only a small minority bind IB4 (14%). TNBS-colitis caused ulceration, thickening of the colon and significantly increased neuronal excitability. The slow TTX-R-inactivating Na current density (Nav1.8) was significantly increased, but other Na currents were unaffected. Most small mouse colonic sensory neurons are CGRP, trkA immunoreactive, but not isolectin B4 reactive and exhibit fast TTX-S, slow TTX-R, but not persistent TTX-R Na+ currents. Colitis-induced hyperexcitability is associated with increased slow TTX-R (Nav1.8) Na+ current. Together, these findings suggest that colitis alters trkA-positive neurons to preferentially increase slow TTX-R Na+ (Nav1.8) currents.