Improving knowledge translation of clinical practice guidelines for epilepsy.

BACKGROUND: Clinical practice guidelines (CPGs) have the potential to improve quality of care. However, implementation of CPGs into the clinical care of people with epilepsy is less than optimal. This study aimed to examine barriers and facilitators to the use of CPGs for the care of people with epilepsy. METHODS: A cross-sectional survey of Canadian neurologists was conducted to evaluate CPG use, barriers and facilitators of CPG use, and factors associated with CPG use among neurologists. The barriers and facilitators of CPG use among neurologists that manage people with epilepsy were compared with those who do not. RESULTS: Of 311 responders (response rate = 38.7%), 78.7% indicated that they manage people with epilepsy. Neurologists that manage people with epilepsy did not differ from those who do not with regard to demographic characteristics nor in the proportion that report using CPGs in their clinical practice. The barriers and facilitators of CPG use were largely similar between neurologist that do and do not manage people with epilepsy; except applicability of CPGs tended to be less commonly endorsed as a barrier to CPG use by those who manage people with epilepsy compared with those who do not. CONCLUSIONS: This study suggests that knowledge, applicability, motivation, resources, and targeting of CPGs to appropriate audience are barriers and facilitators of CPG use among neurologists who manage people with epilepsy. The similarity between barriers and facilitators of CPG use among neurologists who manage people with epilepsy compared with those who do not provides support for the use of a knowledge translation (KT) strategy tailored to these barriers and facilitators of CPG use, and targeted towards neurologists. Implementation of epilepsy CPGs has the potential to improve the quality of care for people with epilepsy.

Knowledge translation of clinical practice guidelines among neurologists: A mixed-methods study.

OBJECTIVES: Clinical practice guidelines have the potential to improve care, but are often not optimally implemented. Improving guideline use in clinical practice may improve care. The objective of this study was to identify the barriers and facilitators (determinants) of guidelines use among neurologists and to propose a strategy to improve guideline implementation. METHODS: This was a mixed-methods study design. A quantitative, population-based, cross-sectional survey of Canadian neurologists was conducted. Associations between guidelines use and determinants of guidelines use were examined. Focus groups and interviews were conducted using purposeful sampling of the population. Determinants of guideline use were mapped to interventions to establish a strategy for guideline implementation among neurologists. RESULTS: 38.7% (n = 311) of neurologists responded to the survey. Typically, respondents had been practicing for 16.6 years and worked in an academic institution in an urban setting. Being male and having an academic affiliation was associated with guideline use. Determinants of guideline use differed between guideline users and non-users; non-users consistently rating determinants lower than users, especially applicability. Two focus groups and one interview (n = 11) identified six main themes of determinants of guideline use: Credibility, knowledge, applicability, resources, motivation, and target audience; which was congruent with the quantitative data. The proposed knowledge translation strategy contains three pillars: guidelines development, dissemination, and interventions. CONCLUSIONS: Several determinants of guideline use not commonly discussed in the literature were identified (applicability, target audience, credibility). The proposed implementation strategy is a valuable resource for guideline developers and policy/decision-makers to improve knowledge translation of guidelines among neurologists.

Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study.

BACKGROUND: There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary. METHODS: We conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians' claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value. RESULTS: Of 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment. INTERPRETATION: Overall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.

Toward systematic reviews to understand the determinants of wait time management success to help decision-makers and managers better manage wait times.

BACKGROUND: Long waits for core specialized services have consistently been identified as a key barrier to access. Governments and organizations at all levels have responded with strategies for better wait list management. While these initiatives are promising, insufficient attention has been paid to factors influencing the implementation and sustainability of wait time management strategies (WTMS) implemented at the organizational level. METHODS: A systematic review was conducted using the main electronic databases, such as CINAHL, MEDLINE, and Cochrane Database of Systematic Reviews, to identify articles published between 1990 and 2011 on WTMS for scheduled care implemented at the organizational level or higher and on frameworks for analyzing factors influencing their success. Data was extracted on governance, culture, resources, and tools. We organized a workshop with Canadian healthcare policy-makers and managers to compare our initial findings with their experience. RESULTS: Our systematic review included 47 articles: 36 related to implementation and 11 to sustainability. From these, we identified a variety of WTMS initiated at the organizational level or higher, and within these, certain factors that were specific to either implementation or sustainability and others common to both. The main common factors influencing success at the contextual level were stakeholder engagement and strong funding, and at the organizational level, physician involvement, human resources capacity, and information management systems. Specific factors for successful implementation at the contextual level were consultation with front-line actors and common standards and guidelines, and at the organizational level, financial incentives and dedicated staffing. For sustainability, we found no new factors. The workshop participants identified the same major factors as found in the articles and added others, such as information sharing between physicians and managers. CONCLUSIONS: Factors related to implementation were studied more than those related to sustainability. However, this finding was useful in developing a tool to help managers at the local level monitor the implementation of WTMS and highlighted the need for more research on specific factors for sustainability and to assess the unintended consequences of introducing WTMS in healthcare organizations.

Colonoscopy and its complications across a Canadian regional health authority.

BACKGROUND: Defining the complication rate of endoscopy performed across an entire city will capture usual as opposed to referral center data. OBJECTIVE: Our purpose was to evaluate the current practice of colonoscopy and complications associated with lower GI endoscopy in usual clinical practice. DESIGN: All admissions within 30 days of an outpatient lower GI endoscopy at any of the 6 adult-care Winnipeg hospitals were identified. This includes endoscopy for both complex and routine patients. A chart audit of all cases with potential complications was performed. RESULTS: A total of 24,509 outpatient lower GI endoscopies for adults were performed at the 6 hospitals over the 2 study years (April 1, 2004, to March 31, 2006). There were 303 admissions with potential complications. The colonoscopy completion rate was 65% (72% for gastroenterologists vs 59% for general surgeons, P < .005). Quality of bowel preparation and nature of polyps were often not documented. The overall rate of complications was 2.9/1000 procedures; the perforation rate after polypectomy was 1.8/1000; and the postpolypectomy bleeding rate was 6.4/1000. Most (67%) complications were recognized after discharge for the index procedure. The complication rate was highest for the endoscopists performing fewer than 200 procedures per year (5.4/1000 vs 2.7/1000 for the rest, P = .02, relative risk 2 [95% CI, 1.1-3.7]). LIMITATIONS: Chart audit was limited to cases requiring admission within 30 days of the index procedure. CONCLUSIONS: The overall complication rate after lower GI endoscopy in usual clinical practice in Winnipeg is comparable to that previously reported. A higher complication rate after endoscopy by low-volume endoscopists needs to be further evaluated. The reporting of endoscopy must be standardized to enhance outcomes interpretation.

Measuring and managing waiting times: what's to be done?

On September 11, 2000, the First Ministers of Canada issued a communiqué pledging to develop and report on waiting times for a number of diagnostic and treatment services. Reporting is to begin by September 2002. Given this commitment, what are the ideal characteristics of such a data collection system? This article defines and evaluates methods of measuring waiting times, and recommends a prioritized waiting-time information system to permit both measurement and management.

Patients hospitalized for medical conditions in Winnipeg, Canada: appropriateness and level of care.

A medical record review of patients hospitalized for medical conditions in Winnipeg, Canada during 1998/99 was completed using InterQual utilization review instruments. On admission, 95% of patients required the services provided in an acute care facility. Fifty-eight percent of days in hospital following the day of admission required an acute care setting, and 42% required an alternate level of care. Our results suggest there is room for treating more acute patients within the existing system.