Parental Knowledge, Attitudes, and Behaviours towards Human Papillomavirus Vaccination for Their Children: A Systematic Review from 2001 to 2011.

Objectives. A systematic review of parental surveys about HPV and/or child HPV vaccination to understand parental knowledge, attitudes, and behaviour before and after FDA approval of the quadrivalent HPV vaccine and the bivalent HPV vaccine. Search Strategy. Searches were conducted using electronic databases limited to published studies between 2001 and 2011. Findings. The percentage of parents who heard about HPV rose over time (from 60% in 2005 to 93% in 2009), as did their appreciation for the HPV infection and cervical cancer link (from 70% in 2003 to 91% in 2011). During the FDA approval, there was a stronger vaccine awareness but it has waned. The same pattern is seen with parents whose children received the HPV vaccine (peak at 84% in 2010 and now 36% in 2011) or the intention to vaccinate (peak at 80% in 2008 and now 41% in 2011). Conclusions. Parents had safety concerns and wanted more information their physician from to recommend and to confidently HPV vaccinate their children.

Ontario care providers' considerations regarding models of maternity care.

OBJECTIVE: There is currently a crisis in the delivery of maternity care in Canada, in part due to the significant decline in the number of professionals who provide intrapartum care. This study was undertaken (1) to elicit care providers' opinions regarding seven proposed models of maternity care, (2) to explore barriers to collaborative interprofessional practice, and (3) to identify factors that would encourage the practice of intrapartum care. METHODS: A survey seeking opinions about models of care, perceived barriers to interprofessional collaboration, and factors that might encourage practising intrapartum care was mailed to all registered midwives (N = 322) and obstetricians (N = 647) in Ontario and to a stratified random sample of family physicians (N = 750) in Ontario. RESULTS: Completed questionnaires were received from 80% of midwives, 64% of obstetricians, and 66% of family physicians. Midwives and obstetricians endorsed uniprofessional models and indicated an interest in multiprofessional practice. Family physicians were reluctant to choose any models that would have them practising intrapartum care. However, family physicians currently providing intrapartum care would consider the uniprofessional model in which they delivered the babies of the women they were caring for unless they were signed out. Midwives identified different philosophies of care as the main barrier to collaborative interprofessional maternity care (60.7%); obstetricians and family doctors identified liability and insurance issues (60.3% and 38.7%, respectively). An adequate on-call arrangement was the key factor potentially encouraging midwives and obstetricians to provide intrapartum care (70.3% and 70.0%, respectively). For family physicians, good medical and obstetrical back-up was the first priority (70.8%), followed by on-call arrangements. CONCLUSION: A variety of models for providing intrapartum care must be available, as no single model meets the needs of all maternity providers. Attention must be given to eliminating barriers to collaborative interprofessional practice, coupled with enhancing factors that facilitate the delivery of intrapartum care.

Level of acceptance of different models of maternity care.

To elicit nurses' opinions on five proposed models of maternity care in Ontario, to examine barriers to collaborative practice, and to identify factors that would encourage nurses to practise in the area of intrapartum care, a survey was mailed to a stratified random sample of nurses in Ontario (N = 750). Participants were asked whether they would consider practising in one or more of the five proposed models of maternity care. Almost half the participants endorsed the model of nurses' providing labour and delivery care to patients of family physicians and obstetricians. Almost one-third (28.7%) reported that they would consider working in an interprofessional maternity care clinic. There was minimal interest in working with midwives. Participants identified resistance to change (49.9%) and lack of communication (47.2%) as the two main barriers to collaborative practice. The majority of respondents (84.2%) ranked good medical and obstetrical backup as the key factor that would encourage them to provide intrapartum care. A respectful work environment and collaborative models of maternity care were also ranked highly.

Evaluation of postoperative pain control for women undergoing surgery for gynaecologic malignancies.

OBJECTIVES: (1) To compare the benefits of epidural analgesia and patient-controlled analgesia (PCA) in the management of postoperative pain in women with gynaecologic malignancies,and (2) to understand issues related to the delivery of pain control strategies. METHODS: A retrospective cohort study, based on chart review, was conducted of all women with gynaecologic malignancies who received either PCA or epidural analgesia at the Henderson Division of Hamilton Health Sciences, Hamilton, Ontario, from May 20, 1999, to July 17, 2001. Both objective (i.e., daily pain scores) and subjective (i.e., nursing progress notes) concerns were captured in the data collection instrument. RESULTS: Ninety-seven women had PCA and 122 had epidural analgesia as their primary form of postoperative analgesia. Pain scores were excellent (<2, range 0-10) in both groups. The nausea score was superior for the epidural group. Twenty percent of women experienced motor blocks and 17% had sensory blocks, which impeded their ability to walk for the first 3 days after surgery. Pruritus, rash, and Benadryl use were seen in more than 20% of the epidural group. Prolonged catheterization and a 3-fold increased risk of urinary tract infections were seen in the epidural group. Epidural catheter leaks occurred in 12.3% of the women on epidural analgesia. CONCLUSIONS: Postoperative pain management was excellent both in women who received PCA and in those who received epidural analgesia. Problems related to the delivery of pain control were more common in the epidural group.

Collaboration between community pharmacists and family physicians: lessons learned from the Seniors Medication Assessment Research Trial.

OBJECTIVES: To learn about the experiences of specially trained expanded role pharmacists (ERPs) and family physicians in a program in which they worked together to optimize drug therapy for elderly patients (aged 65 and older) and to identify shortcomings of the program, obstacles to its implementation, and strategies to overcome these obstacles. DESIGN: Qualitative opinion analysis. PARTICIPANTS: Six family physicians and six community-based ERPs who had participated in a randomized controlled trial (Seniors Medication Assessment Research Trial [SMART]). INTERVENTION: In-depth interviews. MAIN OUTCOME MEASURES: Themes that emerged from the interviews regarding the strengths and weaknesses of and ways to improve the program. RESULTS: ERPs and physicians differed in their perceptions of appropriate roles for ERPs. ERPs saw the program as an opportunity to take on new professional roles. Physicians appreciated the information they received from ERPs about their patients' adherence and use of nonprescription medications, but they did not want ERPs to directly counsel their patients. Some physicians questioned the value of the program for some patients, since the inclusion criteria for patients were broad and not all patients meeting the criteria needed intense interventions by ERPs. Both ERPs and physicians identified the need to refine the referral process and to work out professional role relationships and ongoing collaboration more fully. If the program were to be implemented as a routine service, physicians were concerned about the demands on their staff and office space and the need for an external compensation mechanism. CONCLUSION: Issues to be addressed for future programs include clarification of the roles of pharmacist and physician when the professionals work together, targeting of appropriate patients for the program, identification of a more efficient way to deliver recommendations, and development of an appropriate compensation mechanism.

A randomized controlled trial of a pharmacist consultation program for family physicians and their elderly patients.

BACKGROUND: Pharmacists can improve patient outcomes in institutional and pharmacy settings, but little is known about their effectiveness as consultants to primary care physicians. We examined whether an intervention by a specially trained pharmacist could reduce the number of daily medication units taken by elderly patients, as well as costs and health care use. METHODS: We conducted a randomized controlled trial in family practices in 24 sites in Ontario. We randomly allocated 48 randomly selected family physicians (69.6% participation rate) to the intervention or the control arm, along with 889 (69.5% participation rate) of their randomly selected community-dwelling, elderly patients who were taking 5 or more medications daily. In the intervention group, pharmacists conducted face-to-face medication reviews with the patients and then gave written recommendations to the physicians to resolve any drug-related problems. Process outcomes included the number of drug-related problems identified among the senior citizens in the intervention arm and the proportion of recommendations implemented by the physicians. RESULTS: After 5 months, seniors in the intervention and control groups were taking a mean of 12.4 and 12.2 medication units per day respectively (p = 0.50). There were no statistically significant differences in health care use or costs between groups. A mean of 2.5 drug-related problems per senior was identified in the intervention arm. Physicians implemented or attempted to implement 72.3% (790/1093) of the recommendations. INTERPRETATION: The intervention did not have a significant effect on patient outcomes. However, physicians were receptive to the recommendations to resolve drug-related problems, suggesting that collaboration between physicians and pharmacists is feasible.

A comparison of two prophylactic regimens for hypersensitivity reactions to paclitaxel.

OBJECTIVE: The aim of this study was to compare the rates of hypersensitivity reactions to paclitaxel with the conventional prophylactic regimen of two doses of oral corticosteroids and a modified regimen of a single dose of intravenous corticosteroid. METHODS: This was a retrospective historical cohort study assessing the rates of hypersensitivity reactions in patients receiving paclitaxel for ovarian or primary peritoneal carcinoma at the Hamilton Regional Cancer Centre from 1996 to 2000. Until 1998, all patients received the conventional prophylactic regimen consisting of two doses of oral dexamethasone (20 mg), 12 and 6 h prior to paclitaxel. From 1998 to the present, patients received a single dose of intravenous dexamethasone (20 mg), 30 min prior to paclitaxel. All patients also received an H(1) and H(2) blocker intravenously prior to paclitaxel administration. The analysis was corrected for potential covariates such as dose of paclitaxel and rate of infusion. The primary outcome measure was the rate of hypersensitivity reactions as defined by the National Cancer Institute of Canada-Clinical Trials Group. The Yates-corrected chi(2) test was used to compare the rates of these reactions, and a logistic regression analysis was used to determine whether any of the covariates were significant factors in these reactions. RESULTS: One hundred seven patients received the conventional corticosteroid prophylaxis prior to paclitaxel, and 110 received the single-dose intravenous corticosteroid prophylaxis. Of the 107 patients in the conventional prophylaxis group, 8 had a hypersensitivity reaction (7.5%), and only 1 of these was severe (0.9%). In contrast, of the 110 patients in the single-dose IV corticosteroid group, 19 had a hypersensitivity reaction (17.3%), and 8 of these were severe (7.3%). The difference in hypersensitivity reaction rates was significant (chi(2), P = 0.047). In the logistic regression analysis, the only significant factor related to hypersensitivity reactions was the type of prophylactic steroid regimen. CONCLUSIONS: In this series, the single-dose intravenous corticosteroid prophylactic regimen appeared to be associated with a higher rate of hypersensitivity reactions to paclitaxel than the conventional two-dose oral corticosteroid regimen.

Recruiting family physicians and patients for a clinical trial: lessons learned.

BACKGROUND: The randomized controlled trial (RCT) is the most definitive tool for evaluating an intervention. However, methodological deficiencies may limit the internal or external validity of the RCT. OBJECTIVE: Our aim was to describe the tactics used and the resources required randomly to select and recruit family physicians (FPs) and their patients aged 65 and older (seniors) for a community-based cluster RCT in primary care. METHODS: We randomly selected 48 FPs in 24 urban and rural sites in Southern Ontario, and 889 of their community-dwelling seniors (approximately 20 per FP) taking five or more medications daily. To accomplish this, the principal investigator (an FP) contacted the eligible FPs. The participating FPs' office staff then generated and contacted the roster of eligible seniors, with support provided by the research staff. RESULTS: Of the 163 randomly selected FPs telephoned, 94 were ineligible and 48 (69.6%) of the remaining 69 participated. The rosters were generated with the assistance of the research staff (taking 1.5-8.0 hours) in each of the 48 practices, using electronic appointment records (n = 26), electronic billing records (n = 17), electronic medical records (n = 2) or written charts or file cards (n = 3). Of the 2078 seniors approached, 799 were ineligible and 889 (69.5%) of the remaining 1279 participated. Seniors' refusal rates among practices ranged from 4.8 to 62.3%. CONCLUSIONS: Recruitment of a representative sample and generalizability of results are possible in RCTs in primary care. Involvement of an FP in physician recruitment and clinical research nurses who provided assistance to office staff were keys to success.