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.
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.
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.
Local adaptation of international and national guidelines is feasible following facilitation of the Practice Guidelines Evaluation and Adaptation Cycle.
Laparoscopic surgery may become the standard of care for the treatment of colorectal disease. Little is known regarding North American patterns of practice or the limiting factors and strategies for adoption among surgeons.
We sent a 28-item questionnaire to all general surgeon members of the Royal College of Physicians and Surgeons of Canada. We derived descriptive and correlative information using chi(2), Wilcoxon rank sum and Student t tests and multivariate logistic regression.
The return rate was 55% (694/1266). A total of 67% (462/694; 95% confidence interval 63%-70%) of respondents perform colorectal surgery. Of these, 54% perform laparoscopic colorectal surgery. Multivariate logistic regression identified 5 factors related to performing laparoscopic colorectal surgery: fewer years in practice (p
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.
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.
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.
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.
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.
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.
To describe the barriers to implementation of evidence-based recommendations (EBRs) for stroke rehabilitation experienced by nurses, occupational therapists, physical therapists, physicians and hospital managers.
The Stroke Canada Optimization of Rehabilitation by Evidence project developed EBRs for arm and leg rehabilitation after stroke. Five Canadian stroke inpatient rehabilitation centers participated in a pilot implementation study. At each site, a clinician was identified as the "local facilitator" to promote the 6-month implementation. A research coordinator observed the process. Focus groups done at completion were analyzed thematically for barriers by two raters.
A total of 79 rehabilitation professionals (23 occupational therapists, 17 physical therapists, 23 nurses and 16 directors/managers) participated in 21 focus groups of three to six participants each. The most commonly noted barrier to implementation was lack of time followed by staffing issues, training/education, therapy selection and prioritization, equipment availability and team functioning/communication. There was variation in perceptions of barriers across stakeholders. Nurses noted more training and staffing issues and managers perceived fewer barriers than frontline clinicians.
Rehabilitation guideline developers should prioritize evidence for implementation and employ user-friendly language. Guideline implementation strategies must be extremely time efficient. Organizational approaches may be required to overcome the barriers. [Box: see text].
Radiotherapy is an effective but underutilized treatment modality for cancer patients. We decided to investigate the factors influencing radiotherapy referral among family physicians in our region. A 30-item survey was developed to determine palliative radiotherapy knowledge and factors influencing referral. It was sent to 400 physicians in eastern Ontario (Canada) and the completed surveys were evaluated. The overall response rate was 50% with almost all physicians seeing cancer patients recently (97%) and the majority (80%) providing palliative care. Approximately 56% had referred patients for radiotherapy previously and 59% were aware of the regional community oncology program. Factors influencing radiotherapy referral included the following: waiting times for radiotherapy consultation and treatment, uncertainty about the benefits of radiotherapy, patient age, and perceived patient inconvenience. Physicians who referred patients for radiotherapy were more than likely to provide palliative care, work outside of urban centres, have hospital privileges and had sought advice from a radiation oncologist in the past. A variety of factors influence the referral of cancer patients for radiotherapy by family physicians and addressing issues such as long waiting times, lack of palliative radiotherapy knowledge and awareness of Cancer Centre services could increase the rate of appropriate radiotherapy patient referral.
The purpose of this study was to characterize the diagnostic process, frequency of associated disorders, family history, and impact of a gluten-free diet in individuals with celiac disease. All members of the Canadian Celiac Association (n=5240) were surveyed with a questionnaire. Respondents included 2681 adults with biopsy-proven celiac disease. The mean age was 56 years. Most common presenting symptoms included abdominal pain (83%), diarrhea (76%), and weight loss (69%). The mean delay in diagnosis was 11.7 years. Diagnoses made prior to celiac disease included anemia (40%), stress (31%), and irritable bowel syndrome (29%). Osteoporosis was common. Prior to diagnosis, 27% of respondents consulted three or more doctors about their symptoms. Delays in diagnosis of celiac disease remain a problem. Associated medical conditions occur frequently. More accurate food labeling is needed. Improved awareness of celiac disease and greater use of serological screening tests may result in earlier diagnosis and reduced risk of associated conditions.
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.
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.
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.
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.
Division of Gastroenterology and Nutrition, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada. mohsin.rashid@iwk.nshealth.ca
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.
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 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%.
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.
