Health care guidelines provide a means of assessing the best available research evidence on a given health care topic and offering recommendations about use of specific interventions and management of patient care. Guidelines allow clinicians, patients, health administrators and policy-makers to be efficiently informed and stay up to date on alternative care options. The development of guidelines is a complex and multidisciplinary process, with a defining feature of involving a panel of experts in steps such as selecting health care questions, assessing the research evidence, making judgements about health benefits and harms, and, ultimately, formulating recommendations. Guideline methodology has advanced over the past decades, including establishment of specific steps and standards to ensure trustworthiness of guidelines. However, there remain critical research questions on how to best accomplish and reach these standards, including how to best engage panels in the steps. This thesis presents a body of research on the development and evaluation of new methods for decision-making and considering health outcomes in guidelines, prioritizing health care questions for guidelines, and evaluating the guideline development process. It includes three studies: 1) a methodological study on developing health outcome descriptors to define health outcomes considered in decision-making by guideline panels; 2) a methodological study and randomized controlled trial to evaluate specific criteria for panels to consider when prioritizing health care questions for guidelines and to judge the importance of health outcomes; and 3) an instrument development and validation study to create a tool for panel members to evaluate the appropriateness of the guideline development process they participate in. In these studies, we established a method and steps for creating health outcome descriptors with panels, aimed at achieving consistency in how health outcomes are considered throughout the guideline development process, from prioritization to formulating a recommendation on the basis of those outcomes. The structured approach and criteria evaluated for prioritization of healthcare questions informed panel deliberations and decisions about choosing questions for their guideline topics, and the proposed methods for outcome prioritization facilitated panels in informing what the critical and important outcomes were for decision-making. Finally, the instrument we developed facilitated members of guideline panels to provide their assessment of the guideline development process and identify strengths and weaknesses and areas for improvement. Our findings will allow organizations responsible for guideline development to apply the new methods with their panels and to evaluate their guideline processes to inform quality-improvement efforts. / Thesis / Doctor of Philosophy (PhD) / Health care guidelines, also referred to as clinical practice or public health guidelines, involve summarizing the available research evidence on a given health care topic and issuing recommendations about the best care. Guidelines allow clinicians, patients, health administrators and policy-makers to be efficiently informed and stay up to date on alternative care options, such as the best current treatments and strategies to diagnose various diseases and health conditions. Developing a guideline is a complex and multidisciplinary process that includes involving a panel of experts, typically consisting of clinicians, patients, public health professionals and other providers or consumers of health care. The panel is involved in selecting the health care questions to address (e.g. specific treatments or diagnostic strategies to evaluate), reviewing a summary of the evidence from research studies, and making judgements about benefits and harms of alternate options or strategies. The panel then formulates recommendations that give guidance on what the best options are to use for the health condition in question. The steps and approaches to develop a guideline that is considered trustworthy have been established over the past decades, including universally accepted standards. However, there remain critical research questions on how to best reach these standards, including how to best engage guideline panels in the steps. The research work presented in this thesis focuses on proposing and evaluating new methods and approaches for guidelines panels to make decisions about health outcomes, priority health care questions for guidelines, and to evaluate the guideline development process. It includes three studies: 1) a study on creating health outcome descriptors with panels to provide a commonly accepted definition of a health outcome; 2) a study to evaluate specific criteria that panels can use to prioritize health care questions, and an approach to judge the importance of health outcomes; and 3) a study to develop a survey instrument for guideline panel members to evaluate the guideline development process they participate in. In these studies, we established an approach for creating the health outcome descriptors with panels, which helped in keeping consistency with how panels understood and considered different health outcomes throughout the guideline development process. The criteria evaluated for prioritizing healthcare questions informed panel discussions and selection of questions for their guideline topics. The proposed approach for judging the importance of health outcomes helped panels to select what the critical outcomes were for making decisions about the benefits and harms of alternate options or strategies. Finally, the survey tool we created allowed members of guideline panels to provide feedback on strengths and weaknesses and areas for improvement in the process after they participated in developing a guideline. Our findings will allow organizations responsible for guideline development to apply the new methods with their panels and to evaluate their guideline processes to inform quality-improvement efforts.

Reviews the book, Complementary medicine and clinical practice edited by David P. Rakel and Nancy Faass (2006). Complementary and alternative medicine, or CAM, as it is known, has been an important and controversial topic for allopathic medicine. Although the majority of the patients in this country will use one or more forms of complementary medicine, and spend more out-of-pocket money on CAM techniques and practitioners than on allopathic ones, there is still a great deal of uncertainty among practicing physicians about what exactly CAM consists of. This book goes a long way toward helping to clarify this diverse and changing topic. Overall, each of the topics in the book emphasizes a refreshing focus on health compared with the antidisease focus of many more traditional medical articles and books. Each of the chapters integrates the technique and philosophy of the topic explored into an overall health-oriented approach to patient care. Rakel and Faass's book creates a template for a new model of medicine. Given its broad scope, it is ideal for family physicians to consider as we envision the evolution of our practices.

yes / Binocularity in the human visual system poses two interesting and extremely challenging questions. The first, and perhaps most obvious stems from the singularity of perception even though the neural images we see originate as two separate images in the right and left eyes. Mechanistically we can ask how and where do we convert two images into one? The second question is more of a “why” question. By converting lateral eyes with their inherent panoramic visual field into frontal eyes with overlapping binocular visual fields, primates have developed an extremely large blind region (the half of the world behind us). We generally accept that this sacrifice in visual field size was driven by the potential benefit of extracting information about the 3rd dimension from overlapping right and left eye visual fields. For some people, both of these core processes of binocularity fail: a single fused binocular image is not achieved (when diplopia or suppression is present), and the ability to accurately represent the 3rd dimension is lost (stereo-blindness). In addition to these failures in the core functions of the human binocular system, early imbalances in the quality of right and left eye neural images (e.g. due to anisometropia, monocular deprivation, and/or strabismus), can precipitate profound neurological changes at a cortical level which can lead to serious vision loss in one eye (amblyopia). Caring for patients with malfunctioning binocular visual systems is a core therapeutic responsibility of the eye care professions (optometry, ophthalmology and orthoptics) and significant advances in patient care and subsequent visual outcomes will be gained from a deeper understanding of how the human brain accomplishes full binocular integration. This feature issue on binocular vision brings together original articles and reviews from leading groups of neuroscientists, psychophysicists and clinical scientists from around the world who embrace the multidisciplinary nature of this topic. Our authors have taken on the big issues facing the research community tasked with understanding how binocular vision is meant to work, how it fails, and how to better treat those with compromised binocularity. These studies address deep issues about how the human brain functions and how it fails, as well as how it can be altered by therapy.

Health care changes, including increased hospital admissions, an aging population and the chronicity of diseases and conditions have led to increased collaboration with unregulated professionals. Within the professions of occupational therapy and physiotherapy, there is a paucity of literature that addresses the perceptions of Occupational Therapist Assistants and Physiotherapist Assistants (OTAs and PTAs) with respect to their competence in clinical practice. This research study investigates the perceptions of clinical competence of OTA and PTA graduates from one Ontario community college. A phenomenological theoretical framework was used to explore the participants’ lived experiences. Eight individual in-depth interviews were used to gather data representing the graduate OTAs and PTAs’ perspectives. In addition, the viewpoints from a stakeholder focus group of eight participants comprised of occupational therapists, physiotherapists, and administration personnel from one Ontario hospital were used to triangulate the data.. Four themes emerged: 1) employing effective communication, 2) emerging knowledge, skills and competencies in clinical practice, 3) transitioning into clinical practice, and 4) developing confidence as an OTA and PTA. The Person Environment Occupation (PEO) model (Law et al., 1996) was used to organize the themes and to assist in determining the optimal fit between the themes. Confidence was articulated as a continuous concept that facilitated the graduates’ competence in their clinical skills. Proficiency in their roles, a supportive transition, and demonstrated competence were the presenting factors that empowered the graduate OTAs and PTAs to affirm their competence in clinical practice. This research study is foundational for future research related to OTAs and PTAs in the areas related to use of title, educational credentialing, and collaborative competency documentation. / Thesis / Master of Science (MSc) / Currently, there are changes in health care services that require modifications to the delivery of the treatment. Occupational Therapist Assistants and Physiotherapist Assistants (OTAs and PTAs) work within patient rehabilitation; however, their perceptions of competence have not been assessed. This study reviews the perceptions of the OTAs and PTAs when completing their role with patients by interviewing them and interviewing the staff that work with them. The data from this thesis will provide us with an enhanced understanding of the perceptions of OTAs and PTAs and the supports they believe enable them to be competent and confident health care professionals. This information will facilitate the identification of the next steps in research specific to OTAs and PTAs in the areas of competency and educational programs.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23820号 / 社医博第120号 / 新制||社医||12(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 小杉 眞司, 教授 柳田 素子 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

This thesis explores the Rapid Recommendations process, a new responsive way of creating clinical practice guidelines. / Healthcare workers rely on clinical practice guidelines to inform their practice. However, most guidelines are not trustworthy when judged by accepted standards and they typically take several years to produce. Guideline trustworthiness is undermined by panel members who often have conflicts of interest, by including representation from only a subset of stakeholders, by failing to examine the entirety of the evidence systematically, and by rapid obsolescence. Further, they are often difficult for users to understand in limited time. Rather than updating guidance on a fixed schedule, the Rapid Recommendations approach involves continuous monitoring of the literature and produces guidelines in response to new potentially practice-changing evidence. A collaborative network of clinicians, methodologists, and patients respond by rapidly producing trustworthy evidence syntheses and guidance. We have identified efficiencies at every step of the guideline development process. The guideline panel does not include anyone with a financial conflict of interest and there are strict limits professional and intellectual conflicts. Systematic reviews are produced on the relative effects of each option, on prognosis, and on patient values and preferences with the explicit intent to inform the question at hand. The panel also considers practical issues. Rapid Recommendations are published in a concise multilayered user-friendly format headed by an interactive infographic that contains all of the necessary information for users need to make informed decisions at the point of care. The guideline is published simultaneously in print and electronically, including decision aids that can be used at the point of care and integrated into electronic medical records. In this thesis, you will find a selection of exemplary publications relevant to the Rapid Recommendations process. We show that a responsive approach to rapid and trustworthy guideline creation is possible. It represents a way forward from the current limitations that plague most current clinical practice guidelines. / Thesis / Candidate in Philosophy / Healthcare workers often decide what to do in practice based on the advice of experts through clinical practice guidelines. However, most clinical practice guidelines are not completely trustworthy. Guideline authors often have conflicts of interest, do not include patients or patient views, and are created so slowly that they rapidly fall into obsolescence. This thesis explores a new way of developing clinical practice guidelines that we call Rapid Recommendations. Instead of creating them on a fixed schedule (i.e., every few years), they are created in response to new studies that might change practice. The scope is limited, and timelines are shorter, meaning that the guidelines are published sooner. The guideline authors include all stakeholders, including patients. None of the authors have any financial interests in the topic, and other conflicts are minimized. The guidelines are published on an expedited basis and in an accessible online multilayered format with infographics. This thesis includes a selection of exemplary publications relevant to the Rapid Recommendations process.

Trustworthy clinical practice guidelines assist health care professionals in selecting the management options that optimize patient health outcomes. The development of trustworthy guidelines requires the consideration of many aspects and the involvement of multiple contributors, often working in groups. The guideline panel plays the key role in the development process as it is responsible for prioritizing topics that should be covered as part of the guideline effort, formulating questions, reviewing the evidence, developing and agreeing on the recommendations, and endorsing the final guideline document. Ensuring transparency throughout the process by appropriately organizing and documenting panel activities is an essential standard that is used to assess the credibility of a developed guideline and its resulting recommendations. The adoption of conceptual frameworks that systematically guides panel members in their decision-making process (e.g. the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks) can aid in the formulation of methodologically sound recommendations. In this dissertation, I used the example of a guideline on diagnosis and treatment of autism spectrum disorders to describe how rigorous research methods can support guideline panels in the development process from early stages to the formulation of recommendations. In another prominent guideline development effort with the American Society of Hematology, I have identified two steps in the process where panel members may benefit from further support and addressed these gaps by conceptualizing and developing novel approaches. The first approach comprises modelling baseline risk estimates for patient-important outcomes when only surrogate data is available. The second approach proposes a method to estimate decision thresholds for judgments on health benefits and harms using the GRADE EtD framework. While these approaches are tailored to address specific guideline panel needs, guideline methodologists could use the underlying concepts to find solutions to aid guideline panels in other steps of the development process. / Thesis / Doctor of Philosophy (PhD) / Clinical practice guidelines assist health care professionals in selecting management options that can best improve the health outcomes of their patients. The development of trustworthy guidelines is a complex process that requires the contribution of several entities. The guideline panel, which typically comprises different experts (clinicians, patient representatives, experts in research methodologies) plays the key role in this process as it is responsible for selecting the most important questions to address in the guideline, reviewing the evidence supporting an option, agreeing on the recommendations, and endorsing the final guideline document. To ensure that the process of developing guidelines is transparent and that the recommendations are credible, it is important that panel activities are well documented and follow rigorous methods. Structured frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) approach, have been developed to systematically guide the panel members and to minimize the error that could be introduced while making decisions. In this thesis, I describe the development of an approach and its application for comprehensive guideline development by the Italian National Health Institute, to describe rigorous guideline development and propose two novel approaches to further assist panel members in enhancing their guideline development. The first of these two enhancements to guideline development describes how to derive a modelled estimate of the risk of having certain health conditions when this data is not directly available in the medical literature. The second of the two enhancements is a method to support guideline panels in judging how substantial the desirable and undesirable effects of health interventions are. Both approaches were tailored to fit specific needs but can be adapted to inform the improvement of other steps in the guideline development process.

Yes / To survey the diagnostic radiography workforce in the United Kingdom (UK) at an organisational level to ascertain the scope of advanced practice and compliance with Health Education England standards for multiprofessional advanced clinical practice (ACP). 174 diagnostic imaging departments were invited to participate in a cross-sectional electronic survey focused upon advanced level practice and their educational and accreditation expectations (October-December 2019). Breast imaging, computed tomography, fluoroscopy, interventional radiology, lithotripsy, magnetic resonance imaging and projectional radiography were included. A total of 97 responses were received, of which 79 were eligible for inclusion (45%). Respondents reported advanced-level practice roles across all imaging modalities, which included clinical reporting, procedural-based and combined roles. Radiograph and mammogram reporting were most prevalent (95 and 67% of Trusts), with fluoroscopy the most frequent procedure-only role (25%). Only 39% of trusts required adherence to the four pillars of ACP within job descriptions, and only 12% requiring a full Masters qualification. Diagnostic radiographer reporting and procedure-based roles in the NHS are varied and widespread. However, inconsistencies in fulfilment against the expected standards for advanced practice exist. Realignment of advanced-level roles to delineate enhanced and advanced clinical practice may ensure consistency between roles and professions. A requirement for accreditation as an advanced (clinical) practitioner with adherence to advanced practice requirements could therefore provide value to accreditation for both individual practitioners and Trusts. Within the UK, diagnostic radiographer roles previously self-identified as advanced-level practice may be termed enhanced practice when not adhering to expected ACP standards.

This study retrospectively evaluated patient records from two cardiac rehabilitation (CR) service centers located in large urban hospitals using a Process Evaluation System (PES) recently developed through a collaborative project of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), Madison, WI, and the Center for Clinical Quality Evaluation (CCQE), Washington, DC. The major aims were to: 1) evaluate the utility of the PES as an audit instrument for assessment of adherence to the 24 quality process criteria that comprised the PES; and 2) determine whether adherence to the PES criteria resulted in different patient outcomes for those cases where intervention need was documented at patient admission. Using the data abstraction manual and audit procedures developed by AACVPR/CCQE, a trained medical technician audited 150 CR records for consecutively treated outpatients who typically received 36 sessions of treatment in either Moses H. Cone Memorial Hospital, N.C. Heart Institute, Greensboro, NC, or Carolinaà ­s Medical Center, Charlotte, NC, covering a calendar period between 1995-97. The data were pooled from both sites for analyses and included patients with one or more of the following diagnoses: MI (37%), angina (14%), coronary revascularization (76%), and other (18%). The cost of utilizing the PES was assessed by evaluating the technician time required to abstract a patient record and this was observed to improve over the course of the review period, i.e., mean abstraction time for initial versus final 20 records = 13.2 min. and 4.6 min., respectively. Experience with the PES suggested areas where instrument revision should be considered, e.g., the operational guidelines for extracting acceptable markers were not always clear enough or sufficiently flexible to allow determination of adherence of a record to the 24 quality process criteria. Adherence to the PES was determined, case by case, for each of the 24 criteria. In 129 cases (86% of the sample), complete adherence was found, i.e. 100% adherence to all 24 criteria that included indicators of key clinical steps for patient intake, treatment planning, and follow-up. The remaining 21 records (14%) showed adherence to at least 21 of the 24 criteria (87.5%). Given the uniformly high levels of adherence to the PES documented by these two program sites, the data could not resolve the question of whether patient outcome effects were different between cases of high versus low adherence to PES. Nonetheless, outcome data were examined to evaluate achievement levels in four different areas widely considered by clinicians as important to treatment success: blood cholesterol, smoking status, exercise tolerance, and body mass index (BMI). Of the study patients diagnosed with dyslipidemia 12 of 27 (44%) had levels < 200 mg/dl by exit. Seven of 14 documented smokers (50%) reported quitting at exit from treatment. Forty-nine patients of 117 (42%) who initially could only maintain treadmill walking for 10 min. at levels below 4 METs, were able to exceed this level by treatment end. Six of 104 (6%) with BMI values > 24.9 kg/m2 had a documented decrease in this indicator of overweight by treatment end. The threshold levels for outcome criteria used here to describe achievement levels in this data set are somewhat arbitrary. However, the criteria are reflective of the standards typically suggested as meaningful for effective secondary risk reduction in CR programs (Franklin et al., 1996). The PES system was developed to audit the quality of CR process in treatment centers, as standardized by a consensus panel to reflect the content of the evidenced-based CR guideline recently published by the US Agency for Health Care Policy and Research (Cardiac Rehabilitation as Secondary Prevention: #17, 1995). The findings of this study suggest that the content markers of quality process in the PES are relevant and the instrument is efficient to administer. When field tested against two urban centers in North Carolina where state statutes require program certification for CR treatment centers, these centers demonstrated uniformly high adherence to the PES and a pattern of good achievement for several patient outcome measures accepted as relevant to evaluation of treatment success for individual patients. / Master of Science

This project study addressed the problem of knowledge and skills lost by new graduate RNs while delayed in transitioning to professional nursing practice. There is a paucity of knowledge about how new RNs experience their delay and how a delay may affect their future clinical performance. Mezirow's transformation learning theory was the conceptual framework for this qualitative case study. Research questions addressed new RNs' understanding of their experiences during a delay to professional practice. A purposeful sample included 8 new RNs who had completed a New Graduate Residency Transition Program (NGRTP) after a delay to practice of 6 months to 3 years. Four managers of the RN participants were also included in the sample. Data were collected through audio-recorded semistructured interviews and manager questionnaires. Qualitative data were coded and analyzed to identify themes. Findings indicated that while waiting for a RN position, the delay to practice new RN (DTP-RN) passed through stages that reflected clinical and professional needs. The consequences of the new RNs' delay to practice may impact the required NGRTP process. Findings influenced the development of a white paper to educate hospital nurse educators and managers about the DTP-RNs' unique needs. Recommendations include a NGRTP designed to meet the transition needs of the DTP-RN. Implementation of recommendations for a NGRTP may enhance the DTP-RNs' successful transition into professional practice with a result of greater job satisfaction and decreased RN turnover.