None / Clinicians in general value the use of the best evidence in decision-making and consider that can improve patient care. However, a successful evidence based practice is hard to achieve in real life. In recent years, with the consolidation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the development of improved standards to judge the trustworthiness of guideline recommendations and the adoption of more strict policies to limit the influence of conflict of interests, trustworthy guidelines have become an attractive alternative for an evidence-based clinical practice. In this thesis we offer an explicit and easy-to-use guidance to clinicians regarding how to use guideline recommendations in the context of a real life practice. We also provide an in-depth explanation of the judgments involved in determining the direction and strength of recommendations. Finally, we expand the knowledge about how to manage conflict of interests in guideline developers. Through two studies evaluating the conflict of interest policy implemented at the American College of Chest Physicians 9th edition of the Antithrombotic Guidelines, we show what aspects of the policy were successful and what aspects need to be reformulated. / Thesis / Doctor of Philosophy (PhD) / None

Quelle est la force juridique des RBP en matière sanitaire, en plein contentieux comme en recours pour excès de pouvoir? Quelles sont les différences d'approche entre la France et les Etats-Unis? / What's the legal strength of CPGs in healthcare, in France and in the United States?The Institute of Medicine has defined as soon as 1992 Clinical Practice Guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." As they derive from various public and private bodies, and from the consensus of experts, CPGs are considered as consensus statements representing the prevailing standard of care in the medical profession. Clinicians and judges use clinical practice guidelines in their everyday life to appreciate individual situations and reach the best solutions for patients and plaintiffs: CPGs help improve their decision-making. But the legal strength of these tools is not totally consensual. In France, CPGs are seen as evidence of the standard of care expected from physicians. In theUnited States, where CPGs appeared some years earlier, they have been subject to questions, denounced as symptoms of a “cookbook medicine” and object of experiments by various States and insurance companies – not to mention lobbies. Their legal weight seems all the same better established in the U.S. than in France, although rulings in 2011 and 2016 by the french Conseil d’Etat have given them a more central role and a more recognized legal position in France.

People are seeking health information from a wide variety of sources. The comprehensive information in clinical practice guidelines (CPGs) represents an excellent source of evidence based information which should be communicated to this audience. Currently, there is little research about how to write a version of a CPG that would be easily accessible to people and more information is needed to identify barriers and supports, and potential solutions to disseminate CPGs to this audience (i.e. patients and the public). This thesis represents a body of research consisting of four scientific papers with an overarching objective to understand and explore how CPGs and recommendations primarily developed and written for health care professionals can be disseminated to patients and the public. A CPG was developed using the rigorous methods of the GRADE approach; a randomised controlled trial was conducted to evaluate a format to disseminate synthesised evidence to patients and the public; a systematic review of the literature with a thematic and narrative synthesis of patient and public attitudes towards and awareness of CPGs was performed; and a qualitative description and content analysis of a sample of patients versions of CPGs was conducted. The studies found that people are interested in patient versions of CPGs for a variety of purposes, such as for decision making, as a tool to prepare for consultations with health care providers, and as advice for self-care management. However, barriers to their use may include lack of personalisation of information, negative attitudes towards guidelines as ways to restrict and control access to care, and lack of understanding of the recommendations and the evidence. A format to disseminate the evidence from a guideline is proposed, but future research should focus on strategies to personalise the information, to overcome the negative attitudes towards guidelines, and to communicate the recommendations and the evidence informing the recommendations. / Thesis / Doctor of Philosophy (PhD)

Objective: New Mexico nurse practitioners contribute to the prevention and management of pediatric obesity. This study aimed to assess nurse practitioners' knowledge, attitudes, and behaviors, which were unknown in New Mexico, to counseling frequency in the assessment and management of overweight and obese pediatric patients. This was done using clinical practice guidelines (CPG). The study also sought to learn nurse practitioners' insights on needed resources for clinical practice. Rural and urban nurse practitioners' responses were then compared to the study aims. Methods: This descriptive pilot study surveyed members of the New Mexico Nurse Practitioner Council (NMNPC) to evaluate their knowledge, attitudes, and behaviors, in addition to the counseling frequencies expected to result in patient change. The survey used the platform Qualtrics and measured answers using a four-point Likert scale. Rural and urban comparisons were evaluated for each variable (knowledge, attitudes, and behaviors) in order to investigate relationships. Despite the underpowered sample size, data were analyzed for feasibility of future studies using descriptive statistics, Spearman's Rho Correlation, and Mann-Whitney U testing. Results: Fifteen nurse practitioners were included in the statistical analysis. The data found the nurse practitioners' self-reported responses exhibited knowledge, positive attitudes, and confident behaviors using pediatric obesity CPGs. The increases in these parameters correlated reported needing a quick CPG tool that can be used in practice. In all, rural nurse practitioners reported a slightly higher usage of pediatric obesity CPGs than urban nurse practitioners. Conclusion: The feasibility of this study's assessment of nurse practitioners' knowledge, attitudes, and behaviors using CPGs will assist in developing interventions to impact patient outcomes. The study also found that resources needed by New Mexico nurse practitioners were similar to those desired by other providers throughout literature. Rural compared to urban nurse practitioners findings indicated the need for further research. Future studies should include all health care providers in New Mexico in order to further explore aims of this study and development of interventions on overweight and obese pediatric CPGs to positively impact practice.

The purpose of this thesis was to determine the feasibility of implementing an intervention tailored to overcome barriers to adherence to recommendations of critical care nutrition guidelines in the Intensive Care Unit (ICU). The thesis is comprised of four manuscripts. The first manuscript described the development of a 26 item questionnaire rating the importance of potential barriers as impediments to the provision of enteral nutrition (EN) in the ICU. Preliminary evaluation demonstrated acceptable face and content validity and internal reliability, but the test retest reliability and within group reliability were poor for some items. The second manuscript provided evidence to support the construct validity of the developed questionnaire by reporting the results of a multilevel multivariate regression analysis of cross-sectional data from 55 ICUs that demonstrated that a 10 point increase in the overall barrier score was associated with a statistically significant 3.5% (Standard Error (SE) 1.3) decrease in prescribed calories received from EN. The third manuscript provided data to inform whether the intervention should be tailored to site specific barriers by describing the barriers to enterally feeding critically ill patients identified by 138 nurses, and evaluating whether these barriers differed across the 5 participating sites. Statistically significant differences were found among ICUs for 4 out of the 22 potential barriers. The fourth manuscript described the results of a pretest posttest study involving 5 ICUs in North America and determined that all participating sites successfully developed the tailored intervention. A statistically significant 10% (Site range -4.3 to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5 to17.9%) change in prescribed calories received was observed following the intervention. However, there was variability in the degree of implementation achieved by each site. Taken together, the results of this thesis demonstrated that adopting a tailored approach to improving nutrition practice is feasible. However, the findings also resulted in revisions to the barriers questionnaire and modifications to the design of the tailored intervention. Thus, the next step is to formally test the hypothesis that a tailored intervention designed to address barriers to feeding critically ill patients will improve nutrition performance. / Thesis (Ph.D, Community Health & Epidemiology) -- Queen's University, 2013-04-28 21:37:54.695

Purpose: To examine the effectiveness of a community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes, to evaluate the feasibility of achieving clinical targets for glycemic control in a community setting, and to identify factors that are predictive of glycemic control in this cohort (age, gender, disease duration, continuity of care, pharmacologic treatment, diabetes self-care and smoking status). Methods: Participants with Type 2 diabetes referred to the Diabetes Clinic following dissemination of the 2003 Clinical Practice Guidelines of Canadian Diabetes Association and who attended a minimum of two physician visits within a twelve month period were deemed eligible for participation. 70 patients were included in this retrospective study. Baseline and twelve month values for the following biomedical outcomes were collected via chart audit: BMI, hemoglobin A1c, blood pressure (systolic, diastolic) and lipid profile (HDL, LDL, triglycerides, total cholesterol, TC:HDL ratio). Data for identification of predictive factors for glycemic control were also retrieved by chart audit. Results: The results of the paired t-test yielded a significant improvement in hemoglobin A1c (p<0.05), systolic blood pressure (p<0.01), HDL-cholesterol (p<0.05), LDL-cholesterol (p<0.01), total cholesterol (p<0.05) and total cholesterol:HDL ratio (p<0.05) over twelve months. No significant difference in BMI, diastolic blood pressure or triglycerides was reported over twelve months. Over half the sample (52.9%) achieved clinical targets for glycemic control (hemoglobin A1c <7.0%) at twelve months. Logistic regression analysis identified disease duration (O.R. = 0.90, 95% CI Exp(B) = 0.079 - 0.773, p = 0.01) and continuity of care (O.R. = 0.25, 95% CI Exp(B) = 0.831 - 0.969, p = 0.02) as significant predictors of glycemic control at twelve months. Conclusions: These findings demonstrate the effectiveness of this community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes and show that the implementation of CPGs related to glycemic control is feasible in a community-based setting. Additionally, patients in this cohort with increased disease duration and increased continuity of care were less likely to achieve clinical targets for glycemic control following a twelve month intensive multifactorial clinical intervention for Type 2 diabetes. In summary, health professionals should strive to implement similar intensive multifactorial interventions in community practice in order to decrease the likelihood of diabetes-related complications and improve the patients quality of life.

Organizational theory can assist in better understanding how changes made in clinical practice can be sustained in healthcare organizations. Organizational learning and knowledge transfer theories were used to develop and test a theoretical model, “Sustaining in Memory” (SIM) model, to explore how organizations disperse or distribute newly transferred knowledge in knowledge reservoirs situated in the organization. Three hypotheses were generated from the theoretical model and tested with data from a cross sectional postal survey of 148 patient/resident care units in one large Canadian province where a CPG on prevention of falls was widely disseminated. Findings confirmed that fall prevention practice knowledge was transferred and embedded in all six knowledge reservoirs; however, there were three specific knowledge reservoirs that were found to be significant predictors of perceived CPG adherence (activities consistent with the CPG recommendations). These were staff, policy and role expectation knowledge reservoirs. There was variation in the adherence to the eight CPG recommendations with greater adherence to recommendations that were mandatory. Additionally, findings showed that the relationship between staff knowledge reservoir and CPG adherence was the only relationship moderated by the practices that helped to prevent/address knowledge loss through various activities designed for reviewing and updating practice knowledge. Interestingly, although CPG adherence was reported significantly greater in LTC resident care units, its association with patient outcomes was much weaker than in hospital patient care units. Hospital units had significantly greater correlation between perceived CPG adherence and all four of the falls prevention outcomes reported by study participants. Lastly, quality management culture as managed by senior leaders in the organization was also found to be a significant predicator of adherence to the CPG. The research study validated key assumptions made in the theoretical model while helping to clarify the distinct influence of different knowledge reservoirs. The SIM model provided an alternate perspective within which to study knowledge transfer and sustainability of clinical practices and has potential to apply to other change initiatives. This study answered the call for greater theoretically driven studies of CPG implementation as well as attention on the organizational influences of CPG implementation and sustainability.

Organizational theory can assist in better understanding how changes made in clinical practice can be sustained in healthcare organizations. Organizational learning and knowledge transfer theories were used to develop and test a theoretical model, “Sustaining in Memory” (SIM) model, to explore how organizations disperse or distribute newly transferred knowledge in knowledge reservoirs situated in the organization. Three hypotheses were generated from the theoretical model and tested with data from a cross sectional postal survey of 148 patient/resident care units in one large Canadian province where a CPG on prevention of falls was widely disseminated. Findings confirmed that fall prevention practice knowledge was transferred and embedded in all six knowledge reservoirs; however, there were three specific knowledge reservoirs that were found to be significant predictors of perceived CPG adherence (activities consistent with the CPG recommendations). These were staff, policy and role expectation knowledge reservoirs. There was variation in the adherence to the eight CPG recommendations with greater adherence to recommendations that were mandatory. Additionally, findings showed that the relationship between staff knowledge reservoir and CPG adherence was the only relationship moderated by the practices that helped to prevent/address knowledge loss through various activities designed for reviewing and updating practice knowledge. Interestingly, although CPG adherence was reported significantly greater in LTC resident care units, its association with patient outcomes was much weaker than in hospital patient care units. Hospital units had significantly greater correlation between perceived CPG adherence and all four of the falls prevention outcomes reported by study participants. Lastly, quality management culture as managed by senior leaders in the organization was also found to be a significant predicator of adherence to the CPG. The research study validated key assumptions made in the theoretical model while helping to clarify the distinct influence of different knowledge reservoirs. The SIM model provided an alternate perspective within which to study knowledge transfer and sustainability of clinical practices and has potential to apply to other change initiatives. This study answered the call for greater theoretically driven studies of CPG implementation as well as attention on the organizational influences of CPG implementation and sustainability.

Purpose: To examine the effectiveness of a community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes, to evaluate the feasibility of achieving clinical targets for glycemic control in a community setting, and to identify factors that are predictive of glycemic control in this cohort (age, gender, disease duration, continuity of care, pharmacologic treatment, diabetes self-care and smoking status). Methods: Participants with Type 2 diabetes referred to the Diabetes Clinic following dissemination of the 2003 Clinical Practice Guidelines of Canadian Diabetes Association and who attended a minimum of two physician visits within a twelve month period were deemed eligible for participation. 70 patients were included in this retrospective study. Baseline and twelve month values for the following biomedical outcomes were collected via chart audit: BMI, hemoglobin A1c, blood pressure (systolic, diastolic) and lipid profile (HDL, LDL, triglycerides, total cholesterol, TC:HDL ratio). Data for identification of predictive factors for glycemic control were also retrieved by chart audit. Results: The results of the paired t-test yielded a significant improvement in hemoglobin A1c (p<0.05), systolic blood pressure (p<0.01), HDL-cholesterol (p<0.05), LDL-cholesterol (p<0.01), total cholesterol (p<0.05) and total cholesterol:HDL ratio (p<0.05) over twelve months. No significant difference in BMI, diastolic blood pressure or triglycerides was reported over twelve months. Over half the sample (52.9%) achieved clinical targets for glycemic control (hemoglobin A1c <7.0%) at twelve months. Logistic regression analysis identified disease duration (O.R. = 0.90, 95% CI Exp(B) = 0.079 - 0.773, p = 0.01) and continuity of care (O.R. = 0.25, 95% CI Exp(B) = 0.831 - 0.969, p = 0.02) as significant predictors of glycemic control at twelve months. Conclusions: These findings demonstrate the effectiveness of this community-based intensive multifactorial clinical intervention for patients with Type 2 diabetes and show that the implementation of CPGs related to glycemic control is feasible in a community-based setting. Additionally, patients in this cohort with increased disease duration and increased continuity of care were less likely to achieve clinical targets for glycemic control following a twelve month intensive multifactorial clinical intervention for Type 2 diabetes. In summary, health professionals should strive to implement similar intensive multifactorial interventions in community practice in order to decrease the likelihood of diabetes-related complications and improve the patients quality of life.

Chronic non-cancer pain (CNCP) affects approximately 25% of Canadians. Opioids are medications frequently prescribed for management of patients with CNCP. Concern about addiction, misuse, and diversion for illicit use led the Canadian medical regulatory bodies to release a national guideline on the safe and effective use of opioids in CNCP. This thesis used an online survey to determine how closely the self-reported practices of Canadian family physicians matched the recommendations of the Canadian Guideline. We received 710 responses suitable for analysis. Thirteen percent of respondents did not prescribe strong opioids for CNCP. Practice gaps indentified were infrequently using a management agreement and monitoring pain with a scale; incorrect choice of second line opioid for mild to moderate pain; incorrect choice of first, second, and third line opioids for severe pain, and starting fentanyl incorrectly. Findings provide baseline information for future follow-up to compare physicians’ adherence to the guideline.