Changing relationships: how does patient involvement transform professional identity? An ethnographic study
Marie-Pierre Codsi, Philippe Karazivan, Ghislaine Rouly, Marie Leclaire, Antoine Boivin
Objectives: To understand identity tensions experienced by health professionals when patient partners join a quality improvement committee.
Design: Qualitative ethnographic study based on participatory observation.
Setting: An interdisciplinary quality improvement committee of a Canadian urban academic family medicine clinic with little previous experience in patient partnership. Participants Two patient partners, seven health professionals (two family physicians, two residents, one pharmacist, one nurse clinician and one nurse practitioner) and three members of the administrative team.
Data collection: Data collection included compiled participatory observations, logbook notes and semistructured interviews, collected between the summer of 2017 to the summer of 2019.
Data analysis: Ghadiri’s identity threats theoretical framework was used to analyse qualitative material and to develop conceptualising categories, using QDA Miner software (V.5.0).
Results: All professionals with a clinical care role and patient partners (n=9) accepted to participate in the ethnographic study and semi-structured interviews (RR=100%). Transforming the ‘caregiver–patient’ relationship into a ‘colleague–colleague’ relationship generated identity upheavals among professionals. Identity tensions included competing ideals of the ‘good professional’, challenges to the impermeability of the patient and professional categories, the interweaving of symbols associated with one or the other of these identities, and the inner balance between the roles of caregiver and colleague.
Conclusion: This research provides a new perspective on understanding how working in partnership with patients transform health professionals’ identity. When they are called to work with patients outside of a simple therapeutic relationship, health professionals may feel tensions between their identity as caregivers and their identity as colleague. This allows us to better understand some underlying tensions elicited by the arrival of different patient engagement initiatives (eg, professionals’ resistance to working with patients, patients’ status and remuneration, professionals’ concerns toward patient ‘representativeness’). Partnership with patients imply the construction of a new relational framework, flexible and dynamic, that takes into account this coexistence of identities.
High users of healthcare services: Development and Alpha Testing of a Patient Decision Aid for case management
Marie-Eve Poitras, France Légaré, Vanessa Tremblay Vaillancourt, Isabelle Godbout, Annie Poirier, Karina Prévost, Claude Spence, Maud-Christine Chouinard, Hervé Tchala Vignon Zomahoun, Lobna Khadhraoui, José Massougbodji, Mathieu Bujold, Pierre Pluye & Catherine Hudon
Background
Some patients with complex healthcare needs become high users of healthcare services. Case management allows these patients and their interprofessional team to work together to evaluate their needs, priorities and available resources. High-user patients must make an informed decision when choosing whether to engage in case management and currently there is no tool to support them.
Objective
The objective of this study was to develop and conduct a pilot alpha testing of a patient decision aid that supports high-user patients with complex needs and the teams who guide those patients in shared decision making when engaging in case management.
Methods
We chose a user-centered design to co-develop a patient decision aid with stakeholders informed by the Ottawa Research Institute and International Patient Decision Aid Standards frameworks. Perceptions and preferences for the patient decision aid’s content and format were assessed with patients and clinicians and were iteratively collected through interviews and focus groups. We developed a prototype and assessed its acceptability by using a think-aloud method and a questionnaire with three patient-partners, six clinicians and seven high-user patients with complex needs.
Results
The three rounds of evaluation to assess the decision aid’s acceptability highlighted comments related to simplicity, readability and visual aspect. A section presenting clinical vignettes including story telling was identified as the most helpful.
Conclusions
We created and evaluated a patient decision aid. Considering the positive comments, we believe that this aid has the potential to help high-user patients with complex care needs make better choices concerning case management.
Assessing the scalability of innovations in primary care: a cross-sectional study
Ali Ben Charif, Hervé Tchala Vignon Zomahoun, José Massougbodji, Lobna Khadhraoui, Maxine Dumas Pilon, Elise Boulanger, Amédé Gogovor, Marie-Josée Campbell, Marie-Ève Poitras, and France Légaré
Background
Canadian health funding currently prioritizes scaling up for evidence-based primary care innovations, but not all teams prepare for scaling up. We explored scalability assessment among primary care innovators in the province of Quebec to evaluate their preparedness for scaling up.
Methods
We performed a cross-sectional survey from Feb. 18 to Mar. 18, 2019. Eligible participants were 33 innovation teams selected for the 2019 Quebec College of Family Physicians’ Symposium on Innovations. We conducted a Web-based survey in 2 sections: innovation characteristics and the Innovation Scalability Self-administered Questionnaire. The latter includes 16 criteria (scalability components) grouped into 5 dimensions: theory (1 criterion), impact (6 criteria), coverage (4 criteria), setting (3 criteria) and cost (2 criteria). We classified innovation types using the International Classification of Health Interventions. We performed a descriptive analysis using frequency counts and percentages.
Results
Out of 33 teams, 24 participated (72.7%), with 1 innovation each. The types of innovation were management (15/24), prevention (8/24) and therapeutic (1/24). Most management innovations focused on patient navigation (9/15). In order of frequency, teams had assessed theory (79.2%) and impact (79.2%) criteria, followed by cost (77.1%), setting (59.7%) and coverage (54.2%). Most innovations (16/24) had assessed 10 criteria or more, including 10 management innovations, 5 prevention innovations and 1 therapeutic innovation. Implementation fidelity was the least assessed criterion (6/24).
Interpretation
The scalability assessments of a primary care innovation varied according to its type. Management innovations, which were the most prevalent and assessed the most scalability components, appear to be most prepared for primary care scale-up in Canada.
Improving the usefulness of evidence concerning the effectiveness of implementation strategies for knowledge products in primary healthcare: Protocol for a series of systematic reviews
Hervé Tchala Vignon Zomahoun, José Massougbodji, André Bussières, Aliki Thomas, Dahlia Kairy, Claude Bernard Uwizeye, Nathalie Rheault, Ali Ben Charif, Ella Diendéré, Léa Langlois, Sébastien Tchoubi, Serigne Abib Gaye and France Légaré
Background
The literature on the implementation of knowledge products is extensive. However, this literature is still difficult to interpret for policymakers and other stakeholders when faced with choosing implementation strategies likely to bring about successful change in their health systems. This work has the particularity to examine the scope of this literature, and to clarify the effectiveness of implementation strategies for different knowledge products. Consequently, we aim to (1) determine the strengths and weaknesses of existing literature overviews; (2) produce a detailed portrait of the literature on implementation strategies for various knowledge products; and (3) assess the effectiveness of implementation strategies for each knowledge product identified and classify them.
Methods
We will use a three-phase approach consisting of a critical analysis of existing literature overviews, a systematic review of systematic reviews, and a series of systematic reviews and meta-analyses. We will follow the Cochrane Methodology for each of the three phases. Our eligibility criteria are defined following a PICOS approach: Population, individuals or stakeholders participating in healthcare delivery, specifically, healthcare providers, caregivers, and end users; Intervention, any type of strategy aiming to implement a knowledge product including, but not limited to, a decision support tool, a clinical practice guideline, a policy brief, or a decision-making tool, a one-pager, or a health intervention; Comparison, any comparator will be considered; Outcomes, phases 1 and 2—any outcome related to implementation strategies including, but not limited to, the measures of adherence/fidelity to the use of knowledge products, their acceptability, adoption, appropriateness, feasibility, adaptability, implementation costs, penetration/reach and sustainability; phase 3—any additional outcome related to patients (psychosocial, health behavioral, and clinical outcomes) or healthcare professionals (behavioral and performance outcomes); Setting, primary healthcare has to be covered. We will search MEDLINE (Ovid), EMBASE, Web of Science, PsycINFO, CINAHL, and the Cochrane Library from their inception onwards. For each phase, two reviewers will independently perform the selection of studies, data extraction, and assess their methodological quality. We will analyze extracted data, and perform narrative syntheses, and meta-analyses when possible.
Discussion
Our results could inform not only the overviews’ methodology but also the development of an online platform for the implementation strategies of knowledge products. This platform could be useful for stakeholders in implementation science.
Essential items for reporting of scaling studies of health interventions (SUCCEED): Protocol for a systematic review and Delphi process
Amédé Gogovor, Hervé Tchala Vignon Zomahoun, Ali Ben Charif, Robert K. D. McLean, David Moher, Andrew Milat, Luke Wolfenden, Karina Prévost, Emmanuelle Aubin, Paula Rochon, Giraud Ekanmian, Jasmine Sawadogo, Nathalie Rheault & France Légaré
Background
The lack of a reporting guideline for scaling of evidence-based practices (EBPs) studies has prompted the registration of the Standards for reporting studies assessing the impact of scaling strategies of EBPs (SUCCEED) with EQUATOR Network. The development of SUCCEED will be guided by the following main steps recommended for developing health research reporting guidelines.
Methods
Executive Committee. We established a committee composed of members of the core research team and of an advisory group.
Systematic review. The protocol was registered with the Open Science Framework on 29 November 2019 (https://osf.io/vcwfx/). We will include reporting guidelines or other reports that may include items relevant to studies assessing the impact of scaling strategies. We will search the following electronic databases: EMBASE, PsycINFO, Cochrane Library, CINAHL, Web of Science, from inception. In addition, we will systematically search websites of EQUATOR and other relevant organizations. Experts in the field of reporting guidelines will also be contacted. Study selection and data extraction will be conducted independently by two reviewers. A narrative analysis will be conducted to compile a list of items for the Delphi exercise. Consensus process. We will invite panelists with expertise in: development of relevant reporting guidelines, methodologists, content experts, patient/member of the public, implementers, journal editors, and funders. We anticipated that three rounds of web-based Delphi consensus will be needed for an acceptable degree of agreement. We will use a 9-point scale (1 = extremely irrelevant to 9 = extremely relevant). Participants’ response will be categorized as irrelevant (1–3), equivocal (4–6) and relevant (7–9). For each item, the consensus is reached if at least 80% of the participants’ votes fall within the same category. The list of items from the final round will be discussed at face-to-face consensus meeting. Guideline validation. Participants will be authors of scaling studies. We will collect quantitative (questionnaire) and qualitative (semi-structured interview) data. Descriptive analyses will be conducted on quantitative data and constant comparative techniques on qualitative data.
Discussion
Essential items for reporting scaling studies will contribute to better reporting of scaling studies and facilitate the transparency and scaling of evidence-based health interventions.
The pitfalls of scaling up evidence-based interventions in health
Hervé Tchala Vignon Zomahoun, Ali Ben Charif, Adriana Freitas, Mirjam Marjolein Garvelink, Matthew Menear, Michèle Dugas, Rhéda Adekpedjou & France Légaré
Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs.
Characteristics of case management in primary care associated with positive outcomes for frequent users of healthcare: a systematic review
Catherine Hudon, Maud-Christine Chouinard, Pierre Pluye, Reem El Sherif, Paula Louise Bush, Benoît Rihoux, Marie-Eve Poitras, Mireille Lambert, Hervé Tchala Vignon Zomahoun and France Légaré
Purpose
Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care.
Methods
For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods.
Results
Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes.
Conclusions
Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcome
