Modified Dillman Method Research Articles

Oncologist knowledge of cost of genetic testing.

10591 Background: Genetic testing allows patients and their families to identify hereditary cancer syndromes. Financial barriers to genetic testing are a major concern for patients offered genetic risk assessment. The cost of germline genetic testing has decreased substantially over the last several years. It is not clear, however, that oncologists are knowledgeable about the cost of genetic testing. The purpose of this study was to investigate oncologists’ knowledge of genetic testing costs. Methods: We deployed a survey to all oncologists who are members of the Michigan Oncology Quality Consortium, a physician-led quality improvement collaborative whose members represent 95% of the oncologists in Michigan. The modified Dillman method was used to achieve the maximum response rate. Responses were collected from December 2020 through May 2021. The responses to the question, “If a patient were to ask you how much it would cost for them to have clinical genetic testing for hereditary cancer syndromes, what would you tell them?” were independently coded by three investigators into one of three categories – correct and helpful, correct and not helpful, or incorrect and not helpful. We investigated associations between the number of years in practice and how important was cost as a barrier to genetic risk assessment. Results: The response rate to the survey was 61.2% (194/317). Only 25% of respondents provided an answer that was deemed to be both correct and helpful to a patient, for example “approximately $250 if out of pocket.” Nearly 40% of respondents gave an answer that was correct but was non-specific and would not help a patient decide about pursuing genetic testing. This category included responses such as deferring to a genetic counselor or that cost varies based on insurance. About 28% gave an incorrect response, such as “several thousand dollars” or responded, “I don’t know.” No associations were found between cost response category, number of years in practice, or reported responses that financial barriers play a role in referral patterns. Conclusions: The majority of oncologists in our statewide sample do not have an accurate understanding of the cost of germline genetic testing. Lack of precise information about the costs of testing may lead patients to believe that genetic testing is either not important or not within reach. Furthermore, providing incorrect information can have a downstream effect and prevent patients and their families from pursuing genetic counseling. Improving oncologists’ knowledge about the cost of testing may decrease barriers to uptake of genetic risk assessment. [Table: see text]

Lysine analogue use during cancer surgery: a survey from a Canadian tertiary care centre.

When used during surgery, antifibrinolytic hemostatic agents such as lysine analogues are effective at reducing blood loss and the need for transfusions. Despite proven efficacy, use of hemostatic agents remains low during some surgeries. Our objective was to explore surgeon opinions about, and use of lysine analogues in, oncologic surgeries at a large tertiary care academic institution. We administered a survey to surgeons who perform high-transfusion-risk oncologic surgeries at a large academic hospital in Ottawa, Ontario. Design and distribution of the survey followed a modified Dillman method. To ensure that the survey questionnaire was relevant, clear, and concise, we performed informant interviews, cognitive interviews, and pilot-testing. The final survey consisted of 19 questions divided into 3 sections: respondent demographics, use of hemostatic agents, and potential clinical trial opinions. Of 28 surgeons, 24 (86%) participated. When asked to indicate the frequency of lysine analogue use, "never" accounted for 46% of the responses, and "rarely" (<10% of the time) accounted for 23% of the responses. Reasons for never using included "unfamiliar with benefits" and "prefer alternatives." Fifteen surgeons (63%) felt that a trial was needed to demonstrate the efficacy and safety of lysine analogues in their cancer field. Our survey found that lysine analogues are infrequently used during oncologic surgeries at our institution. Many surgeons are unfamiliar with the benefits and side effects of lysine analogues and, alternatively, use topical hemostatic agents. Our results demonstrate that future trials exploring the efficacy and safety of lysine analogues in oncologic surgery are needed.

Assessment of Voice Outcomes Following Surgery for Thyroid Cancer

An increasing number of surgeries are being performed for differentiated thyroid cancer (DTC). Long-term voice abnormalities are a known risk of thyroid surgery; however, few studies have used validated scales to quantify voice outcomes after surgery. To identify the prevalence, severity, and factors associated with poor voice outcomes following surgery for DTC. A cross-sectional, population-based survey was distributed via a modified Dillman method to 4185 eligible patients and linked to Surveillance, Epidemiology and End Results (SEER) data from SEER sites in Georgia and Los Angeles, California, from February 1, 2017, to October 31, 2018. Multivariable logistic regression and zero-inflated negative binomial analysis were performed to determine factors associated with abnormal voice. Participants included patients undergoing surgery for DTC between January 1, 2014, and December 31, 2015, excluding those with voice abnormalities before surgery. Abnormal Voice Handicap Index (VHI-10) score, defined as greater than 11. The VHI-10 is designed to quantify 10 psychosocial consequences of voice disorders on a Likert scale (0, never; to 4, always). A total of 2632 patients (63%) responded to the survey and 2325 met the inclusion criteria. With data reported as unweighted number and weighted percentage, 1792 were women (77.4%); weighted mean (SD) age was 49.4 (14.4) years. Of these, 599 patients (25.8%) reported voice changes lasting more than 3 months following surgery, 272 patients (12.7%) were identified as having an abnormal VHI-10 score, and 105 patients (4.7%) reported vocal fold motion impairment diagnosed by laryngoscopy. In multivariable analysis, factors associated with an abnormal VHI-10 score included age 45 to 54 years (reference, ≤44 years; odds ratio [OR], 1.49; 95% CI, 1.05-2.11), black race (OR, 1.73; 95% CI, 1.14-2.62), Asian race (OR, 1.66; 95% CI, 1.08-2.54), gastroesophageal reflux disease (OR, 1.67; 95% CI, 1.15-2.43), and lateral neck dissection (OR, 1.99; 95% CI, 1.11-3.56). A high prevalence of abnormal voice per validation with the VHI-10 emphasizes the need for heightened awareness of voice abnormalities following surgery and warrants consideration in the preoperative risk-benefit discussion, planned extent of surgery, and postoperative rehabilitation.

MP50: National survey of 9-1-1 ambulance communication centers’ resources related to prehospital recognition of agonal breathing and cardiac arrest

Introduction: 9-1-1 telecommunicators receive minimal education on agonal breathing, often resulting in unrecognized out-of-hospital cardiac arrest (OHCA). We successfully piloted an educational intervention that significantly improved telecommunicators’ OHCA recognition and bystander CPR rates in Ottawa. We sought to better understand the operations of Canadian 9-1-1 communications centers (CC) in preparation for a multi-centre study of this intervention. Methods: We conducted a National survey of all Canadian CCs. Survey domains included information on organizational structure, dispatch system used, education curriculum, and performance monitoring. It was peer-reviewed, translated in French, pilot-tested, and distributed electronically using a modified Dillman method. We designated respondents in each CC before distribution and used targeted follow-up and small incentives to increase response rate. Respondents also described functioning of neighboring CCs if known. Results: We received information from 51/51 provincial and 1/25 territorial CCs, representing 99.7% of the Canadian population. CCs largely utilize the Medical Dispatch Priority System (MPDS) platform (93%), many are Province/Ministry regulated (50%) and most require a High School diploma as minimum entry level education (78%). Telecommunicators receive initial in-class training (median 1.3 months, IQR 0.3-1.9; range 0.1-2.2), often followed by a preceptorship (84.4%) (median 1.0 months, IQR 0.7-1.7; range 0.4-6.0). Educational curriculum includes information on agonal breathing in 41% of CC, without audio examples in 34%. Among responding CCs, over 39,000 suspected OHCA 9-1-1 calls are received annually. Few CCs maintain local performance statistics on OHCA recognition (25%), bystander CPR rates (25%) or survival rates (50%). Most (97%) expressed interest in future research collaborations. Conclusion: Most Canadian telecommunicators receive no or minimal education in recognizing agonal breathing. Further training and improved OHCA monitoring may assist recognition and enhance outcomes.

SAT-529 Practice Patterns in the Treatment of Male Osteoporosis

Introduction: Although osteoporosis in men is now recognized as a significant public health issue, it still remains undertreated. Despite guidelines recommending treatment for men at high risk for fracture, including those with osteopenia (T-score between -1.0 and -2.5) and a Fracture Risk Assessment Tool (FRAX) score ≥3% for a hip fracture or ≥ 20% for any fracture, little is known about physician practice patterns regarding osteoporosis treatment in men. Methods: We conducted a nationwide survey of physician members of the Endocrine Society, American Academy of Family Practice and American Geriatrics Society. We used the modified Dillman method of survey administration. Respondents were asked to identify scenarios for which they were likely to initiate treatment for osteoporosis in their male patients. We conducted a multivariable logistic regression analysis controlling for physician characteristics to identify correlates of treatment initiation for a man aged ≥50 years with a T score -1.7 and FRAX score 3.2% for a hip fracture. Results: Response rate was 63% (359/566). The majority of respondents reported that they often to almost always prescribe bisphosphonates for treatment of osteoporosis in men (75%). Overall, 76% of respondents reported that they would treat a male patient with a recent non-traumatic fracture and 71% stated that they would treat a male patient with prolonged use of steroids. While the majority of the respondents reported that they would treat a male patient aged ≥50 years with a T-score -2.8 (87%), only 37% reported they would treat a male patient aged ≥50 years with a T-score -1.7 and FRAX score 3.2% for hip fracture. In multivariable analysis, primary care physicians and geriatricians were less likely to initiate treatment in this latter scenario compared to endocrinologists (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.21-0.74; OR 0.31, 95% CI 0.17-0.59, respectively). Additionally, physicians with >20 years in practice were also less likely to initiate treatment for the same scenario (OR 0.36, 95% CI 0.19-0.70). Practice setting, male patient volume and whether physicians read guidelines were not significantly associated with treatment initiation in this scenario. Conclusions: We found that primary care physicians, geriatricians and physicians with >20 years in practice are less likely to treat men with osteopenia at a high risk for fractures based on their FRAX score. These findings emphasize that continued efforts are needed to mitigate undertreatment of osteoporosis in men and improve patient care.

MON-599 Physician Reported Challenges in the Management of Hypothyroidism

Introduction: Thyroid hormone use is widespread and levothyroxine is one of the most commonly prescribed medications in the United States. Although prior research has focused on over- and undertreatment and patient dissatisfaction with thyroid hormone replacement, little is known about physician reported barriers to managing thyroid hormone replacement in patients. Methods: We surveyed physician members of the Endocrine Society, the American Academy of Family Practice and the American Geriatrics Society using the modified Dillman method of survey administration. Respondents were asked to rate barriers to the management of thyroid hormone therapy. As patient requests for tests and treatments was a highly ranked barrier, we conducted a multivariable analysis to determine correlates with physician report of patient requests as a barrier. Results: The survey response rate was 63% (359/566). Patient non-compliance (70%), patient requests for tests and treatments (46%) and multiple providers managing thyroid hormone replacement (45%) were reported as somewhat to very likely barriers to the management of thyroid hormone therapy. Endocrinologists (p=0.045) and physicians with high case volume (p=0.035) were more likely to report patient requests for tests and treatments as a barrier, whereas physicians with more years in practice were less likely to do so (11-20 years: p=0.025; >20 years: p<0.001). Common patient requests reported by surveyed physicians included requests for preparations other than synthetic thyroxine (52%), adjusting thyroid hormone dose based on symptoms when biochemically euthyroid (52%), maintaining thyroid stimulating hormone (TSH) below normal range (32%) and adjusting thyroid hormone dose according to serum T3 level (21%). Conclusion: In addition to patient non-compliance and multiple providers managing thyroid hormone, physicians reported that patient requests for tests and treatments is a common barrier to managing thyroid hormone therapy. Endocrinologists, high case volume physicians and those with fewer years in practice were more likely to report patient requests as a barrier. Along with addressing over- and undertreatment and patient dissatisfaction with thyroid hormone, key to improving care is also understanding physician reported barriers to managing thyroid hormone replacement. Furthermore, more research is needed to understand factors associated with physician perception that patient requests are a barrier.

Connecting medical records: an evaluation of benefits and challenges for primary care practices

BackgroundImplementation of systems to support health information sharing has lagged other areas of healthcare IT, yet offers a strong possibility for benefit. Clinical acceptance is a key limiting factor in...

Male Sexual Function in New Zealand: A Population-Based Cross-Sectional Survey of the Prevalence of Erectile Dysfunction in Men Aged 40–70 Years

BackgroundSexual function declines with age and erectile dysfunction (ED) is a common condition worldwide; however, prevalence rates vary markedly between populations and reliable data specific to New Zealand (NZ) are lacking. AimTo assess the prevalence of ED in NZ men using a population-based cross-sectional survey. MethodsPostal questionnaires were sent, according to a modified Dillman method, to a randomly selected age-stratified population-based sample of 2,000 men 40 to 70 years old obtained from the electoral roll. Self-reported erectile function was assessed using the five-item International Index of Erectile Function (IIEF-5) and the single-question self-assessment tool. OutcomesThe prevalence of ED is presented as crude, age-adjusted to the distribution of the NZ population, and standardized to the World Health Organization World Standard Population (WSP). Associations between sexual function and age were analyzed using χ2 test. ResultsThe response rate was 30% (599) and 28% (562) were complete for analysis. The crude prevalence of ED was 42% (22% mild, 10% mild to moderate, 6% moderate, and 4% severe), the age-adjusted prevalence was 38%, and the WSP-adjusted prevalence was 37%. Among men reporting ED, 16% were medically diagnosed and 22% were treated. ED affected 24% of men in their 40s, 38% in their 50s, and 60% in their 60s (P < .001). Age was associated with a significant increase in diagnosed ED (P = .001), treated ED (P = .006), dissatisfaction with current sexual function (P < .001), associated anxiety or depression (P = .023), and a decrease in sexual activity (P < .001). Clinical TranslationApproximately one in three NZ men 40 to 70 years old might have ED. Although comparable to overseas populations, this prevalence is high. Strengths and LimitationsThis study provides the most reliable, comprehensive, and current information on ED and its risk factors in NZ men. Strengths include the large sample, the use of random selection from a population-based sampling frame, established effective survey methods, and the validated IIEF-5. Limitations include the inability of cross-sectional data to determine causation, non-sampling errors associated with the population-based sampling frame, the low response rate, the inability to assess non-respondents, the possibility of men with ED who were sexually inactive not responding or not completing the IIEF-5, and the inherent inability to rule out recall bias. ConclusionED is a marker of subclinical cardiovascular disease. The high prevalence and low levels of diagnosis and treatment indicate a lost opportunity for timely intervention to delay or prevent the progression toward clinical disease.Quilter M, Hodges L, von Hurst P, et al. Male Sexual Function in New Zealand: A Population-Based Cross-Sectional Survey of the Prevalence of Erectile Dysfunction in Men Aged 40–70 Years. J Sex Med 2017;14:928–936.

Historical influence on the practice of chiropractic radiology: Part I - a survey of Diplomates of the American Chiropractic College of Radiology

BackgroundIt is known that not all chiropractors follow mainstream guidelines on the use of diagnostic ionising radiation. Various reasons have been discussed in the literature, including using radiography to screen for congenital anomalies, to perform postural analysis, to search for contraindications to spinal manipulation, and to document chiropractic subluxations, i.e., tiny anatomical displacements of vertebrae thought to affect nerves and health. The visualisation of subluxations was the reason chiropractic first adopted the x-ray in 1910. There has never been a study of the influence of this historical paradigm of radiography on the practices of chiropractic radiologists (DACBRs or Diplomates of the American Chiropractic College of Radiology).MethodsA survey was administered with a modified Dillman method using SurveyMonkey and supplemented by hard copies distributed at a professional conference. The target population was all active DACBRs. There were 34 items, which consisted of multiple choice and open-ended interrogatives on all three areas in which chiropractic radiologists work: education, clinical practice, and radiology practice.ResultsThe response rate was 38% (73 of 190 DACBRs). Respondents reported that the historical paradigm of radiography was found in all areas of practice, but not as a major aspect. The majority of respondents did not condone that historical paradigm, but many tolerated it, particularly from referring chiropractors. Radiographic subluxation analysis was reportedly perpetuated by private clinical practitioners as well as technique instructors and supervising clinicians in the teaching institutions.ConclusionsWithin the chiropractic profession, there is a continuing belief in radiographically visible subluxations as a cause of suboptimal health. This situation is sustained in part due to the reticence of other chiropractors to report these practices to licensing and registration boards. Investigation into other structures supporting a vitalistic belief system over science in chiropractic is recommended. In addition, it may be useful to explore remunerative systems that move beyond the inherently conflicted fee-for-service model.

I Use the Student Recreation Center, but I Would Use it More if …: Understanding Male and Female Constraints to Student Recreation Center Use

Studies have found that there is a positive relationship between the number of student visits to campus recreation and academic outcomes such as rates of graduation and grade point average (Huesman, Brown, Lee, Kellogg, &amp; Radcliffe, 2009). Despite the strong correlation between use of fitness facilities and academic performance some students choose not to visit, while some who use the facilities may not be maximizing such use due to constraints (barriers). The purpose of this study was to understand the constraints to using the campus recreation facility at a midsized New England university. Moreover, this study sought to understand the types of management actions that would help increase use of the recreation center by current users. An online survey was distributed to a random sample ( N = 2,400) of all campus recreation visitors in fall of 2013 using a modified Dillman method of distribution (2009). A total of 882 respondents completed the survey for a response rate of nearly 37%. Important results from this study included that female students were much more likely than male students to report being constrained by not knowing how to use the free weight section safely ( M = 3.40, SD = 1.143; M = 2.68, SD = 1.166, respectively) and that male students suggested that they were more likely to participate than female students ( M = 3.07, SD = 1.182; M = 2.96, SD = 1.235, respectively) at the Student Recreation Center (SRC) if they were not as involved with other activities. This information can be used to guide the expansion planning of future SRC projects and to help improve the participation habits of students at the case institution.

Mobile Apps for Behavioral Health: A Survey on User Engagement

Background: The number of mobile app interventions for behavioral health has grown exponentially over the last decade. A recent study by the IMS Institute for Healthcare Informatics found that health and wellness apps available to consumers more than doubled between 2013 and 2015, from 43,000 to over 90,000. Despite their availability, mobile app interventions are not yet offered or encouraged routinely in behavioral health treatment planning. One possible reason for minimal implementation is limited knowledge of patient preferences regarding use of these interventions. Objective: The current study seeks to increase knowledge in three key areas related to mobile app interventions designed specifically to address a key area of behavioral health: depression and/or anxiety. Depression and/or anxiety were selected as the focus for this project given that these mental health disorders affect over a quarter of the US population and are highly comorbid. Key research questions include (1) What are the demographics of patients who are most interested in using mobile app interventions for depression and/or anxiety? and (2) What are the reasons patients endorse for disinterest in mobile app interventions for depression and/or anxiety? Methods: Potential participants were identified at random from a list of veterans diagnosed with a mood and/or anxiety disorder (per the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) who attended a primary care appointment during 2014 at a Veterans Affairs Medical Center located in a major metropolitan area of the northeastern United States. A total of 400 potential participants are being mailed a brief (15 minute) survey. A modified Dillman method is being used in which a prenotification letter is mailed out to participants, followed by the survey with an opt-out form, followed by up to two additional mailings for those potential participants who do not respond. Results: Data collection is expected to be complete in late August of 2016. The poster proposed here will include findings from descriptive analyses on use of technology (smart phones, mobile apps in general, mobile apps for any behavioral health concern, and mobile apps for depression and/or anxiety) in different demographics. Additionally, descriptive data on reasons endorsed for low willingness to use mobile app interventions for depression and/or anxiety (when recommended by a health care provider as well as when accessed independently) will be presented. Finally, findings from analyses evaluating the relationship between demographic variables (race, gender, education, age, and symptom severity) and level of interest in mobile app interventions for depression and/or anxiety will be presented. Conclusions: The target audience for mobile app interventions for depression and/or anxiety and reasons patients may choose not to use these interventions will be identified. Limitations include using a veteran-only sample and focusing exclusively on interventions for depression and anxiety rather than other areas of behavioral health. Future research should seek to build upon findings by broadening the scope of investigation to civilians and other areas of behavior change. Findings from this study can inform healthcare providers and app developers on patient preferences regarding mobile app interventions. [iproc 2016;2(1):e42]

Prevalence of Barriers and Facilitators to Enhancing Conservative Kidney Management for Older Adults in the Primary Care Setting.

Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m2) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians. In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method. Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively). We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.

P071: Emergency physician attitudes and perceived barriers to take-home naloxone programs in Canadian emergency departments

Introduction: Unintentional overdose is the leading cause of injurious death among Americans aged 25-64 years. A similar epidemic is underway in Canada. Community-based opioid overdose education and naloxone distribution (OOEND) programs distribute take-home naloxone kits to people at risk of overdose in several cities across Canada. Due to the high rate of drug-related visits, recurrent opioid prescribing, and routine encounters with opioid overdose, Emergency Departments (ED) may represent an under-utilized setting to deliver naloxone to people at risk of opioid overdose or likely to witness overdose. The goal of this study was to identify Canadian emergency physician attitudes and perceived barriers to the implementation of take-home naloxone programs. Methods: This was an anonymous web-based survey of physician and trainee members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals, per the modified Dillman method. Respondent demographics were collected and Likert scales used to assess attitudes and barriers to the prescription of naloxone from the ED. Results: A total of 347/1658 CAEP members responded (20.9%). Of the respondents, 62.1% were male and residents made up 15.6%. The majority (48.2%) worked in Ontario and 55.7% worked in an urban tertiary centre. Overall attitudes to OOEND were strongly positive: 86.6% of respondents identified a willingness to prescribe naloxone from the ED. Perceived barriers included allied health support for patient education (56.4%), access to follow-up (40.3%), and inadequate time in the clinical encounter (37.7%). In addition to people at risk of overdose, 78% of respondents identified that friends and family members may benefit from OOEND programs. Conclusion: Canadian emergency physicians are willing to prescribe take-home naloxone to at-risk patients, but better systems and tools are required to facilitate opioid overdose education and naloxone distribution implementation. This data will inform the development of these programs, with emphasis on allied health support, training and education.

Prevalence and determinants of cannabinoid prescription forthemanagement of chronic noncancer pain: a postal survey of physicians in the Abitibi-Témiscamingue region of Quebec.

Few studies have been conducted to explore physicians' prescription practices and attitudes toward the use of cannabinoids in Canada.We measured the prevalence and identified determinants of cannabinoid prescription for the management of chronic noncancer pain among physicians in southwestern Quebec. In February 2013, we conducted a postal survey using a modified Dillman method that involved physicians practising in the Abitibi-Témiscamingue region of Quebec. We used multivariate logistic regression models to identify determinants of cannabinoid prescription. A total of 166 physicians of 318 practising in the region participated in the survey (response rate 52.2%). The prevalence of cannabinoid prescription was 27.3% (45/165) for any indication and 23.0% (38/165) for the management of chronic noncancer pain; 91.1% (41/45) of the physicians prescribed cannabinoids to 5 or fewer patients. Of the 38 physicians who prescribed cannabinoids for chronic noncancer pain, 35 (92.1%) prescribed nabilone, 7 (18.4%) medical marijuana and 2 (5.3%) nabiximols. The principal determinant of cannabinoid prescription was the physician's level of comfort with prescribing cannabinoids (adjusted odds ratio 1.25, 95% confidence interval 1.01-1.55, per1-point increase in comfort level measured on 10-point scale). Respondents reported that continuing medical education (CME) activities could increase their comfort level. They also indicated a need for guidelines or algorithms that included cannabinoid use as well as more studies about the efficacy and safety of cannabinoids for the management of chronic noncancer pain. We found that cannabinoids were not often prescribed for the management of chronic noncancer pain and that survey respondents were not comfortable with prescribing this drug class. This degree of discomfort could be addressed by CME activities, more effective dissemination of guidelines and more evidence regarding cannabinoid use for the management of chronic noncancer pain.

Physiotherapy clinical educators’ perceptions and experiences of clinical prediction rules

ObjectivesClinical prediction rules (CPRs) are widely used in medicine, but their application to physiotherapy practice is more recent and less widespread, and their implementation in physiotherapy clinical education has not been investigated. This study aimed to determine the experiences and perceptions of physiotherapy clinical educators regarding CPRs, and whether they are teaching CPRs to students on clinical placement. DesignCross-sectional observational survey using a modified Dillman method. ParticipantsClinical educators (n=211, response rate 81%) supervising physiotherapy students from 10 universities across 5 states and territories in Australia. ResultsHalf (48%) of respondents had never heard of CPRs, and a further 25% had never used CPRs. Only 27% reported using CPRs, and of these half (51%) were rarely if ever teaching CPRs to students in the clinical setting. However most respondents (81%) believed CPRs assisted in the development of clinical reasoning skills and few (9%) were opposed to teaching CPRs to students. Users of CPRs were more likely to be male (p<0.001), have post-professional qualifications (p=0.020), work in private practice (p<0.001), and work in the area of musculoskeletal physiotherapy (p<0.001) compared with non-users. The CPRs most commonly known, used and taught were the Ottawa Ankle Rule, the Ottawa Knee Rule, and Wells’ Rule for Deep Vein Thrombosis. ConclusionsStudents are unlikely to be learning about CPRs on clinical placement, as few clinical educators use them. Clinical educators will require training in CPRs and assistance in teaching them if students are to better learn about implementing CPRs in physiotherapy clinical practice.

The use of free online educational resources by Canadian emergency medicine residents and program directors.

Introduction Online educational resources (OERs) are increasingly available for emergency medicine (EM) education. This study describes and compares the use of free OERs by the Royal College of Physicians and Surgeons of Canada (RCPSC) EM residents and program directors (PDs) and investigates the relationship between the use of OERs and peer-reviewed literature. A bilingual, online survey was distributed to RCPSC-EM residents and PDs using a modified Dillman method. The chi-square test and Fisher's exact test were used to compare the responses of residents and PDs. The survey was completed by 214/350 (61%) residents and 11/14 (79%) PDs. Free OERs were used by residents most frequently for general EM education (99.5%), procedural skills training (96%), and learning to interpret diagnostic tests (92%). OER modalities used most frequently included wikis (95%), file-sharing websites (95%), e-textbooks (94%), and podcasts (91%). Residents used wikis, podcasts, vodcasts, and file-sharing websites significantly more frequently than PDs. Relative to PDs, residents found entertainment value to be more important for choosing OERs (p<0.01). Some residents (23%) did not feel that literature references were important, whereas all PDs did. Both groups reported that OERs increased the amount of peer-reviewed literature (75% and 60%, respectively) that they read. EM residents make extensive use of OERs and differ from their PDs in the importance that they place on their entertainment value and incorporation of peer-reviewed references. OERs may increase the use of peer-reviewed literature in both groups. Given the prevalence of OER use for core educational goals among RCPSC-EM trainees, future efforts to facilitate critical appraisal and appropriate resource selection are warranted.

Outcome Feedback within Emergency Medicine Training Programs: An Opportunity to Apply the Theory of Deliberate Practice?

Outcome feedback is the process of learning patient outcomes after their care within the emergency department. We conducted a national survey of Canadian Royal College emergency medicine (EM) residents and program directors to determine the extent to which active outcome feedback and follow-up occurred. We also compared the perceived educational value of outcome feedback between residents and program directors. We distributed surveys to all Royal College-accredited adult and pediatric EM training programs using a modified Dillman method. We analyzed the data using student's t-test for continuous variables and Fisher's exact test for categorical variables. We received 210 completed surveys from 260 eligible residents (80.8%) and 21 of 24 program directors (87.5%) (overall 81.3%). Mandatory active outcome feedback was not present in any EM training program for admitted or discharged patients (0/21). Follow-up was performed electively by 89.4% of residents for patients admitted to the hospital, and by 44.2% of residents for patients discharged home. A majority of residents (76.9%) believed that patient follow-up should be mandatory compared to 42.9% of program directors (p=0.002). The perceived educational value of outcome feedback was 5.8/7 for residents and 5.1/7 for program directors (difference 0.7; p=0.002) based on a seven-point Likert scale (1=not important; 7=very important). While Canadian EM training programs do not mandate follow-up, it is performed electively by the majority of residents surveyed. Residents place a significantly greater educational value on outcome feedback than their program directors, and believe that follow-up should be a mandatory component of EM residencies.

Bronchodilator and steroid use for the management of bronchiolitis in Canadian pediatric emergency departments.

Given the recent publication of several large trials and systematic reviews, we undertook a study of the current management of bronchiolitis in Canadian pediatric emergency departments (EDs) and explored physicians' rationale for their treatment decisions. The overarching purpose of this study was to assist in planning a future trial of combined epinephrine and dexamethasone for bronchiolitis. Physicians in the Pediatric Emergency Research Canada (PERC) database received an 18-item electronic survey. A modified Dillman method was used. Of the 271 physicians surveyed, 191 (70.1%) responded. The majority (120 of 271; 66.5%) reported ''typically'' giving a bronchodilator trial in the ED, with respondents almost evenly divided between treatment with salbutamol (n=62) and treatment with epinephrine (n=61). Of those who use salbutamol, 77.4% indicated that they prefer it because it can be prescribed for home use. Of those who use epinephrine, 80.3% indicated that they believe the medical literature supports its benefit over salbutamol. Few participants (2.6%) reported ''always'' using steroids, whereas the majority (62.8%) reported ''sometimes'' using them. The most common factor reported to influence steroid use was illness severity (73.3%). The majority (60.5%) reported that if corticosteroids were beneficial in bronchiolitis, they prefered treatment with a single dose in the ED as opposed to a multiday course. Our results indicate that physicians practicing in Canadian pediatric EDs commonly use bronchodilators to manage bronchiolitis but use corticosteroids less commonly. They appear to be uncomfortable using corticosteroids, particularly longer courses, and have a stated preference for a single dose. Any future trial examining the role of corticosteroids in bronchiolitis should carefully consider the issue of steroid dosage.

Survey of American and Canadian general surgeons' perceptions of margin status and practice patterns for breast conserving surgery.

Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.

Practice patterns and perceptions of margin status for breast conserving surgery for breast carcinoma: National Survey of Canadian General Surgeons

BackgroundWe surveyed Canadian General Surgeons to examine decision-making in early stage breast cancer. MethodsA modified Dillman Method was used for this mail survey of 1443 surgeons. Practice patterns and factors that influence management choices for: preoperative assessment, definition of margin status, surgical techniques and recommendations for re-excision were assessed. ResultsThe response rate was 51% with 41% treating breast cancer. Most (80%) were community surgeons, with equal distribution of low/medium/high volume and years of practice categories. Approximately 25% of surgeons “sometimes or frequently” performed diagnostic excisional biopsies while 90% report “frequently” or “always” performing preoperative core biopsies. There was marked variation in defining negative and close margins, in the use of intra-operative margin assessment techniques and recommendations for re-excision. ConclusionsResponses revealed significant variation in attitudes and practices. These findings likely reflect an absence of consensus in the literature and potential gaps between best evidence and practice.