Browsing by Author "Niven, Daniel J."
Now showing 1 - 16 of 16
Results Per Page
Sort Options
Item Open Access A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings(2022-10-21) Jaworska, Natalia; Moss, Stephana J.; Krewulak, Karla D.; Stelfox, Zara; Niven, Daniel J.; Ismail, Zahinoor; Burry, Lisa D.; Fiest, Kirsten M.Abstract Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk.Item Open Access Assessment of the safety and feasibility of administering anti-pyretic therapy in critically ill adults: a randomized clinical trial(2012) Niven, Daniel J.; Laupland, K. B.; Stelfox, H. ThomasThere is a paucity of evidence to guide the management of febrile, critically ill patients without acute brain injury. This pilot, randomized clinical trial assessed the safety and feasibility of administering two different fever control strategies in critically ill adults. The biologic response to fever control was also assessed through analysis of several inflammatory mediators. Of the 179 patients screened for enrolment, 14 were randomized to the aggressive treatment group and 12 to the permissive group. The most common reason for exclusion from the trial was the presence of liver disease (22.2%). There were no significant differences in any of the markers of safety, and the fever control strategies did not appreciably influence the biology of fever. The most notable finding was a reduced number of patients with fever compared to that expected (31 % ). This impacted study participant recruitment and will affect the feasibility of completing a larger phase III study.Item Open Access Assessment of the safety and feasibility of administering anti-pyretic therapy in critically ill adults: study protocol of a randomized trial(BioMed Central, 2012-03-12) Niven, Daniel J.; Léger, Caroline; Kubes, Paul; Stelfox, H. Tom; Laupland, Kevin B.Item Open Access Co-development of a transitions in care bundle for patient transitions from the intensive care unit: a mixed-methods analysis of a stakeholder consensus meeting(2022-01-02) Rosgen, Brianna K.; Plotnikoff, Kara M.; Krewulak, Karla D.; Shahid, Anmol; Hernandez, Laura; Sept, Bonnie G.; Morrissey, Jeanna; Robertson, Kristin; Fraser, Nancy; Niven, Daniel J.; Straus, Sharon E.; Leigh, Jeanna P.; Stelfox, Henry T.; Fiest, Kirsten M.Abstract Background Intensive care unit (ICU) patients undergoing transitions in care are at increased risk of adverse events and gaps in medical care. We evaluated existing patient- and family-centered transitions in care tools and identified facilitators, barriers, and implementation considerations for the application of a transitions in care bundle in critically ill adults (i.e., a collection of evidence-based patient- and family-centred tools to improve outcomes during and after transitions from the intensive care unit [ICU] to hospital ward or community). Methods We conducted a concurrent mixed methods (quan + QUAL) study, including stakeholders with experience in ICU transitions in care (i.e., patient/family partners, researchers, decision-makers, providers, and other knowledge-users). First, participants scored existing transitions in care tools using the modified Appraisal of Guidelines, Research and Evaluation (AGREE-II) framework. Transitions in care tools were discussed by stakeholders and either accepted, accepted with modifications, or rejected if consensus was achieved (≥70% agreement). We summarized quantitative results using frequencies and medians. Second, we conducted a qualitative analysis of participant discussions using grounded theory principles to elicit factors influencing AGREE-II scores, and to identify barriers, facilitators, and implementation considerations for the application of a transitions in care bundle. Results Twenty-nine stakeholders attended. Of 18 transitions in care tools evaluated, seven (39%) tools were accepted with modifications, one (6%) tool was rejected, and consensus was not reached for ten (55%) tools. Qualitative analysis found that participants’ AGREE-II rankings were influenced by: 1) language (e.g., inclusive, balance of jargon and lay language); 2) if the tool was comprehensive (i.e., could stand alone); 3) if the tool could be individualized for each patient; 4) impact to clinical workflow; and 5) how the tool was presented (e.g., brochure, video). Participants discussed implementation considerations for a patient- and family-centered transitions in care bundle: 1) delivery (e.g., tool format and timing); 2) continuity (e.g., follow-up after ICU discharge); and 3) continuous evaluation and improvement (e.g., frequency of tool use). Participants discussed existing facilitators (e.g., collaboration and co-design) and barriers (e.g., health system capacity) that would impact application of a transitions in care bundle. Conclusions Findings will inform future research to develop a transitions in care bundle for transitions from the ICU, co-designed with patients, families, providers, researchers, decision-makers, and knowledge-users.Item Open Access Determinants of the de-implementation of low-value care: a multi-method study(2022-04-06) Leigh, Jeanna P.; Sypes, Emma E.; Straus, Sharon E.; Demiantschuk, Danielle; Ma, Henry; Brundin-Mather, Rebecca; de Grood, Chloe; FitzGerald, Emily A.; Mizen, Sara; Stelfox, Henry T.; Niven, Daniel J.Abstract Background There is an urgent need to understand the determinants (i.e., barriers and facilitators) of de-implementation. The purpose of this study was to develop a comprehensive list of determinants of the de-implementation of low-value care from the published literature and to compare this list to determinants identified by a group of stakeholders with lived experience with de-implementation. Methods This was a two-phase multi-method study. First, a systematic review examined published barriers and facilitators to de-implementation. Articles were identified through searches within electronic databases, reference lists and the grey literature. Citations were screened independently and in duplicate and included if they were: 1) written in English; and 2) described a barrier or facilitator to de-implementation of any clinical practice in adults (age ≥ 18 years). ‘Raw text’ determinants cited within included articles were extracted and synthesized into a list of representative determinants using conventional content analysis. Second, semi-structured interviews were conducted with decision-makers (unit managers and medical directors) and healthcare professionals working in adult critical care medicine to explore the overlap between the determinants found in the systematic review to those experienced in critical care medicine. Thematic content analysis was used to identify key themes emerging from the interviews. Results In the systematic review, reviewers included 172 articles from 35,368 unique citations. From 437 raw text barriers and 280 raw text facilitators, content analysis produced 29 distinct barriers and 24 distinct facilitators to de-implementation. Distinct barriers commonly cited within raw text included ‘lack of credible evidence to support de-implementation’ (n = 90, 21%), ‘entrenched norms and clinicians’ resistance to change (n = 43, 21%), and ‘patient demands and preferences’ (n = 28, 6%). Distinct facilitators commonly cited within raw text included ‘stakeholder collaboration and communication’ (n = 43, 15%), and ‘availability of credible evidence’ (n = 33, 12%). From stakeholder interviews, 23 of 29 distinct barriers and 20 of 24 distinct facilitators from the systematic review were cited as key themes relevant to de-implementation in critical care. Conclusions The availability and quality of evidence that identifies a clinical practice as low-value, as well as healthcare professional willingness to change, and stakeholder collaboration are common and important determinants of de-implementation and may serve as targets for future de-implementation initiatives. Trial registration The systematic review was registered in PROSPERO CRD42016050234 .Item Open Access Diagnosis and management of temperature abnormality in ICUs: a EUROBACT investigators’ survey(BioMed Central, 2013-12-10) Niven, Daniel J.; Laupland, Kevin B.; Tabah, Alexis; Vesin, Aurélien; Rello, Jordi; Koulenti, Despoina; Dimopoulos, George; de Waele, Jan; Timsit, Jean-FrancoisItem Open Access Impact of restricted family presence during the COVID-19 pandemic on critically ill patients, families, and critical care clinicians: a qualitative systematic review(2024-08-15) Krewulak, Karla D.; Jaworska, Natalia; Lee, Laurie; Louis, Julia S.; Dmitrieva, Olesya; Leia, Madison P.; Doig, Christopher; Niven, Daniel J.; Parhar, Ken K. S.; Rochwerg, Bram; West, Andrew; Stelfox, Henry T.; Leigh, Jeanna P.; Fiest, Kirsten M.Abstract Background We aimed to synthesize the qualitative evidence on the impacts of COVID-19-related restricted family presence policies from the perspective of patients, families, and healthcare professionals from neonatal (NICU), pediatric (PICU), or adult ICUs. Methods We searched MEDLINE, EMBASE, Cochrane Databases of Reviews and Clinical Trials, CINAHL, Scopus, PsycINFO, and Web of Science. Two researchers independently reviewed titles/abstracts and full-text articles for inclusion. Thematic analysis was completed following appraising article quality and assessing confidence in the individual review findings using standardized tools. Results We synthesized 54 findings from 184 studies, revealing the impacts of these policies in children and adults on: (1) Family integrated care and patient and family-centered care (e.g., disruption to breastfeeding/kangaroo care, dehumanizing of patients); (2) Patients, families, and healthcare professionals (e.g., negative mental health consequences, moral distress); (3) Support systems (e.g., loss of support from friends/families); and (4) Relationships (e.g., loss of essential bonding with infant, struggle to develop trust). Strategies to mitigate these impacts are reported. Conclusion This review highlights the multifaceted impacts of restricted visitation policies across distinct care settings and strategies to mitigate the harmful effects of these policies and guide the creation of compassionate family presence policies in future health crises. Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290263 .Item Open Access Matched case-control studies: a review of reported statistical methodology(Dove Medical Press, 2012-04) Niven, Daniel J.; Berthiaume, Luc R.; Fick, Gordon H.; Laupland, Kevin B.Item Open Access Metabolomics Study of ARDS Diagnosis, Heterogeneity, and Mortality(2020-08-06) Mohamed Metwaly, Sayed Ahmed Osman; Winston, Brent W.; Vogel, Hans J.; Niven, Daniel J.; Lewis, Ian A.Background: Acute Respiratory Distress Syndrome (ARDS) represents 10.4% of all Intensive Care Unit (ICU) admissions with an overall mortality rate of 35.3%. Early diagnosis of ARDS is an important requirement for the timely institution of proper supportive care but it is hampered by the unreliable tissue diagnosis, lack of an early diagnostic biomarker and lack of specific therapy. Metabolomics is a systems biology approach to examine changes in metabolites in response to physiological and pathological stimuli. It is more closely related to observed phenotypes and more responsive to real-time pathophysiological changes, thus constitutes an attractive platform for studying ARDS.Hypothesis: We hypothesize that the diverse inflammatory, pathobiological and adaptive processes involved in ARDS would manifest as unique metabolic fingerprint that sets ARDS apart from other ICU conditions. Biomarker identification may help early diagnosis of ARDS, explore its mechanism, differentiate ARDS subclasses and predict ARDS mortality. Methodology: Serum samples from 108 ARDS patients and 27 ICU ventilated age- and sex-matched controls were included in this study. Samples were analyzed by proton nuclear magnetic resonance spectroscopy (1H-NMR) and gas chromatography mass spectrometry (GC-MS). The proteins/cytokines IL-6, IL-8, IL-10, TNF-?, Ang-2, RAGE, vWF, TNF-RI, ICAM-1, PAI-1, SP-D and Protein-C were also measured. Multivariate statistical models that distinguish ARDS from ICU controls (diagnose ARDS), subclassify ARDS and predict ARDS non-survival were built. Results were externally validated in an independent cohort of 188 patients comprising 118 ARDS patients and 70 ICU ventilated controls.Results: Our data indicates that NMR and GC-MS metabolomics are more accurate than proteins/cytokines in differentiating ARDS from ICU controls and ARDS subgroups. Pathway analysis of ARDS versus controls identified a dominant involvement of serine-glycine metabolism. In external validation, ARDS patients were correctly identified in 93% using NMR and 96% using GC-MS. Metabolomics was not able to predict mortality in the ARDS population studied.Conclusion: ARDS subgroups are metabolically distinct. Further research is needed to explore the role of dysfunctional folate metabolism in the development of ARDS. Metabolomics provides a novel technology to not only understand but intervene on the pathophysiology of ARDS.Item Open Access Optimally Linking Prehospital and Health System Data: The Association between Emergency Medical Services Offload Time, Response Time and Mortality(2020-01-14) Blanchard, Ian; Doig, Christopher James; Lang, Eddy S.; Dean, Stafford R.; Hagel, Brent Edward; Niven, Daniel J.; Williamson, Tyler S.INTRODUCTION: Delays in offloading Emergency Medical Services (EMS) patients in the hospital may impact timely response to emergencies, but no published studies are available. Little research has been conducted on the potential for bias when EMS data are linked to health system outcome and on the optimal EMS response time for survival of critically injured or ill patients. METHODS: Three years of EMS data from a large urban system were used to create hourly estimates of median hospital time and response time, and linked to health system outcome. Multivariable modelling and descriptive statistics were used to: 1. Explore the association between paramedic hospital time and response time while controlling for the effects of system volume, time of day, and season; 2. Describe the linkage rate between the standard strategy and one designed to optimize linkage; and 3. Explore the association between response time and mortality in critically injured or ill patients who did not experience an out-of-hospital cardiac arrest while controlling for age and sex. RESULTS: Depending on the time of day, there was between a one and three minute increase in predicted median response time when the system was experiencing a median hospital time of 90 minutes, during the winter in heavy system volume, compared to a 30 minute median hospital time, during the summer in light system volume. The optimized strategy increased the linkage rate from 88% to 97.1%, and reduced linkage failure in key clinical sub-groups. There was no significant association between response time and mortality except in one secondary analysis subgroup, which suggested longer response decreased mortality. CONCLUSIONS: There is an association between EMS hospital time and response time, but the relationship is complex and influenced by system level factors such as time of day, volume and season. An optimized strategy for linking EMS data to health system outcome improved the linkage rate and reduced the potential for bias. No consistent association between response time and mortality could be demonstrated. These analyses underscore the importance of research quality linked EMS data in the development of knowledge for EMS and paramedic practice.Item Open Access Patient and family involvement in Choosing Wisely initiatives: a mixed methods study(2022-04-07) de Grood, Chloe; Sypes, Emma E.; Niven, Daniel J.; Clement, Fiona; FitzGerald, Emily A.; Kupsch, Shelly; King-Hunter, Shelly; Stelfox, Henry T.; Parsons Leigh, JeannaAbstract Background Patients are important stakeholders in reducing low-value care, yet mechanisms for optimizing their involvement in low-value care remain unclear. To explore the role of patients in the development and implementation of Choosing Wisely recommendations to reduce low-value care and to assess the likelihood that existing patient resources will change patient health behaviour. Methods Three phased mixed-methods study: 1) content analysis of all publicly available Choosing Wisely clinician lists and patient resources from the United States of America and Canada. Quantitative data was summarized with frequencies and free text comments were analyzed with qualitative thematic content analysis; 2) semi-structured telephone interviews with a purposive sample of representatives of professional societies who created Choosing Wisely clinician lists and members of the public (including patients and family members). Interviews were transcribed verbatim, and two researchers conducted qualitative template analysis; 3) evaluation of Choosing Wisely patient resources. Two public partners were identified through the Calgary Critical Care Research Network and independently answered two free text questions “would this change your health behaviour” and “would you discuss this material with a healthcare provider”. Free text data was analyzed by two researchers using thematic content analysis. Results From the content analysis of 136 Choosing Wisely clinician lists, six reported patient involvement in their development. From 148 patient resource documents that were mapped onto a conceptual framework (Inform, Activate, Collaborate) 64% described patient engagement at the level of Inform (educating patients). From 19 interviews stakeholder perceptions of patient involvement in reducing low-value care were captured by four themes: 1) impact of perceived power dynamics on the discussion of low-value care in the clinical interaction, 2) how to communicate about low-value care, 3) perceived barriers to patient involvement in reducing low-value care, and 4) suggested strategies to engage patients and families in Choosing Wisely initiatives. In the final phase of work in response to the question “would this change your health behaviour” two patient partners agreed ‘yes’ on 27% of patient resources. Conclusions Opportunities exist to increase patient and family participation in initiatives to reduce low-value care.Item Open Access Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care(2021-12-17) Plotnikoff, Kara M.; Krewulak, Karla D.; Hernández, Laura; Spence, Krista; Foster, Nadine; Longmore, Shelly; Straus, Sharon E.; Niven, Daniel J.; Parsons Leigh, Jeanna; Stelfox, Henry T.; Fiest, Kirsten M.Abstract Background Critically ill patients require complex care and experience unique needs during and after their stay in the intensive care unit (ICU). Discharging or transferring a patient from the ICU to a hospital ward or back to community care (under the care of a general practitioner) includes several elements that may shape patient outcomes and overall experiences. The aim of this study was to answer the question: what elements facilitate a successful, high-quality discharge from the ICU? Methods This scoping review is an update to a review published in 2015. We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases from 2013-December 3, 2020 including adult, pediatric, and neonatal populations without language restrictions. Data were abstracted using different phases of care framework models, themes, facilitators, and barriers to the ICU discharge process. Results We included 314 articles from 11,461 unique citations. Two-hundred and fifty-eight (82.2%) articles were primary research articles, mostly cohort (118/314, 37.6%) or qualitative (51/314, 16.2%) studies. Common discharge themes across all articles included adverse events, readmission, and mortality after discharge (116/314, 36.9%) and patient and family needs and experiences during discharge (112/314, 35.7%). Common discharge facilitators were discharge education for patients and families (82, 26.1%), successful provider-provider communication (77/314, 24.5%), and organizational tools to facilitate discharge (50/314, 15.9%). Barriers to a successful discharge included patient demographic and clinical characteristics (89/314, 22.3%), healthcare provider workload (21/314, 6.7%), and the impact of current discharge practices on flow and performance (49/314, 15.6%). We identified 47 discharge tools that could be used or adapted to facilitate an ICU discharge. Conclusions Several factors contribute to a successful ICU discharge, with facilitators and barriers present at the patient and family, health care provider, and organizational level. Successful provider-patient and provider-provider communication, and educating and engaging patients and families about the discharge process were important factors in a successful ICU discharge.Item Open Access Patient, Family Member, and Public Involvement in Identifying Low-Value Clinical Practices for De-adoption: A Mixed Methods Study of Choosing Wisely Initatives(2020-01-31) de Grood, Chloe Moira; Stelfox, Henry Thomas; Parsons-Leigh, Jeanna; Niven, Daniel J.; Clement, Fiona M.Low-value care comprises tests, treatments and procedures where the potential risks outweigh benefits for patients. Despite a growing recognition of the importance to reduce the use of low-value care, ineffective and costly clinical practices continue to be used. While Choosing Wisely and other initiatives have implemented strategies to reduce low-value care, little is known about how to best engage the public in these initiatives. The purpose of this study was to explore the role of patient, family and public members in the development and implementation of Choosing Wisely initiatives that aim to reduce low-value care. A mixed methods study design was used to address the objective through content analysis and qualitative interviews. The content analysis examined two different collections of publicly available online materials (Choosing Wisely clinician lists, i.e., Five Things Physicians and Patients Should Question; and Choosing Wisely patient resources) in order to describe members of the public involvement in Choosing Wisely list creation and development. Content analysis revealed that few members of the public were involved in the development of Choosing Wisely clinician lists. The analysis of patient resource documents suggested that the average Simple Measure of Gobbledygook (SMOG) readability score was a Grade nine level and were categorized at the patient engagement level of Inform where the documents engage the reader by providing only information. Qualitative interviews, conducted to explore future public involvement in reducing low-value care generated five overarching themes: 1) factors influencing understandings of what potentially constitutes low-value care in the clinical interaction; 2) how to communicate about low-value care; 3) perceived barriers to public involvement in the reduction of low-value care (e.g., brief clinical interaction); 4) perceived iii facilitators to public involvement in the reduction of low-value care (e.g., use of educational materials); and 5) suggested strategies to engage the public involvement in Choosing Wisely initiatives. This thesis indicates that there is public involvement in reducing low-value care is feasible and that Choosing Wisely initiatives such as identifying and participating in conversations about low-value care may be an appropriate place for such engagement.Item Open Access Restricted visitation policies in acute care settings during the COVID-19 pandemic: a scoping review(2021-09-25) Moss, Stephana J.; Krewulak, Karla D.; Stelfox, Henry T.; Ahmed, Sofia B.; Anglin, Melanie C.; Bagshaw, Sean M.; Burns, Karen E. A.; Cook, Deborah J.; Doig, Christopher J.; Fox-Robichaud, Alison; Fowler, Robert; Hernández, Laura; Kho, Michelle E.; Kredentser, Maia; Makuk, Kira; Murthy, Srinivas; Niven, Daniel J.; Olafson, Kendiss; Parhar, Ken K. S.; Patten, Scott B.; Rewa, Oleksa G.; Rochwerg, Bram; Sept, Bonnie; Soo, Andrea; Spence, Krista; Spence, Sean; Straus, Sharon; West, Andrew; Parsons Leigh, Jeanna; Fiest, Kirsten M.Abstract Background Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals. Methods We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate. Results Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (n = 31, 20%) and mental health outcomes (n = 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (n = 107, 69%), connection and communication (n = 107, 69%), and awareness of state of well-being (n = 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (n = 61, 70%), patients (n = 51, 59%), and healthcare professionals (n = 40, 46%). Conclusions Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals. Trial registration: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.Item Open Access Understanding the Relationship Between Health Technology Reassessment and Knowledge Translation(2020-10-18) Esmail, Rosmin; Clement, Fiona M.; Hanson, Heather M.; Holroyd-Leduc, Jayna M.; Niven, Daniel J.Until now, it was not well understood how the field of Knowledge Translation (KT) would be applicable to Health Technology Reassessment (HTR). This thesis reports on three studies to determine how KT approaches are used to translate HTR outputs to achieve the desired outcomes. The first study was a scoping review of full-spectrum (phases of planning/design, evaluation, implementation, sustainability/scalability) KT Theories, Models, Frameworks (KT TMFs). Thirty-six KT TMFs were identified and categorized according to five approaches: process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. It provided a starting point for the selection of KT TMFs for HTR. The second study employed a modified Delphi process and expert survey to review the 36 full-spectrum KT TMFs and determined which may be suitable for HTR. The three-round modified Delphi process resulted in 16 KT TMFs. Twenty-two international experts (11 KT and 11 HTR) were surveyed. None of the 16 KT TMFs reached ≥ 70% agreement when ratings of “yes” were considered. However when ratings of “yes” and “partially yes” were combined, the Consolidated Framework for Implementation Research (CFIR) was considered the most suitable by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: the Knowledge-to-Action framework. HTR experts selected two additional KT TMFs: the co-KT framework and the Plan-Do-Study-Act cycle. The third study involved 13 one-to-one semi-structured interviews on characteristics of KT TMFs that were important to consider for the HTR outputs of decreased use or de-adoption of a technology. Four foundational principles, three levers of change, and five steps for knowledge to action emerged as KT TMF traits for HTR. From the KT TMFs that were mapped onto the characteristics, CFIR had the most characteristics (11/12) missing only the ability to map to the micro, meso, macro levels. This is the first body of work that examines the relationship between HTR and KT. The findings offer guidance to users on the application of KT TMFs to the HTR process and implementation of its outputs. Practical use of these KT TMFs to the HTR process will provide further advancement in this area.Item Open Access Understanding the Role of the Public in Reducing Low-value Care(2019-06-21) Sypes, Emma Elizabeth; Stelfox, Henry Thomas; Niven, Daniel J.; Parsons-Leigh, Jeanna; Clement, Fiona M.Low-value care consists of medical tests and treatments that are unnecessary, potentially harmful, or not cost-effective and contribute to rising healthcare costs, adverse events, and poor quality of care. In recent years there has been a surge in initiatives aiming to identify and reduce low-value care. However, the role of the public in reducing low-value care remains unclear. The research reported in this thesis aimed to understand the role of the public in reducing low-value care through a systematic and comprehensive review of the literature. A scoping review identified 151 relevant articles. The majority of these articles described or evaluated a strategy for involving the public in reducing low-value care; articles that explored stakeholder perspectives about the role of the public were less common. Public involvement most commonly occurred at the level of the patient-clinician interaction, followed by administrative and policy decision-making and low-value care research. Shared decision-making and patient-oriented education were the most frequent and best supported strategies. There was considerably less support for public involvement at the level of administrative and policy decision-making. A follow-up systematic review and meta-analysis was conducted to estimate the impact of patient-targeted interventions to reduce low-value care. This study found a statistically significant association between patient-targeted interventions (i.e., shared decision-making, patient-oriented education) and a decrease in use of the low-value practices (RR 0.75; 95% CI 0.66-0.84), which remained significant when the meta-analysis was restricted to randomized clinical trials with low risk of bias (RR 0.69; 95% CI 0.58-0.83). Collectively, these two studies show a considerable amount of support for engaging the public in reducing low-value care at the level of the patient-clinician interaction through strategies including shared decision-making and patient-oriented education. There is comparably less evidence to support public involvement in research or administrative and policy decision-making. Additional research to explore stakeholder perspectives and evaluate strategies for public involvement within varying contexts is required to further understand the role of the public in reducing low-value care.