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Background: Although the current Canadian Task Force on Preventive Health Care guideline recommends that physicians should inform women aged 40-49 years of the potential benefits and harms of screening mammography to support individualized decisions, previous reports of variation in clinical practice at the physician level suggest a lack of guideline-concordant care. We explored determinants (barriers and facilitators) of guideline-concordant care by family physicians regarding screening mammography in this age group., Methods: We conducted qualitative semi-structured interviews by phone with family physicians in the Greater Toronto Area from January to November 2020. We structured interviews using the Theoretical Domains Framework to explore determinants (barriers and facilitators) of 5 physician screening behaviours, namely risk assessment, discussion regarding benefits and harms, decision or referral for mammography, referral for genetic counselling and referral to high-risk screening programs. Two independent researchers iteratively analyzed interview transcripts and deductively coded for each behaviour by domain to identify key behavioural determinants until saturation was reached., Results: We interviewed 18 physicians (mean age 48 yr, 72% self-identified as women). Risk assessment was influenced by physicians' knowledge of risk factors, skills to synthesize risk and beliefs about utility. Physicians had beliefs in their capabilities to have informed patient-centred discussions, but insufficient knowledge regarding the harms of screening. The decision or referral for mammography was affected by emotions related to past patient outcomes, social influences of patients and radiology departments, and knowledge and beliefs about consequences (benefits and harms of screening). Referrals for genetic counselling and to high-risk screening programs were facilitated by their availability and by the knowledge and skills to complete forms. Lack of knowledge regarding which patients qualify and beliefs about consequences were barriers to referral., Interpretation: Insufficient knowledge and skills for performance of risk assessment, combined with a tendency to overestimate benefits of screening relative to harms affected provision of guideline-concordant care. These may be effective targets for future interventions to improve guideline-concordant care., Competing Interests: Competing interests: Alexandra Desnoyers reports consulting fees from Novartis and Pfizer, and payments from Novartis, Pfizer, AstraZeneca, Gilead and Apobiologix. Eitan Amir reports consulting fees from Sandoz, Novartis and Exact Sciences. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Investigating the mechanisms of behavior change interventions provides a more fulsome understanding of how and why interventions work (or don't work). We assessed mechanisms of two interventions (mailouts alone, and mailouts plus telephone support, informed by the Health Action Process Approach (HAPA) and Habit Theory), designed to increase medication adherence after myocardial infarction. We conducted a process evaluation alongside a pragmatic trial. Medication adherence was assessed via self-report at 12-months in the trial, and participants in all trial groups were invited to contemporaneously complete an additional questionnaire assessing targeted mechanisms (HAPA constructs and automaticity). We used multiple regression-based mediation models to investigate indirect effects. Of 589 respondents, 497 were analyzed (92 excluded due to missing data). Mailouts plus telephone support had statistically significant but small effects on intention, social support, action planning, coping planning, and automaticity. There were no indirect effects of interventions on medication adherence via these constructs. Therefore, while this intervention led to changes in proposed mechanisms, these changes were not great enough to lead to behavior change. Refinements (and subsequent evaluation) of the interventions are warranted, and our findings indicate that this could involve offering more intensive support to form plans and identify cues for taking medications, in addition to providing physical supports to encourage self-monitoring, feedback, and habit formation. Trial registration: ClinicalTrials.gov: NCT02382731., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: COVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care's potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal., Objective: This study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations., Methods: We conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT., Results: A total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group., Conclusions: As further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient., (©Jennifer Shuldiner, Diya Srinivasan, Justin N Hall, Carl R May, Laura Desveaux. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 12.09.2022.)

Background: Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms., Methods: Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20 th percentile versus "medium" defined as 40 th to 60 th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved., Results: Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician-patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty., Conclusions: Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices., (© 2022. The Author(s).)

Background: Normalization Process Theory (NPT) identifies mechanisms that have been demonstrated to play an important role in implementation processes. It is now widely used to inform feasibility, process evaluation, and implementation studies in healthcare and other areas of work. This qualitative synthesis of NPT studies aims to better understand how NPT explains observed and reported implementation processes, and to explore the ways in which its constructs explain the implementability, enacting and sustainment of complex healthcare interventions., Methods: We will systematically search Scopus, PubMed and Web of Science databases and use the Google Scholar search engine for citations of key papers in which NPT was developed. This will identify English language peer-reviewed articles in scientific journals reporting (a) primary qualitative or mixed methods studies; or, (b) qualitative or mixed methods evidence syntheses in which NPT was the primary analytic framework. Studies may be conducted in any healthcare setting, published between June 2006 and 31 December 2021. We will perform a qualitative synthesis of included studies using two parallel methods: (i) directed content analysis based on an already developed coding manual; and (ii) unsupervised textual analysis using Leximancer® topic modelling software., Other: We will disseminate results of the review using peer reviewed publications, conference and seminar presentations, and social media (Facebook and Twitter) channels. The primary source of funding is the National Institute for Health Research ARC North Thames. No human subjects or personal data are involved and no ethical issues are anticipated., Competing Interests: Competing interests: All authors except Alyson Hillis have been involved in the development or use of Normalization Process Theory.

Background: Centralized drug repositories can reduce adverse events and inappropriate prescriptions by enabling access to dispensed medication data at the point of care; however, how they achieve this goal is largely unknown., Objective: This study aims to understand the perceived clinical value; the barriers to and enablers of adoption; and the clinician groups for which a provincial, centralized drug repository may provide the most benefit., Methods: A mixed methods approach, including a web-based survey and semistructured interviews, was used. Participants were clinicians (eg, nurses, physicians, and pharmacists) in Ontario who were eligible to use the digital health drug repository (DHDR), irrespective of actual use. Survey data were ranked on a 7-point adjectival scale and analyzed using descriptive statistics, and interviews were analyzed using qualitative descriptions., Results: Of the 161 survey respondents, only 40 (24.8%) actively used the DHDR. Perceptions of the utility of the DHDR were neutral (mean scores ranged from 4.11 to 4.76). Of the 75.2% (121/161) who did not use the DHDR, 97.5% (118/121) rated access to medication information (eg, dose, strength, and frequency) as important. Reasons for not using the DHDR included the cumbersome access process and the perception that available data were incomplete or inaccurate. Of the 33 interviews completed, 26 (79%) were active DHDR users. The DHDR was a satisfactory source of secondary information; however, the absence of medication instructions and prescribed medications (which were not dispensed) limited its ability to provide a comprehensive profile to meaningfully support clinical decision-making., Conclusions: Digital drug repositories must be adjusted to align with the clinician's needs to provide value. Ensuring integration with point-of-care systems, comprehensive clinical data, and streamlined onboarding processes would optimize clinically meaningful use. The electronic provision of accessible drug information to providers across health care settings has the potential to improve efficiency and reduce medication errors., (©Charlene Soobiah, Michelle Phung, Mina Tadrous, Trevor Jamieson, R Sacha Bhatia, Laura Desveaux. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.03.2022.)

Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: With the growing need for accessible, high-quality mental health services, especially during the COVID-19 pandemic, there has been increasing development and uptake of web-based interventions in the form of self-directed mental health platforms. The Big White Wall (BWW) is a web-based platform for people experiencing mental illness and addiction that offers a range of evidence-based self-directed treatment strategies. Drawing on existing data from a large-scale evaluation of the implementation of BWW in Ontario, Canada (which involved a pragmatic randomized controlled trail with an embedded qualitative process evaluation), we sought to investigate the influences on the extent to which people engage with BWW., Methods: In this paper we drew on BWW trial participants' usage data (number of logins) and the qualitative data from the process evaluation that explored participants' experiences, engagement with and reactions to BWW., Results: Our results showed that there were highly complex relationships between the influences that contributed to the level of engagement with BWW intervention. We found that a) how people expected to benefit from using a platform like BWW was an important indicator of their future usage, b) moderate perceived symptoms were linked with higher engagement; whereas fewer actual depressive symptoms predicted use and anxiety had a positive linear relationship with usage, and that c) usage depended on positive early experiences with the platform., Conclusions: Our findings suggest that the nature of engagement with platforms such as BWW is not easily predicted. We propose a theoretical framework for explaining the level of user engagement with BWW that might also be generalizable to other similar platforms., (© 2021. The Author(s).)

Background: Audit and feedback (A&F) often successfully enhances health professionals' intentions to improve quality of care but does not consistently lead to practice changes. Recipients often cite data credibility and limited resources as barriers impeding their ability to act upon A&F, suggesting the intention-to-action gap manifests while recipients are interacting with their data. While attention has been paid to the role feedback and contextual variables play in contributing to (or impeding) success, we lack a nuanced understanding of how healthcare professionals interact with and process clinical performance data., Methods: We used qualitative, semi-structured interviews guided by Normalization Process Theory (NPT). Questions explored the role of data in quality improvement, experiences with the A&F report, perceptions of the data, and interpretations and reflections. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using a combination of inductive and deductive strategies using reflexive thematic analysis informed by a constructivist paradigm., Results: Healthcare professional characteristics (individual quality improvement capabilities and beliefs about data) seem to influence engagement with A&F to a greater degree than feedback variables (i.e., delivered by peers) and observed contextual factors (i.e., strong quality improvement culture). Most participants lacked the capabilities to interpret practice-level data in an actionable way despite a motivation to engage meaningfully. Reasons for the intention-to-action gap included challenges interpreting longitudinal data, appreciating the nuances of common data sources, understanding how aggregate data provides insights into individualized care, and identifying practice-level actions to improve quality. These factors limited effective cognitive participation and collective action, as outlined in NPT., Conclusions: A well-designed A&F intervention is necessary but not sufficient to inform practice changes. A&F initiatives must include co-interventions to address recipient characteristics (i.e., beliefs and capabilities) and context to optimize impact. Effective strategies to overcome the intention-to-action gap may include modelling how to use A&F to inform practice change, providing opportunities for social interaction relating to the A&F, and circulating examples of effective actions taken in response to A&F. More broadly, undergraduate medical education and post-graduate training must ensure physicians are equipped with QI capabilities, with an emphasis on the skills required to interpret and act on practice-level data.

Background: Health systems are increasingly looking toward the private sector to provide digital solutions to address health care demands. Innovation in digital health is largely driven by small- and medium-sized enterprises (SMEs), yet these companies experience significant barriers to entry, especially in public health systems. Complex and fragmented care models, alongside a myriad of relevant stakeholders (eg, purchasers, providers, and producers of health care products), make developing value propositions for digital solutions highly challenging., Objective: This study aims to identify areas for health system improvement to promote the integration of innovative digital health technologies developed by SMEs., Methods: This paper qualitatively analyzes a series of case studies to identify health system barriers faced by SMEs developing digital health technologies in Canada and proposed solutions to encourage a more innovative ecosystem. The Women's College Hospital Institute for Health System Solutions and Virtual Care established a consultation program for SMEs to help them increase their innovation capacity and take their ideas to market. The consultation involved the SME filling out an onboarding form and review of this information by an expert advisory committee using guided considerations, leading to a recommendation report provided to the SME. This paper reports on the characteristics of 25 SMEs who completed the program and qualitatively analyzed their recommendation reports to identify common barriers to digital health innovation., Results: A total of 2 central themes were identified, each with 3 subthemes. First, a common barrier to system integration was the lack of formal evaluation, with SMEs having limited resources and opportunities to conduct such an evaluation. Second, the health system's current structure does not create incentives for clinicians to use digital technologies, which threatens the sustainability of SMEs' business models. SMEs faced significant challenges in engaging users and payers from the public system due to perverse economic incentives. Physicians are compensated by in-person visits, which actively works against the goals of many digital health solutions of keeping patients out of clinics and hospitals., Conclusions: There is a significant disconnect between the economic incentives that drive clinical behaviors and the use of digital technologies that would benefit patients' well-being. To encourage the use of digital health technologies, publicly funded health systems need to dedicate funding for the evaluation of digital solutions and streamlined pathways for clinical integration., (©Leah Taylor Kelley, Jamie Fujioka, Kyle Liang, Madeline Cooper, Trevor Jamieson, Laura Desveaux. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 10.12.2020.)

Purpose: Although pulmonary rehabilitation (PR) improves function in people with chronic obstructive pulmonary disease (COPD), a community-based exercise program may be necessary to maintain functional capacity. We aimed to determine the effectiveness of a post-rehabilitation, community-based maintenance program on exercise tolerance, functional capacity and quality of life., Methods: Patients with COPD who completed PR were randomized to receive a community-based maintenance program (intervention) or usual care (control). The primary outcome was 6-min walk distance (6MWD), measured immediately post-PR, 6 months and 12 months later. Secondary outcomes included self-reported functional capacity, health-related quality of life, self-efficacy, program cost, and lower extremity muscle strength., Results: Ninety-seven patients (69 ± 9 years) were enrolled. There was a non-significant trend of an intervention effect on 6MWD over time (β = 42, 95% CI: 0.06 to 83.93, p = 0.053). There was no significant impact of group on any of the secondary outcomes. Restricting the analysis to those who attended ≥50% of the exercise sessions showed a significant intervention effect for 6MWD (β = 69.19, 95% CI = 10.16 to 128.22, p = 0.03). The cost of participating in the community maintenance program for the intervention group was $374.77 (SD 142.12) and membership renewal was highest at community centres offering twice weekly, supervised exercise classes., Conclusions: A post rehabilitation, community-based exercise program, will maintain exercise capacity in people with COPD who attend at least 50% of available sessions over one year. An increased focus on factors that determine adherence would help inform improvements in maintenance program design., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Overcoming barriers to health system innovation is an ongoing challenge in Canada. A total of 51 participants attended a digital health symposium in October 2017 to discuss the role of an academic medical centre (AMC) in advancing innovation. The conversation centred around (i) the current state of innovation in healthcare; (ii) the need for an innovation catalyst; and (iii) the roadmap for an AMC to drive change. AMCs can address the barriers to digital health innovation in Canada by providing a centralized network and infrastructure that supports innovation throughout its journey from "bench to bedside" as well as supporting educational reform., (Copyright © 2020 Longwoods Publishing.)

Background: Timely and comprehensive diagnostic image sharing across institutional and regional boundaries can produce multiple benefits while supporting integrated models of care. In Ontario, Canada, the Diagnostic Imaging Common Service (DICS) was created as a centralized imaging repository to enable the sharing and viewing of diagnostic images and associated reports across hospital-based and community-based clinicians throughout the province., Objective: The aims of this study were as follows: (1) to explore real-world utilization and perceived clinical value of the DICS following the provision of system-wide access and (2) to identify strategies to optimize the technology platform functionality and encourage adoption., Methods: This multimethod study included semistructured interviews with physicians and administrative stakeholders and descriptive analysis of the current DICS usage data., Results: In this study, 41 participants were interviewed, that is, 34 physicians and 7 administrative stakeholders. The following 4 key themes emerged: (1) utilization of the DICS depended on the awareness of the technology and the preferred channels for accessing images, which varied widely, (2) clinical responsibilities and available institutional resources were the drivers of utilization (or lack thereof), (3) centralized image repositories were perceived to offer value at the patient, clinician, and health care system levels, and (4) the enabling factors to realize value included aspects of technology infrastructure (ie, available functionality) alongside policy supports. High-volume DICS usage was not evenly distributed throughout the province., Conclusions: Suboptimal adoption of the DICS was driven by poor awareness and variations in the clinical workflow. Alignment with physician workflow, policy supports, and investment in key technological features and infrastructure would improve functionality and data comprehensiveness, thereby optimizing health system performance, patient and provider experience, population health, and health care costs., (©Lisa Wickerson, Jamie K Fujioka, Vanessa Kishimoto, Trevor Jamieson, Ben Fine, R Sacha Bhatia, Laura Desveaux. Originally published in JMIR Formative Research (http://formative.jmir.org), 27.07.2020.)

Background: As part of their professional role, healthcare providers enact multiple competing goal-directed behaviours in time-constrained environments. Better understanding healthcare providers' motivation to engage in the pursuit of particular goals may help inform the development of implementation interventions. We investigated healthcare providers' pursuit of multiple goals as part of a trial evaluating the effectiveness of an audit and feedback intervention in supporting appropriate adjustment of high-risk medication prescribing by physicians working in nursing homes. Our objectives were to determine whether goal priority and constructs from Social Cognitive Theory (self-efficacy, outcome expectations, and descriptive norms) predicted intention to adjust prescribing of multiple high-risk medications and to investigate how physicians in nursing homes prioritise their goals related to high-risk medication prescribing., Methods: Physicians in Ontario, Canada, who signed up for and accessed the audit and feedback report were invited to complete a questionnaire assessing goal priority, self-efficacy, outcome expectations, descriptive norms, and intention in relation to the three targeted behaviours (adjusting prescribing of antipsychotics, benzodiazepines, and antidepressants) and a control behaviour (adjusting statin prescribing). We conducted multiple linear regression analyses to identify predictors of intention. We also conducted semi-structured qualitative interviews to investigate how physicians in nursing homes prioritise their goals in relation to appropriately adjusting prescribing of the medications included in the report: analysis was informed by the framework analysis method., Results: Thirty-three of 89 (37%) physicians completed the questionnaire. Goal priority was the only significant predictor of intention for each medication type; the greater a priority it was for physicians to appropriately adjust their prescribing, the stronger was their intention to do so. Across five interviews, physicians reported prioritising adjustment of antipsychotic prescribing specifically. This was influenced by negative media coverage of antipsychotic prescribing in nursing homes, the provincial government's mandate to address antipsychotic prescribing, and by the deprescribing initiatives or best practice routines in place in their nursing homes., Conclusions: Goal priority predicted nursing home physicians' intention to adjust prescribing. Targeting goal priority through implementation interventions therefore has the potential to influence behaviour via increased motivation. Implementation intervention developers should consider the external factors that may drive physicians' prioritization., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Background: High-level policy barriers impede widespread adoption for even the most well-positioned innovations. Most of the work in this field assumes rather than analyzes the driving forces of health innovation. Objective: The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario., Objective: The aim of this study was to explore the challenges and opportunities experienced by health system stakeholders in the implementation of digital health innovation in Ontario., Methods: We completed semistructured interviews with 10 members of senior leadership across key organizations that are engaged in health care-related digital health activities. Data were analyzed using qualitative description., Results: A total of 6 key policy priorities emerged, including the need for (1) a system-level definition of innovation, (2) a clear overarching mission, and (3) clearly defined organizational roles. Operationally, there is a need to (4) standardize processes, (5) shift the emphasis to change management, and (6) align funding structures., Conclusions: These findings emphasize the critical role of the government in developing a vision and creating the foundation upon which innovation activities will be modeled., (©Laura Desveaux, Charlene Soobiah, R Sacha Bhatia, James Shaw. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.12.2019.)

Introduction: Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation., Methods: A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method., Results: A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members., Discussion: Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual- and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.

Purpose: We examined the perspectives of family physicians (FPs) on opioid prescribing and management of chronic pain to better understand the barriers to safer prescribing in primary care and differences in perspectives that may be potential drivers of practice variation., Methods: We used an exploratory qualitative study design. Semistructured interviews were conducted in June and July 2017 with 22 FPs in Ontario and coded inductively. Thematic analysis was used to identify themes, and a framework analysis explored the influence of physician demographics on prescribing experience., Results: Three key themes emerged: the discrepancy between FPs' training and current practice, the tension between the FP's role and patient and system expectations, and the influence of length of time in practice and strength of therapeutic relationships on perspectives on opioid prescribing. There was an overarching sentiment among participants that FPs are unsupported in their efforts to manage chronic pain. More years in practice (≥15 years) seems to influence practice patterns by increasing trust in therapeutic relationships and decreasing reliance on emergent guidelines (vs clinical experience)., Conclusion: Number of years in practice influences FPs' response to emergent evidence, requiring initiatives to include strategies tailored to individual beliefs. Initiatives must move beyond dissemination and education to equip FPs with the skills they need to navigate emotionally charged conversations. External pressures and misaligned system and patient expectations place FPs at the center of a challenging situation, which may result in a higher risk of burnout compared with that of their specialist colleagues., (© 2019 Annals of Family Medicine, Inc.)

Background: As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A 1c (HbA 1c ) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear., Objective: The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA 1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA 1c levels compared with controls., Methods: The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA 1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app., Results: The results of an analysis of covariance controlling for baseline HbA 1c levels did not show evidence of intervention impact on HbA 1c levels at 3 months (mean difference [ITG-WLC] -0.42, 95% CI -1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA 1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants' 3-month HbA 1c levels (95% CI -0.03 to -0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51)., Conclusions: The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA 1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed., Trial Registration: Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)., (©Payal Agarwal, Geetha Mukerji, Laura Desveaux, Noah M Ivers, Onil Bhattacharyya, Jennifer M Hensel, James Shaw, Zachary Bouck, Trevor Jamieson, Nike Onabajo, Madeline Cooper, Husayn Marani, Lianne Jeffs, R Sacha Bhatia. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 10.01.2019.)

Background: There is a great deal of variation in the design and delivery of patient navigator (PN) programs, making it difficult to design or adopt these interventions in new contexts. We (1) systematically reviewed the literature to generate a preliminary program theory to describe how patient navigator interventions are designed and delivered; and (2) describe how the resulting program theory was applied in context to inform a prototype for a patient navigator program., Methods: The current study includes a secondary review of a larger systematic review. We reviewed studies included in the primary review to identify those that designed and evaluated programs to assist patients in accessing and/or adhering to care. We conducted a content analysis of included publications to describe the barriers targeted by PN interventions and the navigator activities addressing those barriers. A program theory was constructed by mapping patient navigator activities to corresponding constructs within the capability-opportunity-motivation model of behavior change (COM-B) model of behavior change. The program theory was then presented to individuals with chronic disease, healthcare providers, and system stakeholders, and refined iteratively based on feedback., Results: Twenty one publications describing 19 patient navigator interventions were included. A total of 17 unique patient navigator activities were reported. The most common included providing education, facilitating referrals, providing social and emotional support, and supporting self-management. The majority of navigator activities targeted barriers to physical opportunity, including facilitating insurance claims, assistance with scheduling, and providing transportation. Across all interventions, navigator activities were designed to target a total of 20 patient barriers. Among interventions reporting positive effects, over two thirds targeted knowledge barriers, problems with scheduling, proactive re-scheduling following a missed appointment, and insurance. The final program design included a total of 13 navigator activities-10 informed by the original program theory and 3 unique activities informed by stakeholders., Conclusions: There is considerable heterogeneity in intervention content across patient navigator interventions. Our results provide a schema from which to develop PN interventions and illustrate how an evidence-based model was used to develop a real-world PN intervention. Our findings also highlight a critical need to improve the reporting of intervention components to facilitate translation., Systematic Review Registration: PROSPERO CRD42013005857.

Digital tools have shown great potential to enhance health services' capacity to achieve the goals of the triple aim (enhance patient experience, improve health outcomes, and control or reduce costs), but their actual impact remains variable. In this commentary, we suggest that shifting from a perspective focused on "implementing" new digital tools in health care settings toward one focused on "service design" will help teams execute more successful digital technology adoption projects. We present value proposition design (VPD) as a service design strategy requiring that stakeholders are brutally honest in determining the value of a new digital tool for their everyday work. Incorporating a perspective focused on how the value proposition of a technology is understood by each team member, and implications for their work routines, will help project teams to better understand how services can be reinvented during technology adoption initiatives. We present the simple heuristic [Tool+Team+Routine] as a reminder of the central considerations that make up a service design initiative, and present an illustrative case scenario of designing the use of a digital care coordination platform in an actual digital technology adoption project. We conclude by outlining two important challenges that need to be addressed to advance service design approaches to technology adoption in health care., Competing Interests: Competing interestsThe authors declare no competing interests.

Background: Post-market surveillance of medical devices is reliant on physician reporting of adverse medical device events (AMDEs). Few studies have examined factors that influence whether and how physicians report AMDEs, an essential step in the development of behaviour change interventions. This study was a secondary analysis comparing application of the Theoretical Domains Framework (TDF) and the Tailored Implementation for Chronic Diseases (TICD) framework to identify potential behaviour change interventions that correspond to determinants of AMDE reporting., Methods: A previous study involving qualitative interviews with Canadian physicians that implant medical devices identified themes reflecting AMDE reporting determinants. In this secondary analysis, themes that emerged from the primary analysis were independently mapped to the TDF and TICD. Determinants and corresponding intervention options arising from both frameworks (and both mappers) were compared., Results: Both theoretical frameworks were useful for identifying interventions corresponding to behavioural determinants of AMDE reporting. Information or education strategies that provide evidence about AMDEs, and audit and feedback of AMDE data were identified as interventions to target the theme of physician beliefs; improving information systems, and reminder cues, prompts and awards were identified as interventions to address determinants arising from the organization or systems themes; and modifying financial/non-financial incentives and sharing data on outcomes associated with AMDEs were identified as interventions to target device market themes. Numerous operational challenges were encountered in the application of both frameworks including a lack of clarity about how directly relevant to themes the domains/determinants should be, how many domains/determinants to select, if and how to resolve discrepancies across multiple mappers, and how to choose interventions from among the large number associated with selected domains/determinants., Conclusions: Given discrepancies in mapping themes to determinants/domains and the resulting interventions offered by the two frameworks, uncertainty remains about how to choose interventions that best match behavioural determinants in a given context. Further research is needed to provide more nuanced guidance on the application of TDF and TICD for a broader audience, which is likely to increase the utility and uptake of these frameworks in practice.

Background: As exercise may mitigate cognitive decline in individuals with chronic obstructive pulmonary disease (COPD), its effect has been evaluated in a number of clinical trials. The objective of the present systematic review was to describe the impact of exercise training on cognition in COPD., Methods: Electronic searches of four databases were performed from inception until March 24, 2015 and last updated 23rd October 2017. Included studies reported on at least one cognitive outcome before and after a formal exercise-training program in individuals with COPD. Two reviewers independently rated study quality using the Downs and Black checklist. The protocol was registered on PROSPERO (CRD42015017884)., Results: Seven articles, representing six exercise interventions in 293 individuals with COPD (55% males, mean age 67 ± 2 year) were included. Although each study documented a significant pre-post training improvement in at least one cognitive domain, the heterogeneity in study design, exercise intervention and cognitive outcome measures among studies precluded a meta-analysis. The only randomized controlled trial available reported an improvement on a letter verbal fluency task in the exercise group only., Conclusions: Exercise training may positively impact cognition in COPD patients, but current evidence is limited by the heterogeneity of study design, exercise intervention and cognitive outcome measures. Future studies should emphasize comprehensive reporting of intervention parameters, including program length, type(s) of exercise, and duration of individual sessions, in order to facilitate applied insights to inform replication and/or program development., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Despite well-established improvements following rehabilitation, functional gains often diminish following discharge., Objective: To explore the attitudes of older adults with HF and COPD, who have completed rehabilitation, toward community-based exercise maintenance., Methods: Semi-structured interviews were conducted with 11 individuals with HF or COPD., Results: Deductive thematic analysis uncovered three themes: 1) transitioning to community exercise is challenging, highlighting participants' struggle with unstructured maintenance and a lack of appropriate programs; 2) a structured, group-based program tailored to functional ability facilitates adherence, describing participants views on the importance of routine, and accountability; and 3) "We are all there for the same purpose" - participant support for integrated exercise, including the benefit of multiple perspectives and sustainability., Conclusions: A motivating program leader and access to appropriate facilities are key features to support adherence to prescribed activity. Tailored programs can be delivered consecutively to older adults with HF and COPD., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To determine whether adults with diabetes and with transtibial amputations (TTAs) are meeting the recommended guidelines for physical activity intensity and daily step counts. The secondary objectives were to 1) to explore whether physical activity levels are maintained following discharge from prosthetic rehabilitation and 2) to determine whether clinical measures of physical function are associated with physical activity., Methods: Adults ≥40 years of age with TTAs secondary to diabetes were recruited following discharge from prosthetic rehabilitation. Outcomes included accelerometer-measured physical activity (worn on the ankle of the intact limb), the 2-minute walk test, gait speed, the L-test and balance confidence. Assessments were conducted at 3 months (baseline) and at 9 months following discharge from rehabilitation. Analyses included paired sample t tests and Pearson correlation coefficients., Results: The mean age for all participants (n=22) was 63±12 years. Participants took 3809±2189 steps per day at follow up, markedly lower than the 6500 steps per day recommended for older adults with chronic illness. Participants accumulated 24±41 minutes per week of moderate to vigorous physical activity, falling well below the recommended total of 150 minutes per week. An improvement was observed for performance on the L-test of functional mobility at follow up (-8.7 s±11.4; p=0.008). All other outcomes remained stable over time. Physical activity exhibited a good to excellent correlation with the 2-minute walk test distance (r=0.753; p<0.001) and gait speed (r=0.752; p<0.001) at discharge from rehabilitation., Conclusions: Physical activity levels for adults with diabetes and TTAs remain stable following discharge from prosthetic rehabilitation but fall well below recommended guidelines of 6500 steps per day and 150 minutes of moderate to vigorous physical activity per week., (Copyright © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Heart disease, stroke, and chronic obstructive pulmonary disease (COPD) are the leading causes of death and disability worldwide. Although individuals with these conditions have been reported to benefit from yoga, its effectiveness remains unclear., Objective: To perform a systematic review of the effectiveness of yoga on exercise capacity, health related quality of life (HRQL), and psychological well-being for individuals with chronic disease and describe the structure and delivery of programs., Research Design: We performed a systematic review of randomized controlled trials examining yoga programs for individuals with heart disease, stroke, and COPD compared with usual care. Quality was assessed using the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.3. The protocol was registered on PROSPERO (CRD42014014589)., Results: Ten studies (431 individuals, mean age 56±8 y) were included and were comparable in their design and components, irrespective of the chronic disease. The standardized mean difference for the mean change in exercise capacity was 2.69 (95% confidence interval, 1.39-3.99) and for HRQL it was 1.24 (95% confidence interval, -0.37 to 2.85). Symptoms of anxiety were reduced after yoga in individuals with stroke, although this was not observed in individuals with COPD. The effect of yoga on symptoms of depression varied across studies with no significant effects compared with usual care., Conclusions: Yoga programs have similar designs and components across chronic disease populations. Compared with usual care, yoga resulted in significant improvements in exercise capacity and a mean improvement in HRQL. Yoga programs may be a useful adjunct to formal rehabilitation programs.

Background: Self-management (SM) reduces hospital admissions in patients with stable COPD. However, its role immediately post-acute exacerbation (AE) is unclear. The objectives of this review were to describe SM interventions delivered immediately following an AE of COPD (AECOPD) and to conduct a systematic review with meta-analysis of its impact on health-care utilization and health outcomes., Methods: Randomized controlled trials reporting on SM interventions delivered during hospitalization for an AECOPD or within 1 month of hospital discharge were included. Seven articles were identified. Data were extracted and assessed for quality by two researchers., Results: By definition, all interventions included action plans, education, and at least two SM skills. Nurses were responsible for providing all SM interventions. The delivery and follow-up periods varied widely. At 12 months, there were no significant differences between those who completed the SM intervention and control subjects in the number of patients readmitted to hospital (P = .38), or in health-related quality of life (P = .27). No effects were found on rate of mortality, depressive symptoms, primary care usage, or exercise capacity. Minimal effects were found on self-efficacy, anxiety symptoms, and health promoting behavior. SM was associated with positive effects on knowledge and management of an AECOPD., Conclusions: SM interventions delivered immediately post-AE vary widely and outcome measures are inconsistent, making it difficult to draw strong recommendations regarding its effectiveness. The evaluation of SM interventions, delivered by trained health-care professionals to selected patients and which offer structured follow-up, appears necessary.

Background: Chronic diseases are the leading cause of death and disability worldwide. Preliminary evidence suggests that community-based exercise (CBE) improves functional capacity (FC) and health-related quality of life (HRQL)., Objective: To describe the structure and delivery of CBE programs for chronic disease populations and compare their impact on FC and HRQL to standard care., Research Design: Randomized trials examining CBE programs for individuals with stroke, chronic obstructive pulmonary disease, osteoarthritis, diabetes, and cardiovascular disease were identified. Quality was assessed using the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.1. The protocol was registered on PROSPERO (CRD42012002786)., Results: Sixteen studies (2198 individuals, mean age 66.8±4.9 y) were included to describe program structures, which were comparable in their design and components, irrespective of the chronic disease. Aerobic exercise and resistance training were the primary interventions in 85% of studies. Nine studies were included in the meta-analysis. The weighted mean difference for FC, evaluated using the 6-minute walk test, was 41.7 m (95% confidence interval [CI], 20.5-62.8). The standardized mean difference for all FC measures was 0.18 (95% CI, 0.05-0.3). The standardized mean difference for the physical component of HRQL measures was 0.21 (95% CI, 0.05-0.4) and 0.38 (95% CI, 0.04-0.7) for the total score., Conclusions: CBE programs across chronic disease populations have similar structures. These programs appear superior to standard care with respect to optimizing FC and HRQL in individuals with osteoarthritis; however, the effect beyond this population is unknown. Long-term sustainability of these programs remains to be established.