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Background Clinical practice guidelines are intended to improve patient care and outcomes. Controversy exists about the utility of guidelines and doctors' attitudes toward them. The purpose of the survey was to determine Ontario doctors' attitudes toward practice guidelines in general, awareness of, and attitudes about, Cancer Care Ontario's Practice Guideline Initiative and the evidence-based guidelines it produces, self-reported use of guidelines and, factors related to guideline use. Methods We conducted a cross-sectional, self-administered postal survey of 1034 Ontario doctors who treat cancer. Main outcome measures were attitudes toward practice guidelines in general, attitudes towards those developed by Cancer Care Ontario's Practice Guideline Initiative, and self-reported use of practice guidelines. Findings A total of 520 doctors responded producing a 57% survey response rate. Ontario doctors are quite positive about practice guidelines in general and those developed by Cancer Care Ontario. Forty-four per cent reported using guidelines routinely or most of the time. Positive attitudes towards guidelines in general and the Ontario cancer guidelines specifically were related to more frequent reported use of guidelines. Other factors related to frequent reported use of guidelines included being a medical oncologist, treating gynaecological cancers and not other types of cancers. Interpretation Ontario doctors have positive attitudes toward practice guidelines and report frequent use of them. By understanding the relationship between doctors' perceptions of specific guidelines and their subsequent adherence to them, guideline developers will be better positioned to produce quality evidence-based guidelines that doctors will find acceptable, and therefore, be more predisposed to use. [ABSTRACT FROM AUTHOR]

Abstract Background The Canadian Institutes of Health Research (CIHR) has defined knowledge translation (KT) as a dynamic and iterative process that includes the synthesis, dissemination, exchange, and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the healthcare system. CIHR, the national health research funding agency in Canada, has undertaken to advance this concept through direct research funding opportunities in KT. Because CIHR is recognized within Canada and internationally for leading and funding the advancement of KT science and practice, it is essential and timely to evaluate this intervention, and specifically, these funding opportunities. Design The study will employ a novel method of participatory, utilization-focused evaluation inspired by the principles of integrated KT. It will use a mixed methods approach, drawing on both quantitative and qualitative data, and will elicit participation from CIHR funded researchers, knowledge users, KT experts, as well as other health research funding agencies. Lines of inquiry will include an international environmental scan, document/data reviews, in-depth interviews, targeted surveys, case studies, and an expert review panel. The study will investigate how efficiently and effectively the CIHR model of KT funding programs operates, what immediate outcomes these funding mechanisms have produced, and what impact these programs have had on the broader state of health research, health research uptake, and health improvement. Discussion The protocol and results of this evaluation will be of interest to those engaged in the theory, practice, and evaluation of KT. The dissemination of the study protocol and results to both practitioners and theorists will help to fill a gap in knowledge in three areas: the role of a public research funding agency in facilitating KT, the outcomes and impacts KT funding interventions, and how KT can best be evaluated.

Abstract As the recent collection of papers from the Quality Enhancement Research Initiative (QUERI) Series indicates, knowledge is leading to considerable action in the United States (U.S.) Department of Veterans Affairs (VA). The QUERI Series offers clinical researchers, implementation scientists, health systems, and health research funders from around the globe a unique window into the both the practice and science of implementation or knowledge translation (KT) in the VA. By describing successes and challenges as well as setbacks and disappointments, the QUERI Series is all the more useful. From the vantage point of Canadian KT researchers and officials at a national health research funding agency, we offer a number of observations and lessons that can be learned from QUERI. "Knowledge, if it does not determine action, is dead to us." Plotinus (Roman philosopher 205AD-270AD)

Abstract Background A challenge for implementation researchers is to develop principles that could generate testable hypotheses that apply across a range of clinical contexts, thus leading to generalisability of findings. Such principles may be provided by systematically developed theories. The opportunity has arisen to test some of these theoretical principles in the Ontario Printed Educational Materials (OPEM) trial by conducting a sub-trial within the existing trial structure. OPEM is a large factorial cluster-randomised trial evaluating the effects of short directive and long discursive educational messages embedded into informed, an evidence-based newsletter produced in Canada by the Institute for Clinical Evaluative Sciences (ICES) and mailed to all primary care physicians in Ontario. The content of educational messages in the sub-trial will be constructed using both standard methods and methods inspired by psychological theory. The aim of this study is to test the effectiveness of the TheoRY-inspired MEssage ('TRY-ME') compared with the 'standard' message in changing prescribing behaviour. Methods The OPEM trial participants randomised to receive the short directive message attached to the outside of informed (an 'outsert') will be sub-randomised to receive either a standard message or a message informed by the theory of planned behaviour (TPB) using a two (long insert or no insert) by three (theory-based outsert or standard outsert or no outsert) design. The messages will relate to prescription of thiazide diuretics as first line drug treatment for hypertension (described in the accompanying protocol, "The Ontario Printed Educational Materials trial"). The short messages will be developed independently by two research teams. The primary outcome is prescription of thiazide diuretics, measured by routinely collected data available within ICES. The study is designed to answer the question, is there any difference in guideline adherence (i.e., thiazide prescription rates) between physicians in the six groups? A process evaluation survey instrument based on the TPB will be administered pre- and post-intervention (described in the accompanying protocol, "Looking inside the black box"). The second research question concerns processes that may underlie observed differences in prescribing behaviour. We expect that effects of the messages on prescribing behaviour will be mediated through changes in physicians' cognitions. Trial registration number Current controlled trial ISRCTN72772651

Abstract Background Randomised controlled trials of implementation strategies tell us whether (or not) an intervention results in changes in professional behaviour but little about the causal mechanisms that produce any change. Theory-based process evaluations collect data on theoretical constructs alongside randomised trials to explore possible causal mechanisms and effect modifiers. This is similar to measuring intermediate endpoints in clinical trials to further understand the biological basis of any observed effects (for example, measuring lipid profiles alongside trials of lipid lowering drugs where the primary endpoint could be reduction in vascular related deaths). This study protocol describes a theory-based process evaluation alongside the Ontario Printed Educational Message (OPEM) trial. We hypothesize that the OPEM interventions are most likely to operate through changes in physicians' behavioural intentions due to improved attitudes or subjective norms with little or no change in perceived behavioural control. We will test this hypothesis using a well-validated social cognition model, the theory of planned behaviour (TPB) that incorporates these constructs. Methods/design We will develop theory-based surveys using standard methods based upon the TPB for the second and third replications, and survey a subsample of Ontario family physicians from each arm of the trial two months before and six months after the dissemination of the index edition of informed, the evidence based newsletter used for the interventions. In the third replication, our study will converge with the "TRY-ME" protocol (a second study conducted alongside the OPEM trial), in which the content of educational messages was constructed using both standard methods and methods informed by psychological theory. We will modify Dillman's total design method to maximise response rates. Preliminary analyses will initially assess the internal reliability of the measures and use regression to explore the relationships between predictor and dependent variable (intention to advise diabetic patients to have annual retinopathy screening and to prescribe thiazide diuretics for first line treatment of uncomplicated hypertension). We will then compare groups using methods appropriate for comparing independent samples to determine whether there have been changes in the predicted constructs (attitudes, subjective norms, or intentions) across the study groups as hypothesised, and will assess the convergence between the process evaluation results and the main trial results. Trial registration number Current controlled trial ISRCTN72772651

Abstract Background Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them. Methods We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid. Results Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians ( Conclusion Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.

One of the most common findings from health services research is a failure to routinely trans-late research findings into daily practice. Previous systematic reviews of strategies to promote the uptake of research findings suffered from a range of methodologic problems that have been addressed in a more recent systematic review of guideline dissemination and implementation strategies. Changes in practitioner behavior, in the desired direction, were reported in 86% of the comparisons made. The median effect size overall was approximately 10% improvement in absolute terms. The review suggests that interventions that were previously thought to be ineffective (e.g., dissemination of educational materials) may have modest but worth-while benefits. Also, multifaceted interventions, previously thought to be more effective than single interventions, were found to be no more effective than single interventions. Overall, there is an imperfect evidence base for decision makers to work from. Many studies had methodologic weaknesses, and reporting of this kind of research is generally poor, making the generalizability of study findings frequently uncertain. A better theoretical underpinning of studies would make this body of research more useful. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The aim was to describe how selected health research funding agencies active in low- and middle-income countries promote the translation of their funded research into policy and practice. METHODS: We conducted inductive analysis of semi-structured interviews with key informants from a purposive sample of 23 national and international funding agencies that fund health research in Brazil, Colombia, India, the Philippines, South Africa and Thailand. We also surveyed web sites. FINDINGS: We found a commitment to knowledge translation in the mandate of 18 of 23 agencies. However, there was a lack of common terminology. Most of the activities were traditional efforts to disseminate to a broad audience, for example using web sites and publications. In addition, more than half (13 of 23) of the agencies encouraged linkage/exchange between researchers and potential users, and 6 of 23 agencies described 'pull' activities to generate interest in research from decision-makers. One-third (9 of 23) of funding agencies described a mandate to enhance health equity through improving knowledge translation. Only 3 of 23 agencies were able to describe evaluation of knowledge translation activities. Furthermore, we found national funding agencies made greater knowledge translation efforts when compared to international agencies. CONCLUSION: Funding agencies are engaged in a wide range of creative knowledge translation activities. They might consider their role as knowledge brokers, with an ability to promote research syntheses and a focus on health equity. There is an urgent need to evaluate the knowledge translation activities of funding agencies. [ABSTRACT FROM AUTHOR]

Background: Evidence on the effectiveness of printed educational messages in contributing to increasing evidence-based clinical practice is contradictory. Nonetheless, these messages flood physician offices, in an attempt to promote treatments that can reduce costs while improving patient outcomes. This study evaluated the ability of printed educational messages to promote the choice of thiazides as the first-line treatment for individuals newly diagnosed with hypertension, a practice supported by good evidence and included in guidelines, and one which could reduce costs to the health care system., Methods: The study uses a pragmatic, cluster randomized controlled trial (randomized by physician practice group)., Setting: The setting involves all Ontario general/family practice physicians. Messages advising the use of thiazides as the first-line treatment of hypertension were mailed to each physician in conjunction with a widely read professional newsletter. Physicians were randomized to receive differing versions of printed educational messages: an "insert" (two-page evidence-based article) and/or one of two different versions of an "outsert" (short, directive message stapled to the outside of the newsletter). One outsert was developed without an explicit theory and one with messages developed targeting factors from the theory of planned behaviour or neither (newsletter only, with no mention of thiazides). The percentage of patients aged over 65 and newly diagnosed with hypertension who were prescribed a thiazide as the sole initial prescription medication. The effect of the intervention was estimated using a logistic regression model estimated using generalized estimating equation methods to account for the clustering of patients within physician practices., Results: Four thousand five hundred four physicians (with 23,508 patients) were randomized, providing 97 % power to detect a 5 % absolute increase in prescription of thiazides. No intervention effect was detected. Thiazides were prescribed to 27.6 % of the patients who saw control physicians, 27.4 % for the insert, 26.8 % for the outsert and 28.3 % of the patients who saw insert + outsert physicians, p = 0.54., Conclusions: The study conclusively failed to demonstrate any impact of the printed educational messages on increasing prescribing of thiazide diuretics for first-line management of hypertension., Trial Registration: ISRCTN72772651.

Background: Researchers and funding agencies are increasingly showing interest in the application of research findings and focusing attention on engagement of knowledge-users in the research process as a means of increasing the uptake of research findings. The expectation is that research findings derived from these researcher-knowledge-user partnerships will be more readily applied when they became available. The objective of this study was to investigate the experiences, perceived barriers, successes, and opinions of researchers and knowledge-users funded under the Canadian Institutes of Health Research's integrated Knowledge Translation funding opportunities for a better understanding of these collaborations., Methods: Participants, both researchers and knowledge-users, completed an online survey followed by an individual semi-structured phone interview supporting a mixed methods study. The interviews were analyzed qualitatively using a modified grounded theory approach., Results: Survey analysis identified three major partnership types: token, asymmetric, and egalitarian. Interview analysis revealed trends in perceived barriers and successes directly related to the partnership formation and style. While all partnerships experienced barriers, token partnerships had the most challenges and general poor perception of partnerships. The majority of respondents found that common goals and equality in partnerships did not remove barriers but increased participants' ability to look for solutions., Conclusions: We learned of effective mechanisms and strategies used by researchers and knowledge-users for mitigating barriers when collaborating. Funders could take a larger role in helping facilitate, nurture, and sustain the partnerships to which they award grants.

Background: Theory-based process evaluations conducted alongside randomized controlled trials provide the opportunity to investigate hypothesized mechanisms of action of interventions, helping to build a cumulative knowledge base and to inform the interpretation of individual trial outcomes. Our objective was to identify the underlying causal mechanisms in a cluster randomized trial of the effectiveness of printed educational materials (PEMs) to increase referral for diabetic retinopathy screening. We hypothesized that the PEMs would increase physicians' intention to refer patients for retinal screening by strengthening their attitude and subjective norm, but not their perceived behavioral control., Methods: Design: A theory based process evaluation alongside the Ontario Printed Educational Material (OPEM) cluster randomized trial. Postal surveys based on the Theory of Planned Behavior were sent to a random sample of trial participants two months before and six months after they received the intervention. Setting: Family physicians in Ontario, Canada. Participants: 1,512 family physicians (252 per intervention group) from the OPEM trial were invited to participate, and 31.3% (473/1512) responded at time one and time two. The final sample comprised 437 family physicians fully completing questionnaires at both time points. Main Outcome Measures: Primary: behavioral intention related to referring patient for retinopathy screening; secondary: attitude, subjective norm, perceived behavioral control., Results: At baseline, family physicians reported positive intention, attitude, subjective norm, and perceived behavioral control to advise patients about retinopathy screening suggesting limited opportunities for improvement in these constructs. There were no significant differences on intention, attitude, subjective norm, and perceived behavioral control following the intervention. Respondents also reported additional physician- and patient-related factors perceived to influence whether patients received retinopathy screening., Conclusions: Lack of change in the primary and secondary theory-based outcomes provides an explanation for the lack of observed effect of the main OPEM trial. High baseline levels of intention to advise patients to attend retinopathy screening suggest that post-intentional and other factors may explain gaps in care. Process evaluations based on behavioral theory can provide replicable and generalizable insights to aid interpretation of randomized controlled trials of complex interventions to change health professional behavior., Trial Registration: ISRCTN72772651.

Objective: We synthesized the management and health literatures for insights into implementing evidence-based change in healthcare drawn from industry-specific data. Because change principles based on evidence often fail to be translated into organizational practice or policy, we sought studies at the nexus of organizational change and knowledge translation., Methods: We reviewed five top management journals to identify an initial pool of 3,091 studies, which yielded a final sample of 100 studies. Data were abstracted, verified by the original authors and revised before entry into a database. We employed a systematic narrative synthesis approach using words and text to distill data and explain relationships. We categorized studies by varying levels of relevance for knowledge translation as (1) primary, direct; (2) intermediate; and (3) secondary, indirect. We also identified recurring categories of change-related organizational factors. The current analysis examines these factors in studies of primary relevance to knowledge translation, which we also coded for intervention readiness to reflect how readily change can be implemented. Preliminary, Results and Conclusions: Results centred on five change-related categories: Tailoring the Intervention Message; Institutional Links/Social Networks; Training; Quality of Work Relationships; and Fit to Organization. In particular, networks across institutional and individual levels appeared as prominent pathways for changing healthcare organizations. Power dynamics, positive social relations and team structures also played key roles in implementing change and translating it into practice. We analyzed journals in which first authors of these studies typically publish, and found evidence that management and health sciences remain divided. Bridging these disciplines through research syntheses promises a wealth of evidence and insights, well worth mining in the search for change that works in healthcare transformation., (Copyright © 2012 Longwoods Publishing.)

Objective: To determine the frequency of unpublished systematic reviews (SRs) and explore factors contributing to their occurrence., Study Design and Setting: First or corresponding authors from a sample of SRs published in 2005 were asked to participate in a 26-item survey administered through the Internet, facsimile, and postal mail. Outcomes included median and range of published and unpublished SRs, and barriers, facilitators, and reasons for not publishing SRs. Descriptive analyses were performed., Results: 55.7% (348 of 625) of those invited participated, half of which were from Europe and 22.7% were from the United States. Participants reported 1,405 published (median: 2.0, range: 1-150) and 199 unpublished (median: 2.0, range: 1-33) SRs. Lack of time and lack of funding and organizational support were barriers, whereas time availability and self-motivation were facilitators to publishing reviews. For most recent unpublished SRs (n=52), the reasons for not publishing included lack of time (12 of 52, 23.0%), the manuscript being rejected (10 of 52, 19.0%), and operational issues (six of 52, 11.5%)., Conclusion: Unpublished SRs do exist. Lack of time, funding, and organizational support were consistent reasons for not publishing SRs. Statistical significance of SR results was not reported as being a major barrier or reason for not publishing. Further research on unpublished SRs is warranted.

As the recent collection of papers from the Quality Enhancement Research Initiative (QUERI) Series indicates, knowledge is leading to considerable action in the United States (U.S.) Department of Veterans Affairs (VA). The QUERI Series offers clinical researchers, implementation scientists, health systems, and health research funders from around the globe a unique window into the both the practice and science of implementation or knowledge translation (KT) in the VA. By describing successes and challenges as well as setbacks and disappointments, the QUERI Series is all the more useful. From the vantage point of Canadian KT researchers and officials at a national health research funding agency, we offer a number of observations and lessons that can be learned from QUERI. "Knowledge, if it does not determine action, is dead to us." Plotinus (Roman philosopher 205AD-270AD).

Background: A challenge for implementation researchers is to develop principles that could generate testable hypotheses that apply across a range of clinical contexts, thus leading to generalisability of findings. Such principles may be provided by systematically developed theories. The opportunity has arisen to test some of these theoretical principles in the Ontario Printed Educational Materials (OPEM) trial by conducting a sub-trial within the existing trial structure. OPEM is a large factorial cluster-randomised trial evaluating the effects of short directive and long discursive educational messages embedded into informed, an evidence-based newsletter produced in Canada by the Institute for Clinical Evaluative Sciences (ICES) and mailed to all primary care physicians in Ontario. The content of educational messages in the sub-trial will be constructed using both standard methods and methods inspired by psychological theory. The aim of this study is to test the effectiveness of the TheoRY-inspired MEssage ('TRY-ME') compared with the 'standard' message in changing prescribing behaviour., Methods: The OPEM trial participants randomised to receive the short directive message attached to the outside of informed (an 'outsert') will be sub-randomised to receive either a standard message or a message informed by the theory of planned behaviour (TPB) using a two (long insert or no insert) by three (theory-based outsert or standard outsert or no outsert) design. The messages will relate to prescription of thiazide diuretics as first line drug treatment for hypertension (described in the accompanying protocol, "The Ontario Printed Educational Materials trial"). The short messages will be developed independently by two research teams.The primary outcome is prescription of thiazide diuretics, measured by routinely collected data available within ICES. The study is designed to answer the question, is there any difference in guideline adherence (i.e., thiazide prescription rates) between physicians in the six groups? A process evaluation survey instrument based on the TPB will be administered pre- and post-intervention (described in the accompanying protocol, "Looking inside the black box"). The second research question concerns processes that may underlie observed differences in prescribing behaviour. We expect that effects of the messages on prescribing behaviour will be mediated through changes in physicians' cognitions.

A careful analysis of the definition of knowledge translation highlights the importance of the judicious translation of research into practice and policy. There is, however, a considerable gap between research and practice. Closing the research-to-practice gap involves changing clinical practice, a complex and challenging endeavor. There is increasing recognition that efforts to change practice should be guided by conceptual models or frameworks to better understand the process of change. The authors conducted a focused literature search, developed inclusion criteria to identify planned action theories, and then extracted data from each theory to determine the origins, examine the meaning, judge the logical consistency, and define the degree of generalizability, parsimony, and testability. An analysis was conducted of the concepts found in each theory, and a set of action categories was developed that form the phases of planned action. Thirty-one planned action theories were identified that formed the basis of the analyses. An Access database was created, as well as a KT Theories User's Guide that synthesizes all the planned change models and theories, identifies common elements of each, and provides information on their use. There are many planned change models and frameworks with many common elements and action categories. Whenever any planned change model is used, change agents should consider documenting their experiences with the model so as to advance understanding of how useful the model is and to provide information to others who are attempting a similar project.

The articles in this supplement illustrate the potential value of developing an international research agenda on the science of knowledge translation. Building on the suggestions made by the contributors to the supplement, we offer a number of topics for such an agenda.

A cross-sectional survey was conducted in order to describe the use of oral cobalamin among geriatricians, hematologists, and general practitioners, and to explore factors related to its use. The study population consisted of all geriatricians (n = 138) and hematologists (n = 317) listed in the Canadian Medical Directory plus a random sample of 307 general practitioners. The overall response rate was 40%. Intramuscular and oral cobalamin was prescribed by 76 and 32% of the respondents, respectively. Twenty seven percent reported using both oral and intramuscular cobalamin and 6% reported using only oral cobalamin. Only 25% of respondents indicated they were aware of a RCT demonstrating the efficacy of oral cobalamin prior to reading a synopsis of the study in the survey. After multivariate adjustment, only the belief that oral cobalamin was effective and certainty about who carried oral preparations remained independently associated with oral cobalamin use. Oral cobalamin has been shown to be an efficacious, cost efficient and safe method of treating cobalamin deficiency. Nonetheless, it is not used by the majority of physicians treating this condition. Strategies to promote the use of oral cobalamin should be directed at educating physicians of its efficacy and providing them with prescribing information on where it can be purchased.

There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about planned-action theories to be better able to understand and influence change in practice settings.

The Canadian Medical Association (CMA) maintains a database of clinical practice guidelines (CPGs) developed or endorsed by Canadian organizations. The study purpose was to describe how these guidelines were developed, disseminated and evaluated. A survey was mailed to the developer of each CPG registered in the CMA Infobase between June 1996 and December 1999. Data were received for 730 unique guidelines (response rate of 70%) developed by 75 organizations. Of these, 72% were developed by committees that had a formal process for selecting their members. The scientific literature was reviewed for all of the guidelines, a computerized search undertaken for 88% and the search strategy included 34% of CPG documents. An attempt was made to grade the quality of the evidence underpinning 54% of the guidelines. For most guidelines, consensus about values or judgements was reached by expert opinion through open discussion (78% of guidelines). The most common strategies used to disseminate the guidelines were direct mailing of guidelines to members of the developing organization (80% of all guidelines), publishing guidelines in newsletters/journals (76%), direct mailing to others (73%), electronic dissemination (62%), educational or continuing medical education activities (50%), and providing information about guidelines to patients/consumers (47%). Overall, 5% of the guidelines have been evaluated to determine their impact on health outcomes. During the 5-year study period (1994-99), the more recent guidelines were more likely to use multidisciplinary development panels, report the literature search strategies and grade the quality of the evidence. The CPG development process in Canada is becoming more rigorous and reproducible, but there is still considerable room for improvement. In addition to encouraging Canadian guideline developers to use more rigorous and transparent methods, considerably more attention must be focused on using and identifying effective and cost-effective strategies to promote and facilitate the uptake of guidelines by practitioners and to evaluate the impact of guidelines on patient outcomes.

Background: Decision aids prepare people to participate in preference-sensitive decisions., Objectives: 1. Create a comprehensive inventory of patient decision aids focused on healthcare options. 2. Review randomized controlled trials (RCT) of decision aids, for people facing healthcare decisions., Search Strategy: Studies were identified through databases and contact with researchers active in the field., Selection Criteria: Two independent reviewers screened abstracts for interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes. Information about the decision aids was compiled in an inventory; those that had been evaluated in a RCT were reviewed in detail., Data Collection and Analysis: Two reviewers independently extracted data using standardized forms. Results of RCTs were pooled using weighted mean differences (WMD) and relative risks (RR) using a random effects model., Main Results: Over 200 decision aids were identified. Of the 131 available decision aids, most are intended for use before counselling. Using the CREDIBLE criteria to evaluate the quality of the decision aids: a) most included potential harms and benefits, credentials of the developers, description of their development process, update policy, and were free of perceived conflict of interest; b) many included reference to relevant literature; c) few included a description of the level of uncertainty regarding the evidence; and d) few were evaluated. Thirty of these decision aids were evaluated in 34 RCTs and another trial evaluated a suite of eight decision aids. An additional 30 trials are yet to be published. Among the trials comparing decision aids to usual care, decision aids performed better in terms of: a) greater knowledge (WMD 19 out of 100, 95% CI: 13 to 24; b) more realistic expectations (RR 1.4, 95%CI: 1.1 to 1.9); c) lower decisional conflict related to feeling informed (WMD -9.1 of 100, 95%CI: -12 to -6); d) increased proportion of people active in decision making (RR 1.4, 95% CI: 1.0 to 2.3); and e) reduced proportion of people who remained undecided post intervention (RR 0.43, 95% CI: 0.3 to 0.7). When simpler were compared to more detailed decision aids, the relative improvement was significant in: a) knowledge (WMD 4 out of 100, 95% CI: 3 to 6); b) more realistic expectations (RR 1.5, 95% CI: 1.3 to 1.7); and c) greater agreement between values and choice. Decision aids appeared to do no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. Decision aids had a variable effect on which healthcare options were selected., Reviewer's Conclusions: The availability of decision aids is expanding with many on the Internet; however few have been evaluated. Trials indicate that decision aids improve knowledge and realistic expectations; enhance active participation in decision making; lower decisional conflict; decrease the proportion of people remaining undecided, and improve agreement between values and choice. The effects on persistence with chosen therapies and cost-effectiveness require further evaluation. Finally, optimal strategies for dissemination need to be explored.

Objective: To identify and describe the factors influencing the use and nonuse of blood-sparing methods such as preoperative autologous donation, acute normovolemic hemodilution, and the use of cell salvage devices, hemostatic agents and erythropoietin., Design: An interview survey., Setting: Eight Ontario hospitals., Method: Interviews were conducted with chiefs of surgery, orthopedics, cardiac surgery and anesthesia, and with heads of transfusion medicine and pharmacy. Hospitals were selected using the qualitative sampling strategy of maximum variation based on their use of the methods (as reported in a previous mail survey)., Results: Use of blood-sparing methods was influenced by diverse factors often operating simultaneously. These included the following: characteristics of the method (e.g., evidence of its effectiveness, ease of use, cost); perceptions and experiences of the potential adopters (experience with the method, perception of the current safety of allogeneic blood, perceived convenience or inconvenience of using the method); aspects of the practice setting (inability to move resources between hospital departments, presence of a local clinical champion); and the external environment (patient and public expectations, funding of the blood system, blood shortages)., Interpretation: More rational and evidence-based use of blood-sparing methods could be promoted by the adoption of an interdisciplinary, comprehensive, coordinated approach tailored to each patient's needs.

Objective: To compare the efficacy of a decision-making aid with an information document from the Society of Obstetricians and Gynaecologists of Canada (SOGC) with regard to decisions about hormone replacement therapy (HRT)., Design: Randomized clinical trial., Setting: Quebec city region., Participants: Menopausal Francophone women 45 to 69 years old., Interventions: Subjects were given a manual and an audiocassette describing a six-step approach to making a decision about HRT., Main Outcome Measures: Amount of anxiety over the decision (main outcome), general knowledge of the risks and benefits of HRT, personal expectations and values concerning these risks and benefits, and women's views on HRT., Results: Anxiety levels were significantly reduced in both groups, but the difference between the effectiveness of the two interventions was not significant (P = .77). Percentages of women whose general knowledge increased and of women with realistic expectations were significantly higher in the experimental group (P < .003 and P < .0001, respectively). Congruence between personal values and decisions about HRT increased significantly more in the experimental group (P < or = .003)., Conclusion: The six-step approach to decision making was more helpful than the SOGC's information document in increasing subjects' knowledge of the risks and benefits of HRT, in creating more realistic expectations of HRT, and in increasing the congruence between subjects' personal values and their decisions on HRT.

Background: The Canadian Medical Association maintains a national online database of clinical practice guidelines developed, endorsed or reviewed by Canadian organizations within 5 years of the current date. This study was designed to identify and describe guidelines in the database that make recommendations related to the use of drug therapy, and to assess their quality using a standardized guideline appraisal instrument., Methods: Drug therapy guidelines in the database were identified with the use of search terms and hand searching. Descriptive information about the developers, endorsement by other organizations, publication status, disease and drug focus was abstracted. Each guideline was independently assessed by 3 appraisers (a physician, a pharmacist and a methodologist) with the use of the Appraisal Instrument for Clinical Guidelines. Conditions were classified according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems., Results: We identified 217 drug therapy guidelines produced or reviewed from 1994 to 1998. Guideline developers included national organizations (47.0%), paragovernment organizations (39.6%) and professional associations (30.9%); 31.3% of the guidelines were published, and 10.6% stated drug company sponsorship. The most common conditions addressed by the guidelines were infections and parasitic diseases (39.6%), neoplasms (11.5%) and diseases of the circulatory system (11.5%). Drugs most commonly cited were anti-infective agents (42.9%), antiviral agents (15.2%) and cardiovascular drugs (16.1%). Eleven organizations produced 176 (81.1%) of the guidelines. In all, 14.7% of the guidelines met half or more of the 20 items assessing rigour of guideline development on the appraisal instrument (mean quality score 30.0% [95% confidence interval (CI) 27.5%-32.6%]), 61.8% met half or more of the 12 items assessing guideline context and content (mean score 57.0% [95% CI 54.6%-59.3%]), and none met half or more of the 5 items assessing guideline application (mean score 5.6% [95% CI 4.7%-6.5%]). Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. The quality of the guidelines assessed varied significantly by developer, publication status and drug company sponsorship. No substantial improvement in guideline quality was observed over the 5-year study period., Interpretation: Developers of Canadian drug therapy guidelines are producing guidelines that are often perceived to be clinically useful to physicians and pharmacists, although the methods (or the description of the methods) by which they are developed need to be more rigorous and thorough.

Objective: To describe the development and evaluation of a decision aid for long-term tube feeding in cognitively impaired older people., Design: Before-and-after study., Setting: Acute care hospitals in Ottawa, Canada., Participants: Substitute decision makers for 15 cognitively impaired inpatients 65 years and older being considered for placement of a percutaneous endoscopic gastrostomy tube., Measurements: Questionnaires were used to compare the substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to the decision aid. The acceptability of the decision aid was also assessed., Results: Substitute decision makers significantly increased their knowledge (P = .004) and decreased their decisional conflict (P = .004) regarding long-term tube feeding after using the decision aid. The impact of the decision aid on predisposition toward the intervention was greatest for those who were unsure of their preferences at baseline. All substitute decision makers found the decision aid helpful and acceptable despite very difficult and emotional circumstances., Conclusions: A decision aid improves the decision-making process for long-term tube feeding in cognitively impaired older patients by decreasing decisional conflict and by promoting decisions that are informed and consistent with personal values. There are particular challenges for developing and evaluating these tools in the context of end-of-life decisions.

Background: Decision aids are interventions designed to help people make specific and deliberative choices among options (including status quo) by providing (at a minimum) information on the options and outcomes relevant to a person's health status. A systematic review is needed to summarize what is known about their efficacy., Objectives: 1. To create an inventory of existing decision aids. 2. To conduct a systematic review of randomized controlled trials of decision aids aimed at improving people's decision making and outcomes., Search Strategy: The following electronic databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL, Aidsline, Cancerlit, the Cochrane Controlled Trials Register. In addition, individuals known to be active in the field of decision support were contacted., Selection Criteria: We screened titles and abstracts for all interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Information about the decision aids was compiled in an inventory and those evaluated in a randomized controlled trial were reviewed in detail., Data Collection and Analysis: Using Cochrane review methods, two reviewers independently screened and extracted data on several evaluation criteria. Results of randomized trials were pooled using weighted mean differences and relative risks with all data analysed using a random effects model., Main Results: Eighty-seven decision aids were identified. Twenty-three of them had been evaluated in 24 randomized controlled trials. Among the trials comparing decision aids to usual care interventions, decision aids performed better in terms of: a) greater knowledge of options in seven of seven studies (weighted mean difference (WMD = 19 out of 100, 95% confidence interval (CI): 13,25); b) more realistic expectations in two of three studies (RR=1.48 95%CI 1.02, 2.14); c) lower decisional conflict related to feeling informed in three of three studies (WMD = -9.0 of 100 95%CI: -15, -3); d) reducing the proportion of people who were passive in decision making in three of four studies (RR = 0.63, 95% CI: 0.5, 0.8). When simpler decision aids were compared to more detailed ones, the relative improvement was significant in: a) improved knowledge in two of seven studies (WMD = 4 out of 100, 95% CI: 2, 5); b) realistic expectations in two of two studies (relative risk (RR ranged from 1.5 95%CI: 1.3,1.8); and c) decisional conflict in one of two studies (WMD= -4 95% CI -8,-0.2). There was a consistent trend for decision aids to do no better than comparison interventions in affecting: satisfaction with the decision in five of six studies, satisfaction with the decision making process in four of five studies, and anxiety in four of five studies. Decision aids had a variable effect on which screening or treatment options were selected. Exposure to decision aids relative to controls resulted in a consistent non-significant trend toward reduced preference for major surgery over conservative options by 21 to 42 per cent in five of five studies; however, they had no impact on circumcision in two of two studies. For colon and prostate cancer screening choices, the results were inconsistent. Two studies have shown no impact on persistence with chosen option and few studies have shown significant benefits on general health outcomes (two of three studies), or disease-specific health outcomes (one of four studies)., Reviewer's Conclusions: The number of decision aids is expanding, but there is considerable overlap in some areas leaving gaps in others. Trials of decision aids indicate that they are superior to usual care interventions in improving knowledge and realistic expectations of the benefits and harms of options; reducing passivity in decision making; and lowering decisional conflict stemming from feeling uninformed. When simpler versions of decision aids are compared to more detailed aids, the differences in knowledge are marginal but there are other benefits in terms of creating realistic expectations and in reducing decisional conflict. To date, decision aids have had little effect on anxiety or satisfaction with the decision making process or satisfaction with the decision. Their effects on choices vary with the decision. The effects on persistence with chosen therapies and health outcomes require further evaluation. The essential elements in decision aids for different groups and different types of decisions need to be established. Consensus needs to be reached regarding standards for developing and evaluating decision aids.

Objective: To identify and compare clinical practice guideline appraisal instruments., Methods: Appraisal instruments, defined as instruments intended to be used for guideline evaluation, were identified by searching MEDLINE (1966-99) using the Medical Subject Heading (MeSH) practice guidelines, reviewing bibliographies of the retrieved articles, and contacting authors of guideline appraisal instruments. Two reviewers independently examined the questions/statements from all the instruments and thematically grouped them. The 44 groupings were collapsed into 10 guideline attributes. Using the items, two reviewers independently undertook a content analysis of the instruments., Results: Fifteen instruments were identified, and two were excluded because they were not focused on evaluation. All instruments were developed after 1992 and contained 8 to 142 questions/statements. Of the 44 items used for the content analysis, the number of items covered by each instrument ranged from 6 to 34. Only the instrument by Cluzeau and colleagues included at least one item for each of the 10 attributes, and it addressed 28 of the 44 items. This instrument and that of Shaneyfelt et al. are the only instruments that have so far been validated., Conclusions: A comprehensive, concise, and valid instrument could help users systematically judge the quality and utility of clinical practice guidelines. The current instruments vary widely in length and comprehensiveness. There is insufficient evidence to support the exclusive use of any one instrument, although the Cluzeau instrument has received the greatest evaluation. More research is required on the reliability and validity of existing guideline appraisal instruments before any one instrument can become widely adopted.