Anna MacLellan

OBJECTIVES: To identify nonmedical factors perceived by family physicians (FPs) and consultants as important influences on decisions about referral for consultation, to determine the relative frequency with which such factors are cited and to identify those factors ranked as most important by the FPs and consultants. DESIGN: Survey with semistructured interview between July 1989 and April 1990. PARTICIPANTS: A total of 41 FPs and 20 consultants who were practising or had practised previously in Nova Scotia. INTERVENTIONS: The questionnaire comprised 10 questions: 4 were nondirective "probes" designed to elicit responses without suggesting possible answers, 2 asked the participants to rank such responses in order of importance, and 4 were "prompts" that asked for comments about a list of factors based on a review of the literature. RESULTS: A total of 4845 discrete items were mentioned as being capable of influencing FPs' decisions about referral for consultation. Aggregation of related items resulted in a list of 35 nonmedical factors, of which 11 were identified by at least half the respondents and 14 by less than half but more than 10. These 25 factors fell into three categories: patient and family factors (e.g., patient's wishes), FP and consultant factors (e.g., FP's capabilities), and other influences (e.g., style of practice). On the basis of both frequency of identification and priority scores "patient's wishes" emerged as the most important factor. Two medical factors that were consistently cited--type of problem and age of patient--were thought to interact with the other factors. CONCLUSION: Certain nonmedical considerations may substantially affect physicians' referral practices.

BACKGROUND: Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI. METHODS & RESULTS: Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains. CONCLUSION: Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

OBJECTIVE: To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion. SETTING: Community. PARTICIPANTS: Family physicians in community practice (n = 21 at 5 clinics). DESIGN: Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits. MAIN MEASURES: The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements. RESULTS: Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change. CONCLUSIONS: Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention.

< 0.001) by 24 months post baseline, suggesting that this negative effect on resilience diminished over time.