Daniel J. Niven

BACKGROUND: Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. METHODS: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. RESULTS: From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. CONCLUSIONS: This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.

BACKGROUND: Application of knowledge translation (KT) theories, models, and frameworks (TMFs) is one method for successfully incorporating evidence into clinical care. However, there are multiple KT TMFs and little guidance on which to select. This study sought to identify and describe available full-spectrum KT TMFs to subsequently guide users. METHODS: A scoping review was completed. Articles were identified through searches within electronic databases, previous reviews, grey literature, and consultation with KT experts. Search terms included combinations of KT terms and theory-related terms. Included citations had to describe full-spectrum KT TMFs that had been applied or tested. Titles/abstracts and full-text articles were screened independently by two investigators. Each KT TMF was described by its characteristics including name, context, key components, how it was used, primary target audience, levels of use, and study outcomes. Each KT TMF was also categorized into theoretical approaches as process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. Within each category, KT TMFs were compared and contrasted to identify similarities and unique characteristics. RESULTS: Electronic searches yielded 7160 citations. Additional citations were identified from previous reviews (n = 41) and bibliographies of included full-text articles (n = 6). Thirty-six citations describing 36 full-spectrum were identified. In 24 KT TMFs, the primary target audience was multi-level including patients/public, professionals, organizational, and financial/regulatory. The majority of the KT TMFs were used within public health, followed by research (organizational, translation, health), or in multiple contexts. Twenty-six could be used at the individual, organization, or policy levels, five at the individual/organization levels, three at the individual level only, and two at the organizational/policy level. Categorization of the KT TMFs resulted in 18 process models, eight classic theories, three determinant frameworks, three evaluation frameworks, and four that fit more than one category. There were no KT TMFs that fit the implementation theory category. Within each category, similarities and unique characteristics emerged through comparison. CONCLUSIONS: A systematic compilation of existing full-spectrum KT TMFs, categorization into different approaches, and comparison has been provided in a user-friendly way. This list provides options for users to select from when designing KT projects and interventions. TRIAL REGISTRATION: A protocol outlining the methodology of this scoping review was developed and registered with PROSPERO (CRD42018088564).

Letters5 July 2016Accuracy of Peripheral Thermometers for Estimating TemperatureDaniel J. Niven, MD, MSc, PhD, Kevin B. Laupland, MD, MSc, and Henry Thomas Stelfox, MD, PhDDaniel J. Niven, MD, MSc, PhDFrom University of Calgary, Calgary, Alberta, Canada, and Royal Inland Hospital, Kamloops, British Columbia, Canada., Kevin B. Laupland, MD, MScFrom University of Calgary, Calgary, Alberta, Canada, and Royal Inland Hospital, Kamloops, British Columbia, Canada., and Henry Thomas Stelfox, MD, PhDFrom University of Calgary, Calgary, Alberta, Canada, and Royal Inland Hospital, Kamloops, British Columbia, Canada.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L16-0069 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:Dr. Bonzi and colleagues raise 2 questions about our meta-analysis examining the accuracy of peripheral thermometers. A fundamentally important concern is the effect of interstudy heterogeneity on the clinical applicability of our pooled analyses. Although this heterogeneity was the main limitation of our meta-analysis, we believe that our pooled analyses remain clinically applicable.First, data were pooled across all studies, because our main objective was to describe peripheral thermometer accuracy. Second, we recognize that clinicians caring for different populations of patients benefit from data specific to a population or thermometer; therefore, we conducted prespecified subgroup analyses to examine ...References1. Leeflang MM, Deeks JJ, Gatsonis C, Bossuyt PM; Cochrane Diagnostic Test Accuracy Working Group.. Systematic reviews of diagnostic test accuracy. Ann Intern Med. 2008;149:889-97. [PMID: 19075208] LinkGoogle Scholar2. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209-15. [PMID: 8606715] CrossrefMedlineGoogle Scholar3. Young PJ, Saxena M, Beasley R, Bellomo R, Bailey M, Pilcher D, et al. Early peak temperature and mortality in critically ill patients with or without infection. Intensive Care Med. 2012. [PMID: 22290072] CrossrefMedlineGoogle Scholar4. Saxena M, Young P, Pilcher D, Bailey M, Harrison D, Bellomo R, et al. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection. Intensive Care Med. 2015;41:823-32. [PMID: 25643903] doi:10.1007/s00134-015-3676-6 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From University of Calgary, Calgary, Alberta, Canada, and Royal Inland Hospital, Kamloops, British Columbia, Canada.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-1150. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAccuracy of Peripheral Thermometers for Estimating Temperature Daniel J. Niven , Jonathan E. Gaudet , Kevin B. Laupland , Kelly J. Mrklas , Derek J. Roberts , and Henry Thomas Stelfox Accuracy of Peripheral Thermometers for Estimating Temperature Mattia Bonzi , Elisa Maria Fiorelli , Monica Solbiati , Nicola Montano , and Metrics Cited byPediatric Vital Sign Distribution Derived From a Multi-Centered Emergency Department Database 5 July 2016Volume 165, Issue 1Page: 73-74KeywordsBrainFactor analysisFeversHypothermiaPatientsPopulation statisticsRandomized trialsSafetyTemperatureThermometers ePublished: 5 July 2016 Issue Published: 5 July 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

INTRODUCTION: Engaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown. METHODS: We tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis. RESULTS: Participants described three phases in the patient/family "ICU journey"; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient's voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These "ICU journey" experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes. CONCLUSIONS: Patient and family member-led research is feasible and can identify opportunities for improving care.

Importance: The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown. Objective: To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. Design, Setting, and Participants: Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics. Exposures: Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. Main Outcomes and Measures: The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. Results: Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). Conclusions and Relevance: The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.