Abstract
Objective To present the results of a pilot study of an innovative methodology for translating best evidence about spinal cord injury (SCI) for family practice.
Design Review of Canadian and international peer-reviewed literature to develop SCI Actionable Nuggets, and a mixed qualitative-quantitative evaluation to determine Nuggets’ effect on physician knowledge of and attitudes toward patients with SCI, as well as practice accessibility.
Setting Ontario, Newfoundland, and Australia.
Participants Forty-nine primary care physicians.
Methods Twenty Actionable Nuggets (pertaining to key health issues associated with long-term SCI) were developed. Nugget postcards were mailed weekly for 20 weeks to participating physicians. Prior knowledge of SCI was self-rated by participants; they also completed an online posttest to assess the information they gained from the Nugget postcards. Participants’ opinions about practice accessibility and accommodations for patients with SCI, as well as the acceptability and usefulness of Nuggets, were assessed in interviews.
Main findings With Actionable Nuggets, participants’ knowledge of the health needs of patients with SCI improved, as knowledge increased from a self-rating of fair (58%) to very good (75%) based on posttest quiz results. The mean overall score for accessibility and accommodations in physicians’ practices was 72%. Participants’ awareness of the need for screening and disease prevention among this population also increased. The usefulness and acceptability of SCI Nugget postcards were rated as excellent.
Conclusion Actionable Nuggets are a knowledge translation tool designed to provide family physicians with concise, practical information about the most prevalent and pressing primary care needs of patients with SCI. This evidence-based resource has been shown to be an excellent fit with information consumption processes in primary care. They were updated and adapted for distribution by the Canadian Medical Association to approximately 50 000 primary care physicians in Canada, in both English and French.
When one of the more than 40 000 Canadians living in the community with a spinal cord injury (SCI) faces a health problem, the first line of defence is usually the family physician.1–3 However, the literature suggests that family physicians feel ill-equipped to deal with issues relating to SCI and the disability resulting from it.4–18 Patients with SCI constitute a small percentage of the typical family medicine case load. As the prevalence of SCI is approximately 1.2 per 1000 population, the average family practice would have only 1 or 2 patients with SCI at a time.19–24
Although people with SCI use more health, family medicine, and specialist services than their contemporaries without disabilities do, they report that many of their needs are unmet, particularly for information and preventive health care.25–27 These patients are among the 5% to 6% of the typical family medicine case load with multiple complex chronic conditions who consume about one-third of the practice’s resources and who require multidisciplinary care.28,29 There is good evidence for the effectiveness of a comprehensive annual health examination for patients with SCI in primary care.3 Most of the issues raised in primary care relate to secondary complications of SCI, such as bowel or bladder dysfunction and pain. There are also many general health issues that require attention in this population, such as bone density, depression, and sexual and reproductive issues.3,26
In order to be able to provide optimal care to patients with SCI, family physicians need access to the best quality evidence available in a manner that is compatible with practice constraints and demands. The literature shows that family physicians have distinct preferences for information that provides incentives for learning (eg, continuing medical education credits) and that is focused, practical, action oriented, multifaceted, and credible through affiliation with opinion leaders.30 The purpose of this study was to design and pilot-test an innovative methodology for translating the latest and best evidence about SCI for family physicians to use in practice.
METHODS
Development
The study involved the development of Actionable Nuggets—postcards pertaining to key health issues associated with long-term SCI. The intervention was designed so that 1 postcard would arrive weekly for 20 weeks at the offices of participating family physicians (Figure 1), thus providing needed information for optimal evidence-based care for patients with SCI, while at the same time raising awareness of the issues these patients face.
Sample of an Actionable Nugget: A) Front page, B) back page.
The development of Nuggets began with a scoping review of long-term health issues among people with SCI.31,32 The literature review was conducted by an experienced librarian who used the following key words: spinal cord injury, paraplegia, quadriplegia, tetraplegia; primary care, primary health care, family physician, family practice; long-term health, aging, health outcomes, health promotion, disease prevention, chronic disease management, long-term care, secondary complications; and evidence-based practice, best practice, clinical guidelines, and care guidelines. Peer-reviewed journals were searched for the years 2000 to 2012 using CINAHL, MEDLINE, EMBASE, and the Cochrane Collaboration. In addition, the CMAJ and Canadian Family Physician were searched manually for any articles pertaining to secondary complications and long-term health issues associated with SCI, as well as best practice guidelines for any health issues associated with SCI (eg, urinary tract infection, chronic pain, bowel management). The search was concluded by hand searching through the reference lists of the final set of included references.
The initial search resulted in 4443 citations. Abstracts for all of these citations were reviewed by the staff epidemiologist (G.B.) and at least 1 investigator, and studies were selected for further analysis if they were available in English or French, focused on SCI, and specifically identified patients with SCI as part of the sample. Investigators were assigned to topics based on their expertise. After exclusion of 1658 duplicates, the data set was reduced to 2785 articles. At least 2 investigators scanned the full articles and further excluded 2124 articles because they did not focus on primary care (1358) or they did not explicitly provide data on individuals with SCI (766). No methodologic limitations were applied in order to ensure optimal coverage of the literature.
The remaining 661 articles were reviewed in detail and sorted into 11 key topics that represented either common or urgent health concerns of people with SCI. There is considerable consensus in the literature that these are the key issues for primary care3: pain, bladder management, bowel management, skin care, sexual and reproductive health, autonomic dysreflexia, cardiovascular disease, physical activity, depression or suicide, epidemiology, and office accessibility. Based on a thorough review of the pertinent literature associated with each topic, 20 Actionable Nuggets were drafted by the investigators and the staff epidemiologist. Multiple Nuggets were required for some topics; for example, the topic of pain resulted in 3 Nuggets: neuropathic pain versus musculoskeletal pain, pharmacologic management of pain, and chronic upper extremity pain. Nuggets were designed to address specific knowledge translation guidelines developed in previous research.33 Standard levels of evidence were used to evaluate the data, but rigid criteria were not used to exclude information from consideration at subsequent steps.
Draft Nuggets were reviewed in detail by an expert panel made up of family physicians, rehabilitation specialists, epidemiologists, and knowledge translation specialists. The expert panel considered levels of evidence, practicality in primary care, application in various primary care settings, and supports needed for implementation. Based on the expert panel’s consensus recommendations, the Nuggets were revised and reviewed again. Each Nugget had to be approved by all 9 members of the expert panel before it was finalized. Each Actionable Nugget includes the following:
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a statement of a common problem that brings a person with SCI to see his or her family physician;
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a recommendation for action on the part of a family physician (ie, the Actionable Nugget itself);
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a description of evidence-based best practice in primary care in the area;
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a reproduced-with-permission statement, if applicable (eg, when a particular assessment or tool is mentioned and is required for application of the Nugget, this is reproduced with permission of the original authors);
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a key reference, which often forms the basis for the action recommendation;
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a link to the Actionable Nuggets website, www.actionnuggets.ca, where additional reference material can be found;
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the copyright date for each Nugget, so subscribers can judge how current the information on the Nugget is; and
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the Actionable Nuggets trademarked logo, artwork, and design.
Pilot study
Design
A mixed qualitative-quantitative pilot test was conducted to evaluate the usefulness and acceptability of the SCI Nuggets with a sample of family physicians. Nuggets were disseminated weekly to participating physicians, over a period of 20 weeks. Within 1 month following dissemination, physicians were contacted for data collection.
Sample
The pilot study engaged 49 primary care physicians from 3 research networks (the Atlantic Practice Based Research Network of Memorial University of Newfoundland in St John’s; the Network for Studies in Primary Care of Queen’s University in Kingston, Ont; and the Rural Clinical School Network of the University of New South Wales in Australia). Postcards were sent to network members (N = 430) to identify eligible physicians who had at least 1 person with SCI in their practices; had been in practice at least 1 year; and had been the primary care physician for the designated patient for at least 1 year.
Data collection
Data were collected from participants approximately 1 month following completion of the series of 20 Actionable Nuggets. Qualitative and quantitative data were collected regarding participants’ knowledge of and attitudes toward patients with SCI, participants’ changes in practices, and participants’ opinions about the usefulness and acceptability of the Nuggets. (Further information about measures and detailed findings can be found at www.actionnuggets.ca.)
Knowledge: Participants’ knowledge of SCI was assessed using a multiple-choice quiz designed specifically to test information gained from the Nuggets. The quiz was taken online and submitted electronically via the Nuggets website. The quiz consisted of 1 question for each of the 20 Nuggets, for a total of 20 questions. Physician participants also rated the importance and their prior knowledge of the issues that patients with SCI must face. (For a copy of this quiz, contact the corresponding author, M.A.M.)
Attitudes: Participants’ attitudes toward patients with disabilities were assessed in debriefing interviews. Their willingness to accommodate these patients or give them special consideration was assessed. These indicators are more robust than standardized measures of attitudes toward patients with disabilities, which are highly subject to social desirability bias, especially among well-educated samples.33
Practice accessibility: Practices to enhance access for patients with SCI were also assessed in the interviews, using the Primary Care Accessibility Assessment. This instrument has excellent psychometric properties, as well as a high degree of practice acceptance.30
Acceptability and usefulness: Acceptability and usefulness of Nuggets were also assessed in the debriefing interviews, seeking feedback, suggestions, and observations for revision of the Nuggets.
Data analysis. Analysis of quantitative data was conducted with SPSS, version 19.0, and consisted primarily of computation of scores and averages. Qualitative data were analyzed using NVivo software to conduct descriptive content analysis of the transcripts of the debriefing interviews, to identify general themes in the physician comments, and to collect specific suggestions for improvements.
Ethical review was conducted and approval was granted by the 3 university research ethics boards.
FINDINGS
Of the 430 research network members, 28% (n = 122) responded to the initial postcard indicating eligibility. Practice leaders from each network followed up with eligible physicians and were successful in recruiting 49 (40%) to the study. Table 1 provides descriptive information about the physicians who participated in the study and their practices.
Description of participating physicians: N = 49.
Knowledge
Table 234 shows the mean scores of participants’ pretest and posttest knowledge of key issues associated with long-term SCI care. The mean (SD) score for prior knowledge was 58% (3%). Physicians believed they were most knowledgeable in the areas of depression, cardiovascular disease, and pain. Physicians believed they were least knowledgeable about SCI-specific issues such as autonomic dysreflexia, office accessibility, skin breakdowns, and sexual and reproductive health.
Physicians’ mean rating of the importance of key issues associated with SCI and their mean pretest and posttest knowledge of the key issues: Mean (SD) overall score for pretest knowledge was 58% (3%) and mean (SD) overall score for posttest knowledge was 75% (4%).
The mean (SD) score following review of the Nuggets was 75% (4%). Physicians were most successful on questions about bowel function assessment and management, treatment of skin breakdown, neuropathic pain, physical activity, and the demographic profile of SCI. Physicians performed least well on items relating to screening for colorectal cancer, sexual function, prevalence of pain with SCI, and cardiovascular disease prevention.
Attitudes
The mean (SD) overall score for accessibility of practices was 72% (15%) (Table 3).34 Practices were least likely to be accessible in the following 5 areas: staff being familiar with procedures for assisting disabled patients (55%); having handrails in halls and stairways (52%); providing information products in accessible formats (42%); having adjustable examination tables (26%); and having lifts or hoists to assist with transfers (9%). Several participants referred specifically to increased awareness and sensitivity to the need for screening and disease prevention. The mean (SD) overall score for accommodations for patients with SCI was 79% (5%). A remarkable 96% stated that they would make home visits for their patients with SCI.
Accessibility and accommodations in practice: Mean (SD) overall score for accessibility in practices was 72% (15%) and mean overall score for physician accommodations was 79% (5%).
Practice accessibility
After receiving the Actionable Nuggets, participants were asked about changes they made in their practices. Fifty-three percent of physicians stated that they had made changes. “I used the cards [Actionable Nuggets] to organize a template for SCI clinic encounters, to help me give comprehensive care, and to ensure evidence-based preventative care.”
When asked if they had had a chance to apply any of the information from the Nuggets, 75% of participants said that they had. In particular, participants had improved their care of bladder function, upper extremity pain, autonomic dysreflexia, sexual health, and bowel care. Many of the changes made were in areas in which specific practice tools were provided. Several participants noted that they were making changes to make their practices more accessible. “I did an accessibility audit of my practice [using the tool provided on the card], and asked my SCI patients whether they thought any changes were necessary.”
Thirty-three percent of participants indicated that they had made a referral as a direct result of the Nuggets, specifically to urologists (26%), occupational therapists (13%), physiatrists or physical medicine specialists (7%), physiotherapists (7%), and dietitians (7%).
Usefulness and acceptability
We also asked participants for their opinions about the usefulness and acceptability of SCI Nuggets as a method of knowledge translation for primary care. To measure usefulness, we asked participants how many of the postcards they had actually read. Of the 20 Nugget postcards, participants read a mean (SD) of 16 (6.6) Nuggets. Two-thirds (65%) of participants said they reviewed all 20 Nuggets; 77% reviewed at least 15. The primary reason physicians offered for not reviewing the cards was time constraints. Also, 1 physician volunteered that he or she did not read cards that covered topics that were already familiar.
Based on 7 criteria derived from the literature for excellence in knowledge translation, participants were asked to rate the Nuggets from 1 (poor; not helpful) through 5 (excellent). The mean (SD) score for SCI Nugget usefulness was 4.7 (0.9) or 86% (Table 4). Participants rated the cards in the excellent range in all categories, with particularly high scores for professionalism, appearance, and content.
Acceptability and usefulness of Actionable Nuggets: Overall mean (SD) score for the acceptability and usefulness of Nuggets was 4.7 (0.9).
We also offered participating physicians access to the website www.actionnuggets.ca, which included the references used to develop each Nugget (typically 20 to 40 references per Nugget) and details about the development of Nuggets. Results showed that only 38% of participants visited the website, typically 2 to 4 times throughout the 20 weeks of the study. There appeared to be an effect of years in practice on tendency to visit the website. Those who visited the website only once were in practice for an average of 5.5 years, whereas those who visited the website 2 to 4 times were in practice for an average of 21.5 years, and the 1 participating physician who visited more than 5 times had been in practice for 31 years.
DISCUSSION
This study addressed the need for specialized knowledge about subpopulations within primary care that have very low prevalence in the typical family practice. Actionable Nuggets are a knowledge translation tool designed to provide family physicians with concise, practical information about the most prevalent and pressing primary care needs of patients with SCI. This evidence-based resource has been shown to be an excellent fit with information consumption processes in primary care.30 In particular, pilot study participants were responsive to the opportunity for continuing education credits and physician thought leadership.
Quantitative results showed that overall knowledge about the special health needs of patients with SCI in family practice went from fair (self-evaluation of 58%) to very good (mean test score of 75%). This finding is compatible with literature suggesting that family physicians are aware of their shortcomings with regard to this highly specialized population.3,16,27 The improvement in knowledge is somewhat disappointing, given that the knowledge quiz was in effect an open-book test; that is, participants could complete it on their own time with resources at their disposal. As with many knowledge translation initiatives, there is no guarantee that transmitting the information ensures that it is received; however, uptake was monitored by self-report at posttest. Of greatest concern are those issues peculiar to SCI that have considerable consequences for health and quality of life, but where knowledge is not what it should be, such as for issues like autonomic dysreflexia, syringomyelia, and wheelchair or disability considerations.
With regard to attitudes, the findings in this pilot study were consistent with previous research.27 Family physicians were willing to make accommodations and improve access; recognized that many patients with SCI require additional time and consideration, special equipment, longer visits, and possibly home visits; and were aware that they required specialized knowledge to care for patients with SCI. As in our previous research,27 primary care settings tended not to be equipped with adjustable examining tables and lifts to permit patients using wheelchairs to transfer and be properly examined. Subsequent research has shown that primary care practices are responsive to incentives to increase access, such as cost-sharing and legislative requirements.35
Participating physicians volunteered that they had substantially improved their awareness of their SCI patients and the issues such patients face. Several participants also indicated that they were sensitized to the need for access and redesign of aspects of their practices to accommodate patients with SCI and other mobility impairments. Further, several participants noted improved attention to prevention and referrals to appropriate specialists.
The usefulness and acceptability of SCI Nuggets were rated by participants as excellent. There was a strong preference for the hard-copy postcards with e-mail prompts. Several interesting suggestions emerged regarding alternative applications, CD backup, and review article summaries. Although the website was viewed as essential for background information, it was used very little, and consulted by less than half of the participants. Participants might thus have been largely unaware of the standards of evidence or process for development of Nuggets. The slightly lower score for scientific rigour reflects this lack of knowledge about the standards for evidence described on the website. On several occasions, the expert panel discussed including levels of evidence on the cards themselves but decided against it, as this would have considerably affected one of the most attractive features of Nuggets: their brevity. Instead, physicians interested in a higher degree of methodologic scrutiny were invited to avail themselves of additional information on the website.
Limitations
Several limitations bear on the generalizability of these findings. First, this was a pilot study, with the explicit aim of developing and pilot-testing a novel knowledge translation vehicle for family physicians. The intervention in the pilot study cannot be considered causal, as appropriate controls were not implemented. Participants in the pilot study were volunteers from 3 primary care research networks who had at least 1 patient with SCI at the time of the study. This was a highly purposive sample and might not be representative of all family physicians. However, we do think that they are ideally positioned to provide expert opinions on the pilot study.
Another caveat is the specification that Nuggets are designed specifically for Canadian family physicians. The expert panel reflected this goal and did not include a variety of possible stakeholders and views, including the consumer perspective. Plans are under way to develop a companion product for consumers to assist them with interacting more effectively with their family physicians on important health issues.
A final limitation inherent in the Actionable Nuggets format is the inability to feature detailed information about levels of evidence on the postcards themselves. For those who wished to follow up on methodologic details of individual studies, users were invited to avail themselves of the additional information found on the website. The cards were designed to summarize multiple studies on a given topic and be easily and readily used in family practice.
Conclusion
Based on the findings of the pilot study, it appears that Nuggets are a useful method of translating knowledge about the special health care needs of persons with SCI to family physicians. The relevant information is presented in a manner that is useful and memorable so it can be incorporated easily into daily practice. Actionable Nuggets for SCI were accredited by the College of Family Physicians of Canada for continuing education credits. They were distributed in English and French via the Canadian Medical Association’s e-learning portal for 1 year (2013–2014), and are currently available to Canadian Medical Association members through the website www.actionnuggets.ca.
Acknowledgments
Funding for this project was provided by the Rick Hansen Institute.
Notes
EDITOR’S KEY POINTS
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Actionable Nuggets are a useful method of translating knowledge about the special health care needs of people with spinal cord injury (SCI) for family physicians. The relevant information is presented in a manner that is useful and memorable so it can be incorporated easily into daily practice.
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Fifty-three percent of participants stated that they had made changes to their practices after receiving Actionable Nuggets; 75% said that they had had opportunities to apply information from Nuggets in practice. In particular, participants had improved their care of bladder function, upper extremity pain, autonomic dysreflexia, sexual health, and bowel care.
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Family physicians were willing to make accommodations and improve access for patients with SCI; recognized that many patients with SCI require additional time and consideration, special equipment, longer visits, and possibly home visits; and were aware they required specialized knowledge to care for patients with SCI.
POINTS DE REPÈRE DU RÉDACTEUR
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L’utilisation des pépites de savoir représente un mode de transmission des connaissances avantageux pour le médecin de famille qui traite des personnes atteintes de lésions de la moelle épinière (LME). L’information pertinente y est présentée d’une façon utile et facilement mémorisable de sorte qu’elle puisse aisément être incorporée à la pratique quotidienne.
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Cinquante-trois pour cent des participants ont déclaré qu’ils avaient apporté des changements à leur pratique après avoir reçu ces pépites de savoir; 75 % ont dit avoir eu l’occasion d’utiliser les informations qu’ils contiennent dans leur pratique. Les participants avaient notamment amélioré leur façon de traiter la fonction vésicale, les douleurs des membres supérieurs, la dysréflexie, la santé sexuelle et l’activité intestinale.
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Les médecins de famille étaient disposés à faire des accommodements et à être plus accessibles aux patients souffrant de LME; ils étaient conscients qu’ils avaient souvent besoin de plus de temps et de considération, qu’ils nécessitaient des équipements spéciaux, des consultations plus longues et, éventuellement, des visites à domicile; ils étaient également conscients d’avoir besoin de certaines connaissances pour traiter ces patients.
Footnotes
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This article has been peer reviewed.
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Cet article fait l’objet d’une révision par des pairs.
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Contributors
All authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
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Competing interests
None declared
- Copyright© the College of Family Physicians of Canada
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