Anesthesiologists' and surgeons' perceptions about routine pre-operative testing in low-risk patients: application of the Theoretical Domains Framework (TDF) to identify factors that influence physicians' decisions to order pre-operative tests

ABSTRACT: BACKGROUND: Routine pre-operative tests for anesthesia management are often ordered by bothanesthesiologists and surgeons for healthy patients undergoing low-risk surgery. TheTheoretical Domains Framework (TDF) was developed to investigate determinants ofbehaviour and identify potential behaviour change interventions. In this study, the TDF is used to explore anaesthesiologists' and surgeons' perceptions of ordering routine tests forhealthy patients undergoing low-risk surgery. METHODS: Sixteen clinicians (eleven anesthesiologists and five surgeons) throughout Ontario wererecruited. An interview guide based on the TDF was developed to identify beliefs about preoperativetesting practices. Content analysis of physicians' statements into the relevanttheoretical domains was performed. Specific beliefs were identified by grouping similarutterances of the interview participants. Relevant domains were identified by noting thefrequencies of the beliefs reported, presence of conflicting beliefs, and perceived influence onthe performance of the behaviour under investigation. RESULTS: Seven of the twelve domains were identified as likely relevant to changing clinicians'behaviour about pre-operative test ordering for anesthesia management. Key beliefs wereidentified within these domains including: conflicting comments about who was responsiblefor the test-ordering (Social/professional role and identity); inability to cancel tests orderedby fellow physicians (Beliefs about capabilities and social influences); and the problem withtests being completed before the anesthesiologists see the patient (Beliefs about capabilitiesand Environmental context and resources). Often, tests were ordered by an anesthesiologistbased on who may be the attending anesthesiologist on the day of surgery while surgeonsordered tests they thought anesthesiologists may need (Social influences). There were alsoconflicting comments about the potential consequences associated with reducing testing,from negative (delay or cancel patients' surgeries), to indifference (little or no change inpatient outcomes), to positive (save money, avoid unnecessary investigations) (Beliefs aboutconsequences). Further, while most agreed that they are motivated to reduce orderingunnecessary tests (Motivation and goals), there was still a report of a gap between theirmotivation and practice (Behavioural regulation). CONCLUSION: We identified key factors that anesthesiologists and surgeons believe influence whether theyorder pre-operative tests routinely for anesthesia management for a healthy adults undergoinglow-risk surgery. These beliefs identify potential individual, team, and organisation targetsfor behaviour change interventions to reduce unnecessary routine test ordering.     

Managing low back pain--a comparison of the beliefs and behaviors of family physicians and chiropractors.

Random samples of 605 family physicians and 299 chiropractors in Washington were surveyed to determine their beliefs about back pain and how they would respond to three hypothetic patients with back pain. With 79% of the family physicians and 70% of the chiropractors responding, family physicians and chiropractors differed greatly not only in their technical approaches to back pain--such as drug therapy versus spinal manipulation--but also in their underlying beliefs and attitudes. Family physicians think that most back pain is caused by muscle strain, that lumbosacral radiographs are rarely useful, that appropriate therapy does not depend on a precise diagnosis, and that back pain will usually resolve within a few weeks without professional help. Family physicians were more likely than chiropractors to feel frustrated by patients with back pain, less likely to think they can help patients prevent future episodes of back pain, and less confident that their patients are satisfied with their care. Studies are needed to determine whether the different perspectives of family physicians and chiropractors are associated with differences in the costs and outcomes of care.     

Learning curves, taking instructions, and patient safety: using a theoretical domains framework in an interview study to investigate prescribing errors among trainee doctors

ABSTRACT: BACKGROUND: Prescribing errors are a major source of morbidity and mortality and represent a significant patient safety concern. Evidence suggests that trainee doctors are responsible for most prescribing errors. Understanding the factors that influence prescribing behavior may lead to effective interventions to reduce errors. Existing investigations of prescribing errors have been based on Human Error Theory but not on other relevant behavioral theories. The aim of this study was to apply a broad theory-based approach using the Theoretical Domains Framework (TDF) to investigate prescribing in the hospital context among a sample of trainee doctors. METHOD: Semistructured interviews, based on 12 theoretical domains, were conducted with 22 trainee doctors to explore views, opinions, and experiences of prescribing and prescribing errors. Content analysis was conducted, followed by applying relevance criteria and a novel stage of critical appraisal, to identify which theoretical domains could be targeted in interventions to improve prescribing. RESULTS: Seven theoretical domains met the criteria of relevance: "social professional role and identity," "environmental context and resources," "social influences," "knowledge," "skills," "memory, attention, and decision making," and "behavioral regulation." From critical appraisal of the interview data, "beliefs about consequences" and "beliefs about capabilities" were also identified as potentially important domains. Interrelationships between domains were evident. Additionally, the data supported theoretical elaboration of the domain behavioral regulation. CONCLUSIONS: In this investigation of hospital-based prescribing, participants' attributions about causes of errors were used to identify domains that could be targeted in interventions to improve prescribing. In a departure from previous TDF practice, critical appraisal was used to identify additional domains that should also be targeted, despite participants' perceptions that they were not relevant to prescribing errors. These were beliefs about consequences and beliefs about capabilities. Specifically, in the light of the documented high error rate, beliefs that prescribing errors were not likely to have consequences for patients and that trainee doctors are capable of prescribing without error should also be targeted in an intervention. This study is the first to suggest critical appraisal for domain identification and to use interview data to propose theoretical elaborations and interrelationships between domains.     

What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England

ABSTRACT: BACKGROUND: Around 5,000 miscarriages and 300 perinatal deaths per year result from maternal smoking in the United Kingdom. In the northeast of England, 22% of women smoke at delivery compared to 14% nationally. Midwives have designated responsibilities to help pregnant women stop smoking. We aimed to assess perceived implementation difficulties regarding midwives' roles in smoking cessation in pregnancy. METHODS: A self-completed, anonymous survey was sent to all midwives in northeast England (n?=?1,358) that explores the theoretical explanations for implementation difficulties of four behaviours recommended in the National Institute for Health and Clinical Excellence (NICE) guidance: (a) asking a pregnant woman about her smoking behaviour, (b) referring to the stop-smoking service, (c) giving advice about smoking behaviour, and (d) using a carbon monoxide monitor. Questions covering Michie et al.'s theoretical domain framework (TDF), describing 11 domains of hypothesised behavioural determinants (i.e., 'knowledge', 'skills', 'social/professional role/identity', 'beliefs about capabilities', 'beliefs about consequences', 'motivation and goals', 'memory', 'attention and decision processes', 'environmental context and resources', 'social influences', 'emotion', and 'self-regulation/action planning'), were used to describe perceived implementation difficulties, predict self-reported implementation behaviours, and explore relationships with demographic and professional variables. RESULTS: The overall response rate was 43% (n?=?589). The number of questionnaires analysed was 364, following removal of the delivery-unit midwives, who are not directly involved in providing smoking-cessation services. Participants reported few implementation difficulties, high levels of motivation for all four behaviours and identified smoking-cessation work with their role. Midwives were less certain about the consequences of, and the environmental context and resources available for, engaging in this work relative to other TDF domains. All domains were highly correlated. A principal component analysis showed that a single factor ('propensity to act'), derived from all domains, explained 66% of variance in theoretical domain measures. The 'propensity to act' was predictive of the self-reported behaviour 'Refer all women who smoke……to NHS Stop Smoking Services' and mediated the relationship between demographic variables, such as midwives' main place of work, and behaviour. CONCLUSIONS: Our findings advance understanding of what facilitates and inhibits midwives' guideline implementation behaviours in relation to smoking cessation and will inform the development of current practice and new interventions. Using the TDF as a self-completion questionnaire is innovative, and this study supports previous research that the TDF is an appropriate tool to understand the behaviour of healthcare professionals.     

Rocky mountain spotted Fever

We compare health maintenance organization enrollees'' evaluations of the care they received from family physicians and chiropractors for low back pain. Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were much more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem. Although the more positive evaluations of chiropractors may be related to differences in the patient populations served by the two providers or to benefits of spinal manipulation, it is suggested that a potentially more potent force--the therapeutic effect of the patient and provider interaction itself--may explain the observed differences.     

Community survey of factors associated with consultation for low back pain

ObjectiveTo investigate the psychosocial factors associated with consultation for low back pain.DesignTwo phase cross sectional postal survey.SettingBradford Metropolitan Health District.Subjects1813 adults responding to the phase 1 questionnaire. 540 of the 782 with an episode of low back pain in the past 12 months completed the second questionnaire.Results406 (52%) of the respondents reporting back pain in the past 12 months had not consulted a health professional. Logistic regression showed that consultation was associated with externalised beliefs regarding pain management (odds ratio 3.6; 95% confidence interval 2.1 to 6.0). Duration of pain affected the factors associated with consultation. Consultation for episodes lasting less than two weeks (n=290) was associated with greater than median pain (3.0; 1.7 to 5.5), consultation for episodes over two weeks (n=243) was associated with increased disability (3.7; 1.5 to 9.0), and consultation for episodes over three months (n=143) with increased depression (3.9; 1.3 to 11.8).ConclusionsThe results support a role for psychosocial factors in consultation for low back pain and suggest that the reasons for consultation vary with duration of pain. Duration of the episode may be a useful guide to management of non-specific low back pain.

Key messages

• Only half of those who experience low back pain consult a health service professional
• Most of those who consult have had low back pain for more than two weeks
• The severity of pain may influence consulting behaviour at the acute stage, but after the acute period those who consult are more likely to have increased disability, externalised beliefs about pain management, and depressive symptoms.
• Management of low back pain may need to vary according to the duration of pain

     

Unpacking collaborative depression care: examining two essential tasks for implementation

Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED. Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy. Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of “environmental, context and resources” (such as stressful working conditions or lack of resources) and “knowledge” (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of “knowledge” (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and “skills” (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were “focus on past success” and “information about health consequences.” Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.     

Pain catastrophizing moderates changes in spinal control in response to noxiously induced low back pain

It is generally accepted that spine control and stability are relevant for the prevention and rehabilitation of low back pain (LBP). However, there are conflicting results in the literature in regards to how these variables are modified in the presence of LBP. The aims of the present work were twofold: (1) to use noxious stimulation to induce LBP in healthy individuals to assess the direct effects of pain on control (quantified by the time-dependent behavior of kinematic variance), and (2) to assess whether the relationship between pain and control is moderated by psychological features (i.e. pain catastrophizing (PC) and kinesiophobia). Participants completed three conditions (baseline, pain, recovery) during a task involving completion of 35 cycles of a repetitive unloaded spine flexion/extension movement. The neuromuscular control of spine movements was assessed during each condition using maximum finite-time Lyapunov exponents (λ_max). Nociceptive stimulus involved injection of hypertonic saline into the interspinous ligament, eliciting pain that was greater than baseline and recovery (p < 0.001). Although there was no overall main effect of the nociceptive stimulation (i.e. pain) on λ_max when the whole group was included in the statistical model (p = 0.564), when data were considered separately for those with high and low PC, two distinct and well established responses to the pain were observed. Specifically, those with high PC tightened their control (i.e. stabilized), whereas those with low PC loosened their control (i.e. destabilized). This study provides evidence that individuals’ beliefs and attitudes towards pain are related to individual-specific motor behaviors, and suggests that future research studying spine control/stability and LBP should account for these variables.     

Experimentally induced neck pain causes a decrease in thoracic but not lumbar spine stability

Maintenance of spine stability is considered to be a critical component of spine health. Ross et al. (2015) used a topical capsaicin/heat pain sensitization model to experimentally induce lower back pain, and demonstrated that the experimental pain experience caused a decrease in the muscular contribution to lumbar spine rotational stiffness (related to mechanical stability) as well as lower back local dynamic stability (LDS). It has yet to be established if pain elsewhere in the body, specifically in other regions of the spine, can similarly affect the stability of the lower back. The purpose of this investigation was therefore to quantify thoracic and lumbar spine LDS as well as the muscular contribution to lumbar spine rotational stiffness after an experimental neck pain protocol. Results demonstrated that LDS of the thoracic spine decreased in response to the capsaicin/heat induced neck pain. Limited adaptation was required at the lumbar spine as demonstrated by the lack of statistically significant changes in lower back LDS or rotational stiffness.     

Spatial distribution of erector spinae activity is related to task-specific pain-related fear during a repetitive object lifting task

Fear-avoidance beliefs, particularly the fear of lifting with a flexed spine, are associated with reduced spinal motion during object lifting. Low back pain patients thereby also showed potentially clinically relevant changes in the spatial distribution of back muscle activity, but it remains unknown whether such associations are also present in pain-free individuals. This cross-sectional observational study investigated the relationship between fear-avoidance beliefs and the spatial distribution of lumbar paraspinal muscle activity in pain-free individuals during a repetitive lifting task. Thirty participants completed two pain-related fear questionnaires and performed 25 repetitions of lifting a 5 kg-box from a lower to an upper shelf and back, while multi-channel electromyographic signals were recorded bilaterally from the lumbar erector spinae muscles. Changes in spatial distribution were defined as the differences in vertical position of the weighted centroids of muscle activity (centroid shift) between the first and last few repetitions. Linear regression analyses were performed to examine the relationships between centroid shift and fear-avoidance belief scores. Fear of lifting an object with a flexed spine was negatively associated with erector spinae activity centroid shift (R² adj. = 0.1832; p = 0.045), which might be an expression of behavioral alterations to prevent the back from possible harm.     

Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing

Background

The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.

Methods

Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs’ perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.

Results

Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: ‘Skills’, ‘Beliefs about capabilities’, ‘Beliefs about consequences’, ‘Environmental context and resources’, ‘Memory, attention and decision processes’, ‘Social/professional role and identity’, ‘Social influences’ and ‘Behavioural regulation’. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: ‘Action planning’, ‘Prompts/cues’, ‘Modelling or demonstrating of behaviour’ and ‘Salience of consequences’. An additional BCT (‘Social support or encouragement’) was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.

Conclusions

Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.

     

Underestimation of object mass in lifting does not increase the load on the low back.

Sudden, unexpected loading on the low back is associated with a high incidence of low back pain. Experiments in which sudden loading was applied during standing revealed increased compression forces on the spine and increased trunk angle, which may cause injury to the spine and hence explain this association. During a more dynamic daily activity, i.e. lifting, this could not be demonstrated, which may be due to experimental constraints. We therefore reinvestigated the loading of the low back when subjects were lifting an unexpectedly heavy object. Ten males lifted boxes, weighing 1.6 or 6.6 kg, at a self-selected lifting velocity. In some trials the mass of these boxes was unexpectedly increased by 10 kg. The ground reaction forces, body movements and trunk muscle activity were measured and from these, the L5/S1 torques and compression forces were estimated. Underestimation of the mass did not lead to an increase in low back loading. This finding was independent of the mass the subjects were expecting to lift. In conclusion, no evidence was found to support inference regarding causality of the association between sudden loading and low back pain during whole body lifting movements.     

Consumption by semen loss in India and elsewhere

Using ethnographical data from a rural site of Oriya culture, the purpose of this article is to show that the Indian obsession regarding the harmful consequences of semen loss does not constitute a specific Indian culture-bound preoccupation, but represents a survival example of a much widespread system of beliefs that can be traced for instance in Western culture to the Hippocratic notion of back consumption and the classical concept of gonorrhoea. At the core of this system of beliefs are found ancient conceptions of the nature and functions of semen in human life. These conceptions and their cultural influences incidentally inform us about one of the origins of the reprobation of onanism, as well as one possible way, among many others, for traditional thinking to explain the clinical enigma of depressive syndrome.     

Dynamics and mechanistic interpretations of nonribosomal peptide synthetase cyclization domains

Ox-/thiazoline groups in nonribosomal peptides are formed by a variant of peptide-forming condensation domains called heterocyclization (Cy) domains and appear in a range of pharmaceutically important natural products and virulence factors. Recent cryo-EM, crystallographic, and NMR studies of Cy domains make it opportune to revisit outstanding questions regarding their molecular mechanisms. This review covers structural and dynamical findings about Cy domains that will inform future bioengineering efforts and our understanding of natural product synthesis.     

National Survey of Endocrinologists and Surgeons Regarding Active Surveillance for Low-Risk Papillary Thyroid Cancer

ObjectiveActive surveillance for low-risk papillary thyroid cancer (PTC) was endorsed by the American Thyroid Association guidelines in 2015. The attitudes and beliefs of physicians treating thyroid cancer regarding the active surveillance approach are not known.MethodsA national survey of endocrinologists and surgeons treating thyroid cancer was conducted from August to September 2017 via professional society emails. This mixed-methods analysis reported attitudes toward potential factors impacting decision-making regarding active surveillance, beliefs about barriers and facilitators of its use, and reasons why physicians would pick a given management strategy for themselves if they were diagnosed with a low-risk PTC. Survey items about attitudes and beliefs were derived from the Cabana model of barriers to guideline adherence and theoretical domains framework of behavior change.ResultsAmong 345 respondents, 324 (94%) agreed that active surveillance was appropriate for at least some patients, 81% agreed that active surveillance was at least somewhat underused, and 76% said that they would choose surgery for themselves if diagnosed with a PTC of ≤1 cm. Majority of the respondents believed that the guidelines supporting active surveillance were too vague and that the current supporting evidence was too weak. Malpractice and financial concerns were identified as additional barriers to offering active surveillance. The respondents endorsed improved information resources and evidence as possible facilitators to offering active surveillance.ConclusionAlthough there is general support among physicians who treat low-risk PTC for the active surveillance approach, there is reluctance to offer it because of the lack of robust evidence, guidelines, and protocols.     

Comparison of Modic Changes in the Lumbar and Cervical Spine,in 3167 Patients with and without Spinal Pain

Background Context

There are few comparisons of Modic changes (MCs) in the lumbar and cervical spine.

Purpose

Compare the prevalence of MCs in the lumbar and cervical spine, and determine how MC prevalence depends on spinal pain, age, disc degeneration, spinal level, and the presence or absence of kyphosis.

Study Design

Retrospective clinical survey.

Materials and Methods

Magnetic resonance images (MRIs) were compared from five patient groups: 1. 1223 patients with low-back pain/radiculopathy only; 2. 1023 patients with neck pain/radiculopathy only; 3. 497 patients with concurrent low-back and neck symptoms; 4. 304 asymptomatic subjects with lumbar MRIs; and 5. 120 asymptomatic subjects with cervical MRIs.

Results

The prevalence of MCs was higher in those with spinal pain than in those without, both in the lumbar spine (21.0% vs 10.5%) and cervical spine (8.8% vs 3.3%). Type II MCs were most common and Type III were least common in all groups. The prevalence of lumbar MCs in people with back pain was little affected by the presence of concurrent neck pain, and the same was true for the prevalence of cervical MCs in people with neck pain with or without concurrent back pain. When symptomatic patients were reclassified into two groups (back pain, neck pain), the prevalence of lumbar MCs in people with back pain was greater than that of cervical MCs in people with neck pain. The prevalence of lumbar and cervical MCs increased with age, disc degeneration, (descending) spinal level, and increased kyphosis.

Conclusions

There is a significantly higher prevalence of MCs in patients with back and neck pain. The reported association with increased kyphosis (flat back) is novel.     

Clinical spinal instability and low back pain.

Clinical instability is an important cause of low back pain. Although there is some controversy concerning its definition, it is most widely believed that the loss of normal pattern of spinal motion causes pain and/or neurologic dysfunction. The stabilizing system of the spine may be divided into three subsystems: (1) the spinal column; (2) the spinal muscles; and (3) the neural control unit. A large number of biomechanical studies of the spinal column have provided insight into the role of the various components of the spinal column in providing spinal stability. The neutral zone was found to be a more sensitive parameter than the range of motion in documenting the effects of mechanical destabilization of the spine caused by injury and restabilization of the spine by osteophyle formation, fusion or muscle stabilization. Clinical studies indicate that the application of an external fixator to the painful segment of the spine can significantly reduce the pain. Results of an in vitro simulation of the study found that it was most probably the decrease in the neutral zone, which was responsible for pain reduction. A hypothesis relating the neutral zone to pain has been presented. The spinal muscles provide significant stability to the spine as shown by both in vitro experiments and mathematical models. Concerning the role of neuromuscular control system, increased body sway has been found in patients with low back pain, indicating a less efficient muscle control system with decreased ability to provide the needed spinal stability.     

Regulation of inflammatory arthritis by the upstream kinase mitogen activated protein kinase kinase 7 in the c-Jun N-Terminal kinase pathway

Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. In most health-care systems, the first person to see the patient with a musculoskeletal problem such as back pain is the general practitioner, and access to other professionals such as physiotherapists, chiropractors, or osteopaths is still either largely controlled by a traditional medical model of referral or left to self-referral by the patient. In this paper, we examine the arguments for the general practitioner-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.