Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

Weight Loss in the Chiropractic Profession

Background: Excess weight places a significant burden on health. Clinical practice guidelines advise healthcare professionals to provide weight management interventions to patients with overweight and obesity. Chiropractic practice may provide a unique opportunity to deliver weight management interventions to those with overweight and obesity. However, little has been done to address overweight and obesity within the chiropractic profession. Identifying the extent of this evidence-practice gap in chiropractic practice is the first step in addressing this issue. Objectives: This thesis was to assess the clinical practices of weight loss provided by chiropractors. The primary objectives were to 1) determine the prevalence of overweight and obesity in the adult patient population that sought chiropractic care, 2) describe the frequency and distribution of chiropractor directed weight management intervention, 3) identify associations between chiropractor directed weight management interventions and specific patient-level and chiropractor-level variables, and 4) examine the interaction between patient weight and comorbid conditions and whether chiropractors offered weight management interventions. Methods: Data from the Ontario Chiropractic Observational and Analysis Study was used (N = 42 chiropractors, N = 3523 patient encounters). Multilevel logistic regression was performed. Patient-level as well as chiropractor-level variables were investigated and associations with weight management provided by chiropractors were identified. Results: The majority of patients who sought chiropractic were overweight or obese (61.2%). Weight loss was provided to only 5.4% of patients. Chiropractors who graduated between 1995 and 2005 (OR: 0.02, 95% CI: 0.00 - 0.13) or prior to 1995 (OR: 0.08, 95% CI: 0.01 - 0.42) provided weight management significantly less than chiropractors who graduated between 2005 and 2014. No significant interaction was observed between patient adiposity and comorbid conditions with chiropractors directed weight loss. Conclusion: The majority of patients who seek chiropractic care are overweight and obese. Chiropractors are in a unique position to help improve patient health through offering weight management. However, this opportunity has not been fully realized by the chiropractic profession.

Weight Loss in the Chiropractic Profession

Background: Excess weight places a significant burden on health. Clinical practice guidelines advise healthcare professionals to provide weight management interventions to patients with overweight and obesity. Chiropractic practice may provide a unique opportunity to deliver weight management interventions to those with overweight and obesity. However, little has been done to address overweight and obesity within the chiropractic profession. Identifying the extent of this evidence-practice gap in chiropractic practice is the first step in addressing this issue. Objectives: This thesis was to assess the clinical practices of weight loss provided by chiropractors. The primary objectives were to 1) determine the prevalence of overweight and obesity in the adult patient population that sought chiropractic care, 2) describe the frequency and distribution of chiropractor directed weight management intervention, 3) identify associations between chiropractor directed weight management interventions and specific patient-level and chiropractor-level variables, and 4) examine the interaction between patient weight and comorbid conditions and whether chiropractors offered weight management interventions. Methods: Data from the Ontario Chiropractic Observational and Analysis Study was used (N = 42 chiropractors, N = 3523 patient encounters). Multilevel logistic regression was performed. Patient-level as well as chiropractor-level variables were investigated and associations with weight management provided by chiropractors were identified. Results: The majority of patients who sought chiropractic were overweight or obese (61.2%). Weight loss was provided to only 5.4% of patients. Chiropractors who graduated between 1995 and 2005 (OR: 0.02, 95% CI: 0.00 - 0.13) or prior to 1995 (OR: 0.08, 95% CI: 0.01 - 0.42) provided weight management significantly less than chiropractors who graduated between 2005 and 2014. No significant interaction was observed between patient adiposity and comorbid conditions with chiropractors directed weight loss. Conclusion: The majority of patients who seek chiropractic care are overweight and obese. Chiropractors are in a unique position to help improve patient health through offering weight management. However, this opportunity has not been fully realized by the chiropractic profession.