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.

An Evidence-Based Approach to Access Reform (Working Paper 22)

In August 2000, the federal government began an internal review of the Access to Information Act (ATIA). The ATIA gives Canadians a qualified right of access to records held by federal institutions. Decisions about reform should be based on good evidence about the operation of the Act and the likely impact of proposed reforms. This paper describes how data on ATIA operations is collected by federal institutions and provides a guide to academic researchers interested in conducting empirical research on the operation of the law. It constructs a small dataset that describes the processing of a sample of 663 requests received in 1999, and uses this dataset to illustrate the potential of an evidence-based approach to ATIA reform. The dataset can be downloaded from http://evidence.foilaw.net. The project was supported by a $4,800 grant from the Principal’s Development Fund of Queen’s University awarded in May 2001. Comments should be sent to the principal investigator, Alasdair Roberts, at roberts@policystudies.ca.

Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care

Background: Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care.

Methods: A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models’ characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria.

Results: From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0–32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported.

Conclusions: The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Sustainability Enhancement of a Turbine Vane Manufacturing Cell through Digital Simulation based Design

Modern manufacturing systems should satisfy emerging needs related to sustainable development. The design of sustainable manufacturing systems can be valuably supported by simulation, traditionally employed mainly for time and cost reduction. In this paper, a multi-purpose digital simulation approach is proposed to deal with sustainable manufacturing systems design through Discrete Event Simulation (DES) and 3D digital human modelling. DES models integrated with data on power consumption of the manufacturing equipment are utilized to simulate different scenarios with the aim to improve productivity as well as energy efficiency, avoiding resource and energy waste. 3D simulation based on digital human modelling is employed to assess human factors issues related to ergonomics and safety of manufacturing systems. The approach is implemented for the sustainability enhancement of a real manufacturing cell of the aerospace industry, automated by robotic deburring. Alternative scenarios are proposed and simulated, obtaining a significant improvement in terms of energy efficiency (−87%) for the new deburring cell, and a reduction of energy consumption around −69% for the coordinate measuring machine, with high potential annual energy cost savings and increased energy efficiency. Moreover, the simulation-based ergonomic assessment of human operator postures allows 25% improvement of the workcell ergonomic index.

Towards a performance based design of shear walls based on damage criteria = Vers un dimensionnement performanciel des murs de refend basé sur des critères d'endommagement

Le dimensionnement basé sur la performance (DBP), dans une approche déterministe, caractérise les objectifs de performance par rapport aux niveaux de performance souhaités. Les objectifs de performance sont alors associés à l'état d'endommagement et au niveau de risque sismique établis. Malgré cette approche rationnelle, son application est encore difficile. De ce fait, des outils fiables pour la capture de l'évolution, de la distribution et de la quantification de l'endommagement sont nécessaires. De plus, tous les phénomènes liés à la non-linéarité (matériaux et déformations) doivent également être pris en considération. Ainsi, cette recherche montre comment la mécanique de l'endommagement pourrait contribuer à résoudre cette problématique avec une adaptation de la théorie du champ de compression modifiée et d'autres théories complémentaires. La formulation proposée adaptée pour des charges monotones, cycliques et de type pushover permet de considérer les effets non linéaires liés au cisaillement couplé avec les mécanismes de flexion et de charge axiale. Cette formulation est spécialement appliquée à l'analyse non linéaire des éléments structuraux en béton soumis aux effets de cisaillement non égligeables. Cette nouvelle approche mise en œuvre dans EfiCoS (programme d'éléments finis basé sur la mécanique de l'endommagement), y compris les critères de modélisation, sont également présentés ici. Des calibrations de cette nouvelle approche en comparant les prédictions avec des données expérimentales ont été réalisées pour les murs de refend en béton armé ainsi que pour des poutres et des piliers de pont où les effets de cisaillement doivent être pris en considération. Cette nouvelle version améliorée du logiciel EFiCoS a démontrée être capable d'évaluer avec précision les paramètres associés à la performance globale tels que les déplacements, la résistance du système, les effets liés à la réponse cyclique et la quantification, l'évolution et la distribution de l'endommagement. Des résultats remarquables ont également été obtenus en référence à la détection appropriée des états limites d'ingénierie tels que la fissuration, les déformations unitaires, l'éclatement de l'enrobage, l'écrasement du noyau, la plastification locale des barres d'armature et la dégradation du système, entre autres. Comme un outil pratique d'application du DBP, des relations entre les indices d'endommagement prédits et les niveaux de performance ont été obtenus et exprimés sous forme de graphiques et de tableaux. Ces graphiques ont été développés en fonction du déplacement relatif et de la ductilité de déplacement. Un tableau particulier a été développé pour relier les états limites d'ingénierie, l'endommagement, le déplacement relatif et les niveaux de performance traditionnels. Les résultats ont démontré une excellente correspondance avec les données expérimentales, faisant de la formulation proposée et de la nouvelle version d'EfiCoS des outils puissants pour l'application de la méthodologie du DBP, dans une approche déterministe.

User-centered, research-based design of futuristic intensive care units