BackgroundAudit and feedback interventions may be strengthened using social interaction. With this in mind, the Calgary office of the Alberta Physician Learning Program developed a process for audit and group feedback for physician groups. As a part of a larger project to develop a practical approach to the design and implementation of audit and group feedback projects, we explored patterns of physician behavior during facilitated audit and group feedback sessions.MethodsSix audit and group feedback sessions were recorded, transcribed, and analyzed thematically to derive a conceptual model of physicians’ behaviors during audit and group feedback sessions.ResultsA predictable cycle of behaviors emerged from audit and group feedback sessions. This cycle would repeat with discussion of each new data element: reacting to the data, questioning and understanding the data, justifying and contextualizing, sharing and reflecting on the data and relevant guidelines, and planning for change. “Change cues” that emerged within groups reliably pivoted the discussion towards action planning.ConclusionsIn audit and group feedback sessions, physicians display a predictable series of behaviors as they move towards commitment to change. Establishing the meaning and credibility of the data is a necessary precursor to reflection. Group reflection leads to “change cues” triggered by group members, which stimulate action planning.
BackgroundAudit and feedback interventions may be strengthened using social interaction. The Calgary office of the Alberta Physician Learning Program (CPLP) developed a process for audit and group feedback for physicians. This paper extends previous work in which we developed a conceptual model of physician responses to audit and group feedback based on a qualitative analysis of six audit and group feedback sessions. The present study explored the mediating factors for successfully engaging physician groups in change planning through audit and group feedback.MethodsTo understand why some groups were more interactive than others, we completed a comparative case analysis of the six audit and group feedback projects from the prior study. We used framework analysis to build the case studies, triangulated our observations across data sources to validate findings, compared the case studies for similarities and differences that influenced social interaction (mediating factors), and thematically categorized mediating factors into an organizing framework.ResultsMediating factors for socially interactive AGFS were a pre-existing relationship between the program team and the physician group, projects addressing important, actionable questions, easily interpretable data visualization in the reports, and facilitation of the groups that included reflective questioning. When these factors were in place (cases 1, 2A, 3), the audit and group feedback sessions were dynamic, with physicians sharing and comparing practices, and raising change cues (such as declaring commitments to de-prescribing, planning educational interventions, and improving documentation). In cases 2C–D, the mediating factors were less well established and in these cases, the sessions showed little physician reflection or change planning. We organized the mediating factors into a framework linking the factors for successful sessions to the conceptual model of physician behaviors which these mediating factors drive.ConclusionsWe propose the Calgary Audit and Feedback Framework as a practical tool to help foster socially constructed learning in audit and group feedback sessions. Ensuring that the four factors, relationship, question choice, data visualization, and facilitation, are considered for design and implementation of audit and group feedback will help physicians move from reactions to their data towards planning for change.
The differential diagnosis and malignancy risk stratification of thyroid nodules requires multidisciplinary expertise and knowledge of both local ultrasonography practices and the local malignancy rates for a given fine-needle aspiration (FNA) result. Even in such a multidisciplinary setting, FNA cytology has the inherent limitation that indeterminate cytology results cannot distinguish between follicular adenomas, follicular thyroid carcinomas or follicular variant papillary thyroid carcinomas. Accumulating evidence suggests that this limitation can be overcome by using molecular diagnostic approaches. In this Review, we present the advantages and disadvantages of the different molecular diagnostic methodologies, which can be divided into two approaches: those that 'rule out' malignancy (to reduce the overtreatment of benign nodules) and those that 'rule in' malignancy (to optimize surgical planning). We identify microRNA classifiers as potential additional markers for use in a two-step diagnostic approach, consider the potential implications of the reclassification of noninvasive encapsulated follicular variant papillary thyroid carcinomas to noninvasive follicular thyroid neoplasms with papillary-like nuclear features and discuss the cost-effectiveness of molecular testing. Molecular FNA diagnostics is an important complementary addition to FNA cytology that could substantially reduce unnecessary surgery and better define the need for appropriate surgery in patients who have thyroid nodules with indeterminate FNA cytology.
ObjectiveThe objective of this study was to evaluate trends in prescribing of the second-generation antipsychotic medication quetiapine to adults in the province of Alberta from 2008 to 2013 through examination of dispensed prescriptions, and diagnoses associated with users of quetiapine in 2013.MethodsWe analysed administrative data from Alberta Health; the Alberta Pharmaceutical Information Network (PIN) Dispenses health data set, the Practitioner Payments (Fee-For-Service claims) health data set and the Population Registry health data set. These data sets allowed us to identify discrete quetiapine recipients for each calendar year from 2008 to 2013. To evaluate diagnoses associated with users of quetiapine, we evaluated diagnostic codes used by physicians in billings claims in 2013.ResultsQuetiapine use increased over the 6-year time period studied. In 2008, there were 16 087 unique quetiapine recipients in Alberta (7.2 per 1000). By 2013, there were 35 314 unique quetiapine recipients (13.3 per 1000). Use by women was higher than men at all time points. Depression was most common diagnosis associated with quetiapine recipients, which was present in 56% of users of quetiapine. Other common diagnoses associated with quetiapine use included neurotic disorders, bipolar disorder and sleep disturbances.ConclusionsThe current study of quetiapine use in the province of Alberta provides confirmatory data of the increasing use of quetiapine for the treatment of depression and anxiety disorders. Safe and rational prescribing practices must be encouraged in light of the modest advantages of quetiapine over no treatment as an adjunctive treatment of major depression, and the known harms of this medication.
Our retrospective analysis of a large number of consecutive thyroid ultrasound reports in routine clinical practice suggests that the vast majority provide insufficient information to allow the clinician to risk stratify the nodules by estimating the ROM. This could lead to both over-diagnosis and over-treatment of benign/indolent thyroid lesions or under-diagnosis of clinically important thyroid cancers.
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