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BACKGROUND: The Internet has the potential to be an effective medium for delivering health care knowledge to consumers. While computer usability research makes recommendations about how to present Web-based information generally, there remains no clear guidance on how to present specific forms of health care research evidence online in a way that facilitates understanding and good health care decision making. OBJECTIVE: The two goals of this study were to describe the Cochrane Musculoskeletal Group's (CMSG's) process for developing online patient-focused summaries of systematic reviews and to evaluate the impressions of these summaries formed by users. METHODS: A process for summarizing the results of systematic reviews via consumer summaries has evolved over 15 years. An evaluation of this approach took the form of Internet surveys on the Arthritis Society of Canada website and surveys of members of the Canadian Arthritis Patient Alliance (CAPA). Respondents provided information on background, relationship to the decision, their satisfaction with and preparation for decision making, and suggestions for improvements to the summaries. Survey data were collected between August 1, 2005, and February 28, 2006. RESULTS: A total of 261 respondents completed the survey. The majority (226/261 or 87%) of respondents reported having an arthritis-related condition. The consumer summary approach was generally reviewed favorably by respondents, with most agreeing that the summary provided appropriate information (177/261 or 68%), would be useful to others (160/261 or 61%), was well laid out (159/261 or 61%), was easy to learn from (157/261 or 60%), and was useful to the reader (153/261 or 59%). Areas of potential improvement were indicated by relatively fewer respondents agreeing that they could easily find all the information they wanted (118/261 or 45%), by a substantial proportion being unable to judge whether the providers of the information are reliable (80/261 or 31%), and by a similar proportion being unable to determine whether the information presented was the best available (68/261 or 26%). CONCLUSIONS: The CMSG has developed an approach to summarizing the results of often-technical systematic reviews into public-friendly consumer summaries. Our online survey showed that this approach was generally well liked but identified specific areas for improvement. Feedback from this survey will help to reshape and improve the current template for consumer summaries used by the CMSG.

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BACKGROUND: Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. METHODS: The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. RESULTS: As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ''all of the time'' v. ''most of the time'' v. ''some of the time,'' and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. CONCLUSIONS: The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ''protorules'' during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.

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BACKGROUND: Evidence shows that the standard process for obtaining informed consent in clinical trials can be inadequate, with study participants frequently not understanding even basic information fundamental to giving informed consent. Patient decision aids are effective decision support tools originally designed to help patients make difficult treatment or screening decisions. We propose that incorporating decision aids into the informed consent process will improve the extent to which participants make decisions that are informed and consistent with their preferences. A mixed methods study will test this proposal. METHODS: Phase one of this project will involve assessment of a stratified random sample of 50 consent documents from recently completed investigator-initiated clinical trials, according to existing standards for supporting good decision making. Phase two will involve interviews of a purposive sample of 50 trial participants (10 participants from each of five different clinical areas) about their experience of the informed consent process, and how it could be improved. In phase three, we will convert consent forms for two completed clinical trials into decision aids and pilot test these new tools using a user-centered design approach, an iterative development process commonly employed in computer usability literature. In phase four, we will conduct a pilot observational study comparing the new tools to standard consent forms, with potential recruits to two hypothetical clinical trials. Outcomes will include knowledge of key aspects of the decision, knowledge of the probabilities of different outcomes, decisional conflict, the hypothetical participation decision, and qualitative impressions of the experience. DISCUSSION: This work will provide initial evidence about whether a patient decision aid can improve the informed consent process. The larger goal of this work is to examine whether study recruitment can be improved from (barely) informed consent based on disclosure-oriented documents, towards a process of high-quality participant decision-making.

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The individual practitioner is a linchpin in the process of translating new knowledge into practice, particularly in the emergency department, where physician autonomy is high, resources are limited, and decision-making situations are complex. An understanding of the cognitive and social processes that affect knowledge translation (KT) in emergency medicine (EM) is crucial and at present understudied. As part of the 2007 Academic Emergency Medicine Consensus Conference on KT in EM, our group sought to identify key research areas that would inform our understanding of these cognitive and social processes. We combined an online discussion group of interdisciplinary stakeholders, an extensive review of the existing literature, and a "public hearing" of the recommendations at the Consensus Conference to establish relative preference for the recommendations, as well as their relevance and clarity to attendees. We identified five key research areas as follows. 1) What provider-specific barriers/facilitators to the use of new knowledge are relevant in the EM setting? 2) Can social psychological theories of behavior change be used to develop better KT interventions for EM? 3) Can the study of "distributed cognition" suggest new vehicles for KT in the emergency department? 4) Can the concept of dual-process reasoning inform our understanding of the KT process? 5) Can patient-specific, immediate feedback serve as a vehicle for KT in EM? We believe that exploring these key research questions will directly lead to improved KT interventions and to further discussion of the cognitive and social factors impacting KT in EM.

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BACKGROUND: There are many examples of physicians using treatments inappropriately, despite clear evidence about the circumstances under which the benefits of such treatments outweigh their harms. When such over- or under- use of treatments occurs for common diseases, the burden to the healthcare system and risks to patients can be substantial. We propose that a major contributor to inappropriate treatment may be how clinicians judge the likelihood of important treatment outcomes, and how these judgments influence their treatment decisions. The current study will examine the role of judged outcome probabilities and other cognitive factors in the context of two clinical treatment decisions: 1) prescription of antibiotics for sore throat, where we hypothesize overestimation of benefit and underestimation of harm leads to over-prescription of antibiotics; and 2) initiation of anticoagulation for patients with atrial fibrillation (AF), where we hypothesize that underestimation of benefit and overestimation of harm leads to under-prescription of warfarin. METHODS: For each of the two conditions, we will administer surveys of two types (Type 1 and Type 2) to different samples of Canadian physicians. The primary goal of the Type 1 survey is to assess physicians' perceived outcome probabilities (both good and bad outcomes) for the target treatment. Type 1 surveys will assess judged outcome probabilities in the context of a representative patient, and include questions about how physicians currently treat such cases, the recollection of rare or vivid outcomes, as well as practice and demographic details. The primary goal of the Type 2 surveys is to measure the specific factors that drive individual clinical judgments and treatment decisions, using a 'clinical judgment analysis' or 'lens modeling' approach. This survey will manipulate eight clinical variables across a series of sixteen realistic case vignettes. Based on the survey responses, we will be able to identify which variables have the greatest effect on physician judgments, and whether judgments are affected by inappropriate cues or incorrect weighting of appropriate cues. We will send antibiotics surveys to family physicians (300 per survey), and warfarin surveys to both family physicians and internal medicine specialists (300 per group per survey), for a total of 1,800 physicians. Each Type 1 survey will be two to four pages in length and take about fifteen minutes to complete, while each Type 2 survey will be eight to ten pages in length and take about thirty minutes to complete. DISCUSSION: This work will provide insight into the extent to which clinicians' judgments about the likelihood of important treatment outcomes explain inappropriate treatment decisions. This work will also provide information necessary for the development of an individualized feedback tool designed to improve treatment decisions. The techniques developed here have the potential to be applicable to a wide range of clinical areas where inappropriate utilization stems from biased judgments.

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Voluntary movements result in internal perturbations of balance and equilibrium. One variable regulated during movement is the position of the center of pressure (COP). Sensory information from the visual, vestibular and somatosensory systems is used in establishing relevant frames of reference for postural control. In this study, we were interested in determining whether different limitations of COP movement occur when different approaches to delivering virtual environments are used and when visual information incoherent with vestibular and somatosensory information is provided. Eighteen healthy adults completed voluntary lateral reaches under three conditions: continuous lateral reach (CLR), flatscreen virtual reality (FS), and head-mounted display virtual reality (HMD). Reaching behavior was indexed by force plate measures of maximum anterior-posterior and lateral displacement of the COP. The COP movement decreased in the lateral direction in the HMD condition relative to the FS. The maximum range of COP movement in the anterior-posterior direction increased as a function of reaching task with HMD realizing the greatest amount of movement. The lack of an exocentric frame of reference in HMD coherent with information from other sensory systems results in limiting COP movement within the base of support (BOS) in order to decrease the challenge to the postural control system.

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