Anna Gagliardi is a Senior Scientist at the Toronto General Hospital Research Institute and Professor at the University of Toronto. Her research employs both qualitative and quantitative methods, and focuses on optimizing guideline development and implementation, and organizational and individual patient engagement. She has administered over $4.6 million in research funding as PI/co-PI and published over 100 peer-reviewed articles as principal/senior author. Leadership roles included Chair of the Implementation Working Group for the Guidelines International Network (2012-2017), and advisor to national and international government and professional societies on guideline implementation and patient-centred care. Anna was a CIHR New Investigator in Knowledge Translation (2013-2018). She completed a PhD in Health Policy, Management and Evaluation at the University of Toronto, and her background includes a Masters in Biochemistry, a Master of Library Science, and a Bachelor of Education.
- Improving the development, implementation and use of guidelines
Guidelines synthesize scientific evidence on a given condition, disease, procedure or therapy. Guideline recommendations are therefore fundamental to health care planning, delivery, evaluation and quality improvement. However, guidelines are widely under-utilized, leading to suboptimal health care and poor patient outcomes, and increased costs for health systems. It is also a waste of considerable resources that are used by government, academic, professional and not-for-profit organizations in Canada and worldwide to develop guidelines that are not used. We investigated how the content and format of guidelines could be improved to optimize guideline use:
- Established the absence of guidance on how to make guidelines implementable
- Demonstrated that guidelines generated internationally on a variety of clinical conditions scored poorly for implementability and for the inclusion of guideline implementation tools
- Generated a Framework of Guideline Implementability
- In collaboration with the international guideline community, generated criteria and considerations for developing guideline implementation tools
- Evaluated 178 questionnaires used from 2005 to 2015 to pre-identify barriers of guideline implementation, found that none were reliable or valid, and in collaboration with international guideline experts, developed a more comprehensive survey instrument
- Reviewed 175 studies of guideline implementation published from 2006 to 2016 and found that half employed theory, and those that did provided scant details about how theory was used, which limits interpretation and replication of those implementation interventions
- Developed and validated the Clinician Guideline Determinants Questionnaire
- We are currently investigating how to optimize the collection, integration and reporting of patient preferences in guidelines, an approach shown to improve patient-provider communication and guideline use.
- Preventing and managing adverse medical device events
Medical devices (i.e. cardiovascular, orthopedic) extend life and improve quality of life; however, adverse medical device events (AMDEs) constitute approximately 10% of hospital incidents. We consulted with multi-sector professionals from the United States and Canada to generate a research agenda, then explored patient safety issues related to preventing and managing AMDEs:
- During a 10-year period in Canada, 24,849 new device licenses were issued. Of 7,226 recalls among those devices, 5.0% were judged to have a reasonable probability of serious consequences or death
- Physicians typically choose devices for individual patients based on personal preference, availability based on local inventory or purchasing contracts, and tacit knowledge from trusted colleagues and less-trusted industry representatives such that choice of device most suitable for a given patient was perceived to be sometimes compromised, potentially leading to sub-optimal clinical outcomes
- Patient engagement in discussions and decisions about devices was said to be constrained by patient (demographic/clinical characteristics), physician (preferences), health system (purchasing contracts) and device factors (availability, affordability, advantage)
- AMDE reporting was limited by physician beliefs (AMDEs expected) and behaviour (work-around strategies), and reinforced by hospital (lack of processes and infrastructure to detect, capture, share and act on information about AMDEs) and device industry (little to no response to physician reports of AMDEs) factors
- Industry representatives hold 10 distinct roles, including supporting operating room staff with device assembly and insertion. Physicians described the relationship as “symbiotic” but recognized the potential for conflict of interest. Physicians described a concurrent tension with hospitals: they were required to comply with purchasing contracts despite concerns about device safety and effectiveness
- We shared these findings with 50 participants at a national multi-sector meeting; they identified pre- and post-market strategies needed to drive medical device safety.
- How best to engage patients in hospital service planning and improvement
Hospitals increasingly involve patients (or family members/care partners/consumers) in planning or improving hospital services; it is required by law and for hospital accreditation, and research shows that it improves patient and hospital outcomes. Little research has studied whether and how Canadian hospitals engage patients, or identified the most impactful patient engagement (PE) activities. This information is needed to ensure that the patient voice is actually used to improve what hospitals do, as this will lead to a better hospital experience and health care results for all patients. We will survey hospitals in Ontario to learn about PE activities, then interview a selection of patients, clinicians and managers to describe PE activities, perceived benefits, impacts it achieved, barriers they experienced, and suggested solutions to address barriers or enhance benefits/impacts. Their recommendations for ideal PE approaches and supports will be translated to performance measures of PE. Accumulated knowledge on the most feasible and impactful ways to achieve PE in hospital planning and improvement will be shared with hospitals in Ontario, and with government policy-makers, hospital and health system leaders and researchers from across Canada so that hospitals in other provinces can optimize PE. Long-term, this could improve health service delivery, patient experiences and health among Canadians.
- Improving patient-centred care for women across the lifespan
Compared with men, women in Ontario are less likely to access the care they need for health issues across their lifespan, and have poorer health outcomes. Patient-centred care (PCC) -- approaches that inform, educate and engage patients -- improves patient knowledge, relationships with providers, service use, satisfaction, adherence to treatment, lifestyle choices, and health outcomes; it also reduces health care costs. However, PCC is not well-implemented due to patient, clinician, organizational and system-level factors. This research will generate practical strategies to implement patient-centred care for women (PCCW). We have reviewed published research to identify how PCCW has been achieved elsewhere; assessed how Canadian and international government policies and clinical guidelines currently do, and could better promote PCCW; and interviewed women and clinicians about how to improve PCCW. Based on compiled findings, we are engaging an expert panel comprised of women, clinicians and researchers to generate recommendations for PCCW, and will soon test patient-provider communication tools (i.e. question prompt list) that support PCCW.
Professor, University of Toronto: Department of Surgery; Institute for Health Policy, Management & Evaluation; Institute of Medical Science