Knowledge translation in the management of acute calculous cholecystitis
Bibliographic record
Abstract
Background Acute calculous cholecystitis (ACC) is a common surgical disease and definitive treatment is cholecystectomy. Despite evidence and international consensus supporting early laparoscopic cholecystectomy as optimal management, variations in practice persist, supporting the existence of an evidence-practice gap. Research objective and methods Knowledge translation (KT) consists in raising knowledge users' awareness of specific clinical evidence to facilitate the use of this evidence in patient care. While implementation of an institutional care pathway for ACC may decrease unwanted variations in practice, prior to implementing any intervention, the KT approach requires identification of factors preventing proper application of knowledge and contributing to an evidence-practice gap. The aim of this thesis was to use the KT approach to identify variability in management of ACC within the McGill Division of General Surgery. To do so, 3 studies were completed. The first study was an institutional survey aiming to identify practice variations in the management of ACC within our division. The second study was a qualitative study using semi-structured interviews aiming to delineate overarching themes driving decision-making in the management of ACC. The third study was a retrospective observational study aiming to identify variables associated with non-operative management of ACC. Results Study #1: From 92 potential respondents, 40 faculty members and 26 senior residents responded to the survey. For mild ACC, 92% of respondents agreed with optimal management of emergency cholecystectomy, but this decreased as case complexity increased. Multivariate analysis showed that patient comorbidities, higher age, increased severity of ACC, longer duration of symptoms and respondent level of training were all significant independent predictors of discordance with optimal management. Study #2: 3 main themes influenced decision-making in the management of ACC: patient factors, surgeon factors and institutional factors. Patient factors included overall clinical status and presentation. Surgeon factors included perceived difficulty of cholecystectomy, comfort with the procedure and threshold to operate. Institutional factors included access to the operating room (OR) and the surgical team's relationship with OR staff Study #3: 374 patients were included. 246 patients underwent operative management with early cholecystectomy. When comparing early cholecystectomy and non-operative management groups, there were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total length of stay (3 days [2-5] vs 5 [4-9], p<0.001). On multiple logistic regression, higher age, hospital site and higher risk of concurrent choledocholithiasis were significantly associated with non-operative management. Conclusion The presence of an evidence-practice gap in the management of ACC within the McGill Division of General Surgery was successfully identified using a KT approach. The institutional survey identified that patient and respondent factors were independent predictors of discordance with optimal management. The qualitative study demonstrated that patient and surgeon factors are important components of decision-making, but that institutional factors also play a significant role in variability. The retrospective observational study confirmed that patient and institutional factors were associated with non-operative management of ACC. Multiple strategies will be necessary to implement institutional best practices in the management of ACC. More importantly, the KT approach presented in this thesis demonstrates the use of a methodology which can be reproduced and applied to a variety of clinical contexts to identify a potential evidence-practice gap.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".