PRISM :: Browsing by Author "Clement, Fiona"

Browsing by Author "Clement, Fiona"

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Open Access
A mapping review of interventions to address patients who frequently seek care in the emergency department
(2024-03-27) Memedovich, Ally; Asante, Benedicta; Khan, Maha; Eze, Nkiruka; Holroyd, Brian R.; Lang, Eddy; Kashuba, Sherri; Clement, Fiona
Abstract Background The high utilization of acute care services, particularly emergency departments (ED), continues to be a significant concern for healthcare providers. Numerous approaches have been studied to meet the care needs of patients who frequently seek care in the ED; however, there is no comprehensive review of the current literature base. As such, a current understanding of the interventions initiated within the ED to address the needs of frequent users is required. This mapping review had three objectives: identify the characteristics associated with the need to frequently seek care in the ED; identify interventions implemented to address the needs of this population; and identify gaps in the current evidence base. Methods A knowledge map was created by scoping the literature to identify characteristics associated with frequent ED use and interventions implemented to address frequent use. Then, a literature search was conducted to determine what has been implemented by EDs to reduce frequent ED use. The literature was searched from 2013 to January 2023. MeSH terms and keywords were used to identify relevant studies. Studies implementing an intervention for those with characteristics associated with frequent ED use and reporting on ED use were included. Results Twenty-three (23) controlled trials and 35 observational studies were included. The most common populations were older adults, those with chronic conditions, and generic “frequent users”. No studies assessed Indigenous Peoples or racial minorities, and few assessed patients with a disability or patients experiencing homelessness. The most common interventions were referrals, care plans, case management, care coordination, and follow-up phone calls. Most studies reported ED revisits, hospitalization, costs, length-of-stay, or outpatient utilization. Few assessed patient or staff perspectives. About one-third of studies (n = 24) reported significant reductions in ED revisits. Conclusions Similar interventions, mainly focused on care coordination and planning, have been implemented to address frequent use of the ED. There are still significant gaps in the populations that have been studied. Efforts now must be undertaken to study more diverse populations whose care needs are not being met elsewhere and thus frequent the ED often.
Open Access
A multi-step approach to developing a health system evaluation framework for community-based health care
(2022-07-09) Ludlow, Natalie C.; de Grood, Jill; Yang, Connie; Murphy, Sydney; Berg, Shannon; Leischner, Rick; McBrien, Kerry A.; Santana, Maria J.; Leslie, Myles; Clement, Fiona; Cepoiu-Martin, Monica; Ghali, William A.; McCaughey, Deirdre
Abstract Background Community-based health care (CBHC) is a shift towards healthcare integration and community services closer to home. Variation in system approaches harkens the need for a conceptual framework to evaluate outcomes and impacts. We set out to develop a CBHC-specific evaluation framework in the context of a provincial ministry of health planning process in Canada. Methods A multi-step approach was used to develop the CBHC evaluation framework. Modified Delphi informed conceptualization and prioritization of indicators. Formative research identified evaluation framework elements (triple aim, global measures, and impact), health system levels (tiers), and potential CBHC indicators (n = 461). Two Delphi rounds were held. Round 1, panelists independently ranked indicators on CBHC relevance and health system tiering. Results were analyzed by coding agreement/disagreement frequency and central tendency measures. Round 2, a consensus meeting was used to discuss disagreement, identify Tier 1 indicators and concepts, and define indicators not relevant to CBHC (Tier 4). Post-Delphi, indicators and concepts were refined, Tier 1 concepts mapped to the evaluation framework, and indicator narratives developed. Three stakeholder consultations (scientific, government, and public/patient communities) were held for endorsement and recommendation. Results Round 1 Delphi results showed agreement for 300 and disagreement for 161 indicators. Round 2 consensus resulted in 103 top tier indicators (Tier 1 = 19, Tier 2 = 84), 358 bottom Tier 3 and 4 indicators, non-CBHC measure definitions, and eight Tier 1 indicator concepts—Mortality/Suicide; Quality of Life, and Patient Reported Outcome Measures; Global Patient Reported Experience Measures; Cost of Care, Access to Integrated Primary Care; Avoidable Emergency Department Use; Avoidable Hospitalization; and E-health Penetration. Post Delphi results refined Tier 3 (n = 289) and 4 (n = 69) indicators, and identified 18 Tier 2 and 3 concepts. When mapped to the evaluation framework, Tier 1 concepts showed full coverage across the elements. ‘Indicator narratives’ depicted systemness and integration for evaluating CBHC. Stakeholder consultations affirmed endorsement of the approach and evaluation framework; refined concepts; and provided key considerations to further operationalize and contextualize indicators, and evaluate CBHC as a health system approach. Conclusions This research produced a novel evaluation framework to conceptualize and evaluate CBHC initiatives. The evaluation framework revealed the importance of a health system approach for evaluating CBHC.
Open Access
An Economic Evaluation of a Novel Electronic Discharge Communication Tool
(2017) Sevick, Laura; Clement, Fiona; Ghali, William; Santana, Maria
The transition from acute-care hospitalization to community-based care is a vulnerable period in healthcare delivery due to potential for post-discharge adverse events. This vulnerability has been attributed to the miscommunication between acute and community-based physicians, as current systems do not control for legibility, completeness or timeliness of the discharge summary. One potential approach to bridging this communication gap is the use of electronic discharge communication tools, which can be designed to ensure the consistent and timely transfer of information. Given the limited healthcare budget, the costs and benefits of these tools should be considered prior to large scale implementation. Thus, the goal of this thesis is to establish the cost-effectiveness of electronic discharge communication tools. To achieve this, a systematic review of published literature was conducted (Chapter 2), a prospective economic evaluation of a novel electronic discharge communication tool was completed (Chapter 3), and policy options/considerations were presented (Chapter 4).
Open Access
Co-designing strategies to support patient partners during a scoping review and reflections on the process: a commentary
(2021-05-10) McCarron, Tamara L; Clement, Fiona; Rasiah, Jananee; Moffat, Karen; Wasylak, Tracy; Santana, Maria Jose
Abstract Background Patient partners can be described as individuals who assume roles as active members on research teams, indicative of individuals with greater involvement, increased sharing of power, and increased responsibility than traditionally described by patient participants who are primarily studied. A gap still remains in the understanding of how to engage patients. The objective of this commentary is to describe the involvement of four patient partners who worked with researchers during a scoping review. Main body We describe approaches to meaningfully engage patient partners in conducting a scoping review. Patient partners were recruited through existing patient networks. Capacity development in the form of the training was provided to these four patient partners. Engagement strategies were co-designed with them to address potential barriers of involvement and acquiring the necessary skills for the successful completion of this scoping review. Conclusion Involving patients partners early in the project established the foundational relationship so patient partners could contribute to their fullest. We witnessed the success of working alongside patient partners as members of the research team with a clear and mutually agreed upon purpose of the engagement in health research activities and how this seemed to contribute to an effective and rewarding experience for both researcher and patient partner.
Open Access
Cost-effectiveness of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors: An Economic Evaluation
(2017) Zhang, Ziyu; Clement, Fiona; McBrien, Kerry; Spackman, Eldon
Familial hypercholesterolemia is an autosomal inherited genetic disorder characterized by high levels of low-density lipoprotein cholesterol circulating in the bloodstream. If left untreated, this condition can substantially increase cardiovascular risk, lead to the rapid development of premature coronary artery disease, or cause sudden cardiac death. Despite the high risks associated with familial hypercholesterolemia, a considerable number of these individuals are unable to achieve adequate reductions in low-density lipoprotein cholesterol levels with conventional lipid lowering therapy. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are emerging pharmacological treatments for managing patients with these conditions. Therefore, the goal of this thesis is to assess the cost-effectiveness of PCSK9 inhibitors for the treatment of elevated low-density lipoprotein cholesterol in individuals with familial hypercholesterolemia.
Open Access
Costs of the Acute Respiratory Distress Syndrome
(2023-11-29) Boucher, Paul; Clement, Fiona; Noseworthy, Tom; McBrien, Kerry
The acute respiratory distress syndrome (ARDS) is an inflammatory condition of the lungs and is a common condition in adult intensive care units (ICU). The resources required and costs of care for patients with ARDS are substantial due to the severity of illness, resource intensity and extended lengths of stay. There are two parts to this thesis: to systematically review the costing literature in ARDS and to perform a costing study of a cohort of patients with ARDS. The systematic review searched the literature through to April 29, 2021 for articles relevant to ARDS and costs. 4633 publications were found of which 110 were included for full-text review. A total of 22 publications met inclusion criteria and were kept for the final analysis. The assessment was done independently by two reviewers and the systematic review followed PRISMA guidelines. Quality assessment was done using a modified version of the Quality of Health Economic Studies Instrument. This review helped contextualize the results of the costing study. The aim of the costing study was to calculate both hospital inpatient costs and post discharge costs for the three years that followed for patients with ARDS. Clinical factors associated with costs during both the time periods were examined. The costing study was done on a cohort of 585 patients with ARDS who were prospectively identified using a standardized screening protocol in the 4 adults ICUs in Calgary, Alberta, Canada. The post discharge costs were calculated on 364 patients who survived their initial hospital stay and had a traceable, valid Alberta postal codes at the end of the three year follow-up period.
Open Access
Economic Evaluation of a Human Papillomavirus Vaccination Program for Grade 5 Boys in Alberta
(2017) Kim, Jong; Clement, Fiona; Musto, Richard; Strong, David; Chuck, Anderson
Vaccination prevents Human papillomavirus (HPV) associated diseases. This study is a cost-utility analysis about adding boys to the HPV immunization program for girls in an Albertan and Canadian context, using a decision tree based model. Individuals in Grade 5 can be a boy or girl, and vaccinated or not vaccinated. Then, they can get a disease; and either survive or die. Included diseases were cervical, anal, head and neck, vaginal, vulvar, penile cancers, and anogenital warts. Parameters were adjusted to 2016 Canadian dollar and discounted 5% annually. The incremental cost effectiveness ratio (ICER) per quality adjusted life years for adding boys to the girls-only vaccination is $333,420. In sensitivity analysis, discount rate and herd immunity had the largest impact. Given the female coverage rate in Alberta, additional vaccination of boys would not be cost-effective because herd immunity reduces benefits. Policy justification of adding boys should expand beyond cost-effectiveness.
Open Access
The Economic Impact of Dietary Sodium Reduction in Canada
(2017-12-21) Qureshi, Hena; McBrien, Kerry; Campbell, Norman; Clement, Fiona
OBJECTIVES: To determine the cost-utility of dietary sodium reduction in the Canadian population, given on the anticipated effect on incident cardiovascular disease (CVD). METHODS: The Canadian Cardiovascular Disease Policy Model is a state transition model, which simulates CVD events, healthcare costs and consequences from the perspective of a publically funded healthcare system for the Canadian population. We evaluated the economic impact of reducing the dietary sodium intake of Canadian adults. RESULTS: Over a 50-year time horizon, reducing dietary sodium by 1800 mg/day is projected to reduce the cumulative incidence of coronary heart disease and stroke by 2.66% and 4.45% respectively, while decreasing the total number of myocardial infarctions and strokes by 2.23% and 4.45% respectively. The model predicted a decrease in overall mortality of 0.47%, a gain of 1.22 million QALYs, and a savings of $20.7 billion in healthcare costs. CONCLUSION: Reducing dietary sodium intake at the population level has the potenital to substantially decrease healthcare costs and improve health outcomes.
Open Access
Estimating additional health and social costs in eating disorder care for young people during the COVID-19 pandemic: implications for surveillance and system transformation
(2024-04-26) Obeid, Nicole; Coelho, Jennifer S.; Booij, Linda; Dimitropoulos, Gina; Silva-Roy, Patricia; Bartram, Mary; Clement, Fiona; de Oliveira, Claire; Katzman, Debra K.
Abstract Background The impact of the COVID-19 pandemic on young people with eating disorders (EDs) and their families was profound, with surging rates of hospitalizations and referrals reported internationally. This paper provides an account of the additional health and social costs of ED care for young people living in Canada incurred during the COVID-19 pandemic, drawing attention to the available data to inform these estimates while noting gaps in data capacities to account for a full view of the ED system of care. Methods Three methodologies were used to capture costs: (1) provincial administrative data holdings available at the Canadian Institute of Health Information (CIHI) were used by Deloitte Access Economics to conduct analyses on costs related to hospitalizations, emergency room visits, outpatient visits with physicians and loss of well-being from being on a waitlist. These were examined across three fiscal years (April 1 to March 31, 2019–2022) to compare costs from one year before to two years after the onset of the pandemic, (2) data collected on support-based community ED organizations and, (3) costs identified by young people, caregivers and health care professionals. Results Estimates of additional health care costs and social costs arising from ED care waitlists were estimated to have increased by 21% across the two years after the onset of the pandemic and is likely to represent an underestimate of costs. Costs related to some standard ED care services (e.g. day treatment programs) and support-based community ED organizations that saw a 118% increase in services during this time, are some examples of costs not captured in the current cost estimate. Conclusions This paper provides a first account of the additional health and social ED care costs associated with the pandemic, which indicate at minimum, a 21% increase. The results invite discussion for more investments in ED services for young people in Canada, as it is unclear if needs are expected to remain elevated. We suggest a call for a national surveillance strategy to improve data holdings to aid in managing services and informing policy. A robust strategy could open the door for much-needed, data-informed, system transformation efforts that can improve ED care for youth, families and clinicians.
Open Access
Knowledge translation and health technology reassessment: identifying synergy
(2018-08-30) Esmail, Rosmin; Hanson, Heather; Holroyd-Leduc, Jayna; Niven, Daniel J; Clement, Fiona
Abstract Background Health Technology Reassessment (HTR) is an emerging field that shifts the focus from traditional methods of technology adoption to managing technology throughout its lifecycle. HTR is a mechanism to improve patient care and system efficiency through a reallocation of resources away from low-value care towards interventions and technologies that are high value. To achieve this, the outputs of HTR and its recommendations must be translated into practice. The evolving field of knowledge translation (KT) can provide guidance to improve the uptake of evidence-informed policies and recommendations resulting from the process of HTR. This paper argues how the theories, models and frameworks from KT could advance the HTR process. Discussion First, common KT theories, models and frameworks are presented. Second, facilitators and barriers to KT within the context of HTR are summarized from the literature. Facilitators and barriers to KT include ensuring a solid research evidence-base for the technology under reassessment, assessing the climate and context, understanding the social an political context, initiating linkage and exchange, having a structured HTR Process, adequate resources, and understanding the roles of researchers, knowledge users, and stakeholders can enhance knowledge translation of HTR outputs. Third, three case examples at the individual (micro), organizational (meso), and policy (macro) levels are used to illustrate to describe how a KT theory, model or framework could be applied to a HTR project. These case studies show how selecting and applying KT theories, models and frameworks can facilitate the implementation of HTR recommendations. Conclusion HTR and KT are synergistic processes that can be used to optimize technology use throughout its lifecycle. We argue that the application of KT theories, models and frameworks, and the assessment of barriers and facilitators to KT can facilitate translation of HTR recommendations into practice.
Open Access
Optimizing Value from Cardiac Rehabilitation: A Cost-Utility Analysis Comparing Age, Sex and Clinical Subgroups
(2014-05-23) Leggett, Laura; Clement, Fiona
Background: Cardiac rehabilitation reduces mortality and subsequent cardiac events in patients with coronary heart disease. While economic evaluations of cardiac rehabilitation have been published, none consider clinical, age and sex subgroups to demonstrate how the cost-effectiveness varies. Methods: We performed a cost-utility analysis comparing cardiac rehabilitation with no cardiac rehabilitation, for patients who had a cardiac catheterization, using a health system payer perspective. The model was stratified by clinical presentation, age and sex. Clinical, quality of life and cost data were provided by the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) and TotalCardiology. Data on efficacy was obtained from a meta-analysis of randomized controlled trials. Results: The incremental cost per quality-adjusted life year (QALY) gained for cardiac rehabilitation is $37,662. The incremental cost per QALY gained varies by subgroup, from $18,101 per QALY gained to $104,518 per QALY gained. There is significant uncertainty in the estimates due to uncertainty in the clinical effectiveness of cardiac rehabilitation. Overall, the probabilistic sensitivity analysis found that 75% of the time, cardiac rehabilitation is more effective and expensive than no cardiac rehabilitation. Conclusions: The cost-effectiveness of cardiac rehabilitation varies depending on patient characteristics. However, irrespective of baseline characteristics, the cost per QALY gained for cardiac rehabilitation is less than or similar to other technologies funded in many health systems. The current analysis indicates that cardiac rehabilitation is most cost effective for those who suffered an ACS and those who are at higher risk for subsequent cardiac events. The findings of the current study provide insight into who may benefit most from cardiac rehabilitation, with important implications for patient referral patterns.
Open Access
Overview of the Alberta Kidney Disease Network
(BioMed Central, 2009-10-19) Hemmelgarn, Brenda; Clement, Fiona; Manns, Braden J.; Klarenbach, Scott; James, Matthew T.; Ravani, Pietro; Pannu, Neesh; Ahmed, Sofia B; MacRae, Jennifer; Scott-Douglas, Nairne; Jindal, Kailash; Quinn, Robert; Culleton, Bruce F.; Wiebe, Natasha; Krause, Richard; Thorlacius, Laurel; Tonelli, Marcello
Open Access
Palliative care in the home: a scoping review of study quality, primary outcomes, and thematic component analysis
(2018-03-07) Hofmeister, Mark; Memedovich, Ally; Dowsett, Laura E; Sevick, Laura; McCarron, Tamara; Spackman, Eldon; Stafinski, Tania; Menon, Devidas; Noseworthy, Tom; Clement, Fiona
Abstract Background The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work. Methods A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the “home of the patient” as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions. Results Fifty-three studies formed the final data set. The literature varied extensively. Five themes were identified: accessibility of healthcare, caregiver support, individualized patient centered care, multidisciplinary care provision, and quality improvement. Primary outcomes were resource use, symptom burden, quality of life, satisfaction, caregiver distress, place of death, cost analysis, or described experiences. The majority of studies were of moderate or unclear quality. Conclusions There is robust literature of varying quality, assessing different components of palliative care in the home interventions, and measuring different outcomes. To be meaningful to patients, these interventions need to be consistently evaluated with outcomes that matter to patients. Future research could focus on reaching a consensus for outcomes to evaluate palliative care in the home interventions.
Open Access
Patient and family involvement in Choosing Wisely initiatives: a mixed methods study
(2022-04-07) de Grood, Chloe; Sypes, Emma E.; Niven, Daniel J.; Clement, Fiona; FitzGerald, Emily A.; Kupsch, Shelly; King-Hunter, Shelly; Stelfox, Henry T.; Parsons Leigh, Jeanna
Abstract Background Patients are important stakeholders in reducing low-value care, yet mechanisms for optimizing their involvement in low-value care remain unclear. To explore the role of patients in the development and implementation of Choosing Wisely recommendations to reduce low-value care and to assess the likelihood that existing patient resources will change patient health behaviour. Methods Three phased mixed-methods study: 1) content analysis of all publicly available Choosing Wisely clinician lists and patient resources from the United States of America and Canada. Quantitative data was summarized with frequencies and free text comments were analyzed with qualitative thematic content analysis; 2) semi-structured telephone interviews with a purposive sample of representatives of professional societies who created Choosing Wisely clinician lists and members of the public (including patients and family members). Interviews were transcribed verbatim, and two researchers conducted qualitative template analysis; 3) evaluation of Choosing Wisely patient resources. Two public partners were identified through the Calgary Critical Care Research Network and independently answered two free text questions “would this change your health behaviour” and “would you discuss this material with a healthcare provider”. Free text data was analyzed by two researchers using thematic content analysis. Results From the content analysis of 136 Choosing Wisely clinician lists, six reported patient involvement in their development. From 148 patient resource documents that were mapped onto a conceptual framework (Inform, Activate, Collaborate) 64% described patient engagement at the level of Inform (educating patients). From 19 interviews stakeholder perceptions of patient involvement in reducing low-value care were captured by four themes: 1) impact of perceived power dynamics on the discussion of low-value care in the clinical interaction, 2) how to communicate about low-value care, 3) perceived barriers to patient involvement in reducing low-value care, and 4) suggested strategies to engage patients and families in Choosing Wisely initiatives. In the final phase of work in response to the question “would this change your health behaviour” two patient partners agreed ‘yes’ on 27% of patient resources. Conclusions Opportunities exist to increase patient and family participation in initiatives to reduce low-value care.
Open Access
Radiofrequency Ablation for Chronic Low Back Pain: A Systematic Review of Randomized Controlled Trials
(2014-01-01) Leggett, Laura E; Soril, Lesley JJ; Lorenzetti, Diane L; Noseworthy, Tom; Steadman, Rodney; Tiwana, Simrandeep; Clement, Fiona
BACKGROUND: Radiofrequency ablation (RFA), a procedure using heat to interrupt pain signals in spinal nerves, is an emerging treatment option for chronic low back pain. Its clinical efficacy has not yet been established.OBJECTIVE: To determine the efficacy of RFA for chronic low back pain associated with lumbar facet joints, sacroiliac joints, discogenic low back pain and the coccyx.METHODS: A systematic review was conducted. Medline, EMBASE, PubMed, SPORTDiscus, CINAHL and the Cochrane Library were searched up to August 2013. Abstracts and full-text articles were reviewed in duplicate. Included articles were sham-controlled randomized controlled trials (RCTs), assessed the efficacy of RFA, reported at least one month of follow-up and included participants who had experienced back pain for at least three months. Data were extracted in duplicate and quality was assessed using the Cochrane Risk of Bias tool. Due to heterogeneity, as well as a lack of reported mean differences and SDs, meta-analysis was not possible using these data.RESULTS: The present systematic review retrieved 1063 abstracts. Eleven sham-controlled RCTs were included: three studies involving discogenic back pain; six studies involving lumbar facet joint pain; and two studies involving sacroiliac joint pain. No studies were identified assessing the coccyx. The evidence supports RFA as an efficacious treatment for lumbar facet joint and sacroiliac joint pain, with five of six and both of the RCTs demonstrating statistically significant pain reductions, respectively. The evidence supporting RFA for the treatment of discogenic pain is mixed.CONCLUSIONS: While the majority of the studies focusing on lumbar facet joints and sacroiliac joints suggest that RFA significantly reduces pain in short-term follow-up, the evidence base for discogenic low back pain is mixed. There is no RCT evidence for RFA for the coccyx. Future studies should examine the clinical significance of the achieved pain reduction and the long-term efficacy of RFA.
Open Access
Risk of transmission of respiratory viruses during aerosol-generating medical procedures (AGMPs) revisited in the COVID-19 pandemic: a systematic review
(2022-08-11) Leal, Jenine; Farkas, Brenlea; Mastikhina, Liza; Flanagan, Jordyn; Skidmore, Becky; Salmon, Charleen; Dixit, Devika; Smith, Stephanie; Tsekrekos, Stephen; Lee, Bonita; Vayalumkal, Joseph; Dunn, Jessica; Harrison, Robyn; Cordoviz, Melody; Dubois, Roberta; Chandran, Uma; Clement, Fiona; Bush, Kathryn; Conly, John; Larios, Oscar
Abstract Background In many jurisdictions healthcare workers (HCWs) are using respirators for aerosol-generating medical procedures (AGMPs) performed on adult and pediatric populations with all suspect/confirmed viral respiratory infections (VRIs). This systematic review assessed the risk of VRIs to HCWs in the presence of AGMPs, the role respirators versus medical/surgical masks have on reducing that risk, and if the risk to HCWs during AGMPs differed when caring for adult or pediatric patient populations. Main text We searched MEDLINE, EMBASE, Cochrane Central, Cochrane SR, CINAHL, COVID-19 specific resources, and MedRxiv for English and French articles from database inception to September 9, 2021. Independent reviewers screened abstracts using pre-defined criteria, reviewed full-text articles, selected relevant studies, abstracted data, and conducted quality assessments of all studies using the ROBINS-I risk of bias tool. Disagreements were resolved by consensus. Thirty-eight studies were included; 23 studies on COVID-19, 10 on SARS, and 5 on MERS/ influenza/other respiratory viruses. Two of the 16 studies which assessed associations found that HCWs were 1.7 to 2.5 times more likely to contract COVID-19 after exposure to AGMPs vs. not exposed to AGMPs. Eight studies reported statistically significant associations for nine specific AGMPs and transmission of SARS to HCWS. Intubation was consistently associated with an increased risk of SARS. HCWs were more likely (OR 2.05, 95% CI 1.2–3.4) to contract human coronaviruses when exposed to an AGMP in one study. There were no reported associations between AGMP exposure and transmission of influenza or in a single study on MERS. There was limited evidence supporting the use of a respirator over a medical/surgical mask during an AGMP to reduce the risk of viral transmission. One study described outcomes of HCWs exposed to a pediatric patient during intubation. Conclusion Exposure to an AGMP may increase the risk of transmission of COVID-19, SARS, and human coronaviruses to HCWs, however the evidence base is heterogenous and prone to confounding, particularly related to COVID-19. There continues to be a significant research gap in the epidemiology of the risk of VRIs among HCWs during AGMPs, particularly for pediatric patients. Further evidence is needed regarding what constitutes an AGMP.
Open Access
Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review
(2024-02-01) Memedovich, Ally; Asante, Benedicta; Khan, Maha; Eze, Nkiruka; Holroyd, Brian R.; Lang, Eddy; Kashuba, Sherri; Clement, Fiona
Abstract Background Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized. Methods A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible. Results Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives. Conclusion Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients’ needs should focus on interventions initiated outside the ED.
Open Access
Sustainment, Sustainability, and Spread Study (SSaSSy): protocol for a study of factors that contribute to the sustainment, sustainability, and spread of practice changes introduced through an evidence-based quality-improvement intervention in Canadian nursing homes
(2019-12-19) Berta, Whitney B; Wagg, Adrian; Cranley, Lisa; Doupe, Malcolm B; Ginsburg, Liane; Hoben, Matthias; MacEachern, Lauren; Chamberlain, Stephanie; Clement, Fiona; Easterbrook, Adam; Keefe, Janice M; Knopp-Sihota, Jennifer; Rappon, Tim; Reid, Colin; Song, Yuting; Estabrooks, Carole A
Abstract Background Implementation scientists and practitioners, alike, recognize the importance of sustaining practice change, however post-implementation studies of interventions are rare. This is a protocol for the Sustainment, Sustainability and Spread Study (SSaSSy). The purpose of this study is to contribute to knowledge on the sustainment (sustained use), sustainability (sustained benefits), and spread of evidence-based practice innovations in health care. Specifically, this is a post-implementation study of an evidence-informed, Care Aide-led, facilitation-based quality-improvement intervention called SCOPE (Safer Care for Older Persons (in long-term care) Environments). SCOPE has been implemented in nursing homes in the Canadian Provinces of Manitoba (MB), Alberta (AB) and British Columbia (BC). Our study has three aims: (i) to determine the role that adaptation/contextualization plays in sustainment, sustainability and spread of the SCOPE intervention; (ii) to study the relative effects on sustainment, sustainability and intra-organizational spread of high-intensity and low-intensity post-implementation “boosters”, and a “no booster” condition, and (iii) to compare the relative costs and impacts of each booster condition. Methods/design SSaSSy is a two-phase mixed methods study. The overarching design is convergent, with qualitative and quantitative data collected over a similar timeframe in each of the two phases, analyzed independently, then merged for analysis and interpretation. Phase 1 is a pilot involving up to 7 units in 7 MB nursing homes in which SCOPE was piloted in 2016 to 2017, in preparation for phase 2. Phase 2 will comprise a quasi-experiment with two treatment groups of low- and high-intensity post-implementation “boosters”, and an untreated control group (no booster), using pretests and post-tests of the dependent variables relating to sustained care and management practices, and resident outcomes. Phase 2 will involve 31 trial sites in BC (17 units) and AB (14 units) nursing homes, where the SCOPE trial concluded in May 2019. Discussion This project stands to advance understanding of the factors that influence the sustainment of practice changes introduced through evidence-informed practice change interventions, and their associated sustainability. Findings will inform our understanding of the nature of the relationship of fidelity and adaptation to sustainment and sustainability, and afford insights into factors that influence the intra-organizational spread of practice changes introduced through complex interventions.
Open Access
The Brain in Motion II Study: study protocol for a randomized controlled trial of an aerobic exercise intervention for older adults at increased risk of dementia
(2021-06-14) Krüger, Renata L.; Clark, Cameron M.; Dyck, Adrienna M.; Anderson, Todd J.; Clement, Fiona; Hanly, Patrick J.; Hanson, Heather M.; Hill, Michael D.; Hogan, David B.; Holroyd-Leduc, Jayna; Longman, R. S.; McDonough, Meghan; Pike, G. B.; Rawling, Jean M.; Sajobi, Tolulope; Poulin, Marc J.
Abstract Background There remains no effective intervention capable of reversing most cases of dementia. Current research is focused on prevention by addressing risk factors that are shared between cardiovascular disease and dementia (e.g., hypertension) before the cognitive, functional, and behavioural symptoms of dementia manifest. A promising preventive treatment is exercise. This study describes the methods of a randomized controlled trial (RCT) that assesses the effects of aerobic exercise and behavioural support interventions in older adults at increased risk of dementia due to genetic and/or cardiovascular risk factors. The specific aims are to determine the effect of aerobic exercise on cognitive performance, explore the biological mechanisms that influence cognitive performance after exercise training, and determine if changes in cerebrovascular physiology and function persist 1 year after a 6-month aerobic exercise intervention followed by a 1-year behavioural support programme (at 18 months). Methods We will recruit 264 participants (aged 50–80 years) at elevated risk of dementia. Participants will be randomly allocated into one of four treatment arms: (1) aerobic exercise and health behaviour support, (2) aerobic exercise and no health behaviour support, (3) stretching-toning and health behaviour support, and (4) stretching-toning and no health behaviour support. The aerobic exercise intervention will consist of three supervised walking/jogging sessions per week for 6 months, whereas the stretching-toning control intervention will consist of three supervised stretching-toning sessions per week also for 6 months. Following the exercise interventions, participants will receive either 1 year of ongoing telephone behavioural support or no telephone support. The primary aim is to determine the independent effect of aerobic exercise on a cognitive composite score in participants allocated to this intervention compared to participants allocated to the stretching-toning group. The secondary aims are to examine the effects of aerobic exercise on a number of secondary outcomes and determine whether aerobic exercise-related changes persist after a 1-year behavioural support programme (at 18 months). Discussion This study will address knowledge gaps regarding the underlying mechanisms of the pro-cognitive effects of exercise by examining the potential mediating factors, including cerebrovascular/physiological, neuroimaging, sleep, and genetic factors that will provide novel biologic evidence on how aerobic exercise can prevent declines in cognition with ageing. Trial registration ClinicalTrials.gov NCT03035851 . Registered on 30 January 2017
Open Access
Trends in Canadian prescription drug purchasing: 2001–2020
(2022-03-17) Hofmeister, Mark; Sivakumar, Ashwinie; Clement, Fiona; Hayes, Kaleen N.; Law, Michael; Guertin, Jason R.; Neville, Heather L.; Tadrous, Mina
Abstract Background In 2019, more than $34.5 billion was spent on prescription drugs in Canada. However, little is known about the distribution of this spending across medications and settings (outpatient and inpatient) over time. The objective of this paper is to describe the largest expenditures by medication class over time in inpatient and outpatient settings. This information can help to guide policies to control prescription medication expenditures. Methods IQVIA’s Canadian Drugstore and Hospital Purchases Audit data from January 1, 2001, to December 31, 2020, were used. In this dataset, purchasing was stratified by outpatient drugstore and inpatient hospital. Spending trajectories in both settings were compared to total expenditure over time. Total expenditure of the 25 medications with the largest expenditure were compared over time, stratified by setting. Nominal costs were used for all analysis. Results In 2001, spending in the outpatient and inpatient settings was greatest on atorvastatin ($467.0 million) and erythropoietin alpha ($91.2 million), respectively. In 2020, spending was greatest on infliximab at $1.2 billion (outpatient) and pembrolizumab at $361.6 million (inpatient). Annual outpatient spending, although increasing, has been growing at a slower rate (5.3%) than inpatient spending (7.0%). In both settings, spending for the top 25 medications has become increasingly concentrated on biologic agents, with a reduction in the diversity of therapeutic classes of agents over time. Discussion Identification of the concentration on spending on biologic agents is a key step in managing costs of prescription medications in Canada. Given the increases in spending on biologic agents over the last 20 years, current cost-control mechanisms may be insufficient. Future research efforts should focus on examining the effectiveness of current cost-control mechanisms and identifying new approaches to cost control for biologic agents.