Browsing by Author "Clement, Fiona M."
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Item Open Access An Economic Evaluation of the Syncope: Pacing or Recording in the Later Years (SPRITELY) Trial(2018-07-06) Hofmeister, Mark Ronald; Clement, Fiona M.; Spackman, David Eldon; Sheldon, Robert S.The Syncope: Pacing or Recording In ThE Later Years (SPRITELY) trial tests the hypothesis that pacemaker insertion in patients with syncope, bifascicular block, and age greater than 50 years prevents syncope recurrences and major clinical events more effectively than therapy guided by monitoring with an implantable loop recorder. Equipoise or uncertainty reflected in guidelines and recommendations for both strategies may contribute to variation in management and inefficient resource use. Clinical analysis of the SPRITELY trial is complemented with an economic evaluation. The goal of this thesis was to establish the relative cost-effectiveness of the implantable loop recorder and the pacemaker in patients with bifascicular block, unexplained syncope, and age greater than 50 years. An economic evaluation of the SPRITELY trial was conducted to match the prespecified time horizon of two years for the clinical analysis (Chapter 3), and a decision analytic model was built to extend the time horizon to three years to match clinical practice (Chapter 4). In Chapter 5, the effect of taking three different national perspectives for the SPRITELY trial evaluation was explored. This thesis ends with a discussion and conclusions in Chapter 6.Item Open Access Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review(2022-04-21) Kjelle, Elin; Andersen, Eivind R.; Krokeide, Arne M.; Soril, Lesley J. J.; van Bodegom-Vos, Leti; Clement, Fiona M.; Hofmann, Bjørn M.Abstract Background Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. Methods A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. Results A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. Conclusions A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. Systematic review registration: PROSPERO: CRD42020208072.Item Open Access The Effects of Cannabis and Alcohol on Driving Performance and Driver Behaviour: A Systematic Review and Meta-Analysis(2020-08-12) Simmons, Sarah Michelle; Caird, Jeff K.; O'Neill, Thomas A.; Steel, Piers D.G.; Clement, Fiona M.; Asbridge, MarkCannabis is the most frequently used drug in the world, and it is commonly detected in fatal crashes. Epidemiological research indicates that cannabis is associated with an increase in crash risk, but the mechanisms underlying this association remain unclear. The objective of the current systematic review and meta-analysis is to provide insight into these mechanisms by synthesizing experimental research focused on the effects of cannabis on driving performance and behaviour. Additionally, the experimental literature focused on the effects of alcohol on driving performance and behaviour is synthesized for comparative purposes. The four key aims of this dissertation are to (1) quantify the magnitude of the effect of cannabis on driving performance and behaviour; (2) compare the influence of cannabis to that of alcohol; (3) assess the effect of the combination of cannabis and alcohol on driving performance and behaviour; and, (4) identify knowledge gaps and quality limitations in the extant literature to direct the conduct of high quality research in the future. Academic Search Complete, CINAHL, Embase, Scopus, MEDLINE, PsycINFO, SportDISCUS and TRID were systematically searched in May 2018. Driving performance and behaviour data from experimental driving studies involving healthy participants of any age and sex collected in driving simulator, closed-course and on-road studies involving cannabis and/or alcohol administration, published in any language, were eligible for inclusion. Of 120 eligible studies, 81 were ultimately included in the meta-analysis. Most notably, cannabis was associated with impaired lateral control and decreased driving speed. Alcohol was associated with a variety of driving performance decrements and increased driving speed. The combination of drugs was associated with greater driving performance decrements than either drug in isolation. Finally, indirect comparisons indicated that the effects of cannabis on experimental driving measures were generally similar to low blood alcohol concentrations. However, imprecision in effect size estimates limits interpretation, and more research in the area is needed. Future research directions and quality recommendations are identified and described to aid in this endeavour. Nonetheless, the meta-analysis indicates that cannabis, like alcohol, impairs driving, and the combination of the two drugs is more detrimental to driving performance than either in isolation.Item Open Access Forecasting the Future: A Trek through the Changing Landscape of Inflammatory Bowel Disease(2019-06-06) Coward, Stephanie; Kaplan, Gilaad G.; Clement, Fiona M.; McBrien, Kerry Alison; Hazlewood, Glen S.; Congly, Stephen E.Inflammatory bowel disease (IBD) is an immune-mediated disease of the gastrointestinal tract. It imparts a lifelong burden once diagnosed, which can lead to medication reliance, hospitalizations, and surgeries. Previous research has elucidated the current state of knowledge on IBD, but what is missing from the field are analyses of IBD-related outcomes within a specific population, and analyses of what these outcomes mean for the future of IBD in that population.1,2 Therefore, the aim of this thesis is to give an overarching understanding of the current burden of IBD; forecast the future burden; and, illustrate what these findings mean for the future of Canadians and our healthcare systems. Administrative data were used to identify prevalent cases from seven provinces (95% of the Canadian population). In Alberta specifically, prevalent and incident cases were isolated and data on hospitalizations, surgeries, medications, and all-cause mortality data were obtained. Using regression analyses, temporal trends of prevalence, incidence, hospitalization (total, IBD-related, and IBD-specific), surgery, biologics (an expensive medication increasing in popularity for the treatment of IBD), and mortality were analyzed. Data on prevalence from all seven provinces were analyzed and forecasted to 2030. Alberta-specific data were used to forecast incidence to 2030, and hospitalizations and surgeries to 2021. Overall, the prevalence of IBD in Canada is significantly increasing. By 2030, an estimated 402,853 Canadians will be living with IBD. In Alberta, incidence is forecasted to continue to significantly decrease from 2015 through to 2030. Hospitalizations and surgeries have also been significantly decreasing in Alberta and are forecasted to continue decreasing through to 2021. The proportion of patients dispensed biologics has been significantly increasing, which is indicative of an increasing utilization of this medication. Finally, the mortality rate has remained stable. While the decrease of adverse IBD-related outcomes (e.g., hospitalization and surgery) prove to be beneficial for patients with IBD and healthcare systems, the significant increase in the number of people with the disease may still overwhelm the system and inhibit patients from receiving necessary care.Item Open Access A Health Technology Reassessment of Red Blood Cell Transfusions in the Intensive Care Unit(2019-08-23) Soril, Lesley Jeanne Josephine; Noseworthy, Tom W.; Clement, Fiona M.; Stelfox, Henry Thomas; Zygun, David A.Health technology reassessment (HTR) is the systematic, evidence-based assessment of the clinical, economic, ethical, and social impacts of an existing health technology to inform its optimal use. A novel model to guide HTR processes has been proposed. The overall aim of this thesis was to test the HTR model in a real-world healthcare context with the technology of red blood cell (RBC) transfusions in the intensive care unit (ICU). This thesis is comprised of 4 studies. The first study was a retrospective observational study of RBC transfusions in 9 Alberta ICUs. Between April 1, 2014 and December 31, 2016, we found that 61% of included RBC transfusions in stable, non-bleeding ICU patients were associated with a pre-transfusion hemoglobin value of 70 g/L or more and cost an estimated $1.82M in healthcare costs. Second, we conducted a systematic review and meta-analyses to determine the effectiveness of interventions on healthcare providers’ RBC transfusion practices. We identified a large and heterogenous body of evidence. Use of any intervention was associated with reduced odds of transfusion, including inappropriate transfusions. However, there was limited understanding of why interventions were selected over others and how this may have affected outcomes. In the third study, we conducted a population-based cross-sectional survey of Alberta ICU physicians to understand their perceptions of RBC transfusions practices using the Theoretical Domains Framework. We identified self-reported facilitators and barriers to practicing a guideline-recommended restrictive RBC transfusion strategy, which could then be mapped to relevant behaviour change interventions to optimize RBC transfusions. Finally, we conducted a controlled before and after pilot study to assess the feasibility of implementing a multi-modal intervention to optimize RBC transfusions in the ICU. The intervention was theory-informed and co-designed with local clinical leaders and included group education and audit and feedback. Early and meaningful stakeholder engagement and tailoring the intervention to interdisciplinary healthcare providers were important for achieving feasibility. Overall, we uncovered critical methodological and practical considerations to advance the emerging field of HTR. With regards to optimizing RBC transfusions, we established the necessary foundation to implement, monitor, and evaluate a larger-scale HTR initiative for ICUs in Alberta.Item Open Access Patient, Family Member, and Public Involvement in Identifying Low-Value Clinical Practices for De-adoption: A Mixed Methods Study of Choosing Wisely Initatives(2020-01-31) de Grood, Chloe Moira; Stelfox, Henry Thomas; Parsons-Leigh, Jeanna; Niven, Daniel J.; Clement, Fiona M.Low-value care comprises tests, treatments and procedures where the potential risks outweigh benefits for patients. Despite a growing recognition of the importance to reduce the use of low-value care, ineffective and costly clinical practices continue to be used. While Choosing Wisely and other initiatives have implemented strategies to reduce low-value care, little is known about how to best engage the public in these initiatives. The purpose of this study was to explore the role of patient, family and public members in the development and implementation of Choosing Wisely initiatives that aim to reduce low-value care. A mixed methods study design was used to address the objective through content analysis and qualitative interviews. The content analysis examined two different collections of publicly available online materials (Choosing Wisely clinician lists, i.e., Five Things Physicians and Patients Should Question; and Choosing Wisely patient resources) in order to describe members of the public involvement in Choosing Wisely list creation and development. Content analysis revealed that few members of the public were involved in the development of Choosing Wisely clinician lists. The analysis of patient resource documents suggested that the average Simple Measure of Gobbledygook (SMOG) readability score was a Grade nine level and were categorized at the patient engagement level of Inform where the documents engage the reader by providing only information. Qualitative interviews, conducted to explore future public involvement in reducing low-value care generated five overarching themes: 1) factors influencing understandings of what potentially constitutes low-value care in the clinical interaction; 2) how to communicate about low-value care; 3) perceived barriers to public involvement in the reduction of low-value care (e.g., brief clinical interaction); 4) perceived iii facilitators to public involvement in the reduction of low-value care (e.g., use of educational materials); and 5) suggested strategies to engage the public involvement in Choosing Wisely initiatives. This thesis indicates that there is public involvement in reducing low-value care is feasible and that Choosing Wisely initiatives such as identifying and participating in conversations about low-value care may be an appropriate place for such engagement.Item Open Access The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool(BioMed Central, 2012-11-21) Okoniewska, Barbara M.; Santana, Maria J.; Holroyd-Leduc, Jayna M.; Flemons, W. Ward; O'Beirne, Maeve; White, Deborah; Clement, Fiona M.; Forster, Alan; Ghali, William A.Item Open Access The Building Emotional Awareness and Mental health (BEAM) program developed with a community partner for mothers of infants: protocol for a feasibility randomized controlled trial(2023-03-09) Joyce, Kayla M.; Rioux, Charlie; MacKinnon, Anna L.; Katz, Laurence Y.; Reynolds, Kristin; Kelly, Lauren E.; Klassen, Terry; Afifi, Tracie O.; Mushquash, Aislin R.; Clement, Fiona M.; Chartier, Mariette; Xie, Elisabeth B.; Penner, Kailey E.; Hunter, Sandra; Berard, Lindsay; Tomfohr-Madsen, Lianne; Roos, Leslie E.Abstract Background Drastic increases in the rates of maternal depression and anxiety have been reported since the COVID-19 pandemic began. Most programs aim to improve maternal mental health or parenting skills separately, despite it being more effective to target both concurrently. The Building Emotional Awareness and Mental health (BEAM) program was developed to address this gap. BEAM is a mobile health program aiming to mitigate the impacts of pandemic stress on family well-being. Since many family agencies lack infrastructure and personnel to adequately treat maternal mental health concerns, a partnership will occur with Family Dynamics (a local family agency) to address this unmet need. The study’s objective is to examine the feasibility of the BEAM program when delivered with a community partner to inform a larger randomized controlled trial (RCT). Methods A pilot RCT will be conducted with mothers who have depression and/or anxiety with a child 6–18 months old living in Manitoba, Canada. Mothers will be randomized to the 10 weeks of the BEAM program or a standard of care (i.e., MoodMission). Back-end App data (collected via Google Analytics and Firebase) will be used to examine feasibility, engagement, and accessibility of the BEAM program; cost-effectiveness will also be examined. Implementation elements (e.g., maternal depression [Patient Health Questionnaire-9] and anxiety [Generalized Anxiety Disorder-7]) will be piloted to estimate the effect size and variance for future sample size calculations. Discussion In partnership with a local family agency, BEAM holds the potential to promote maternal-child health via a cost-effective and an easily accessible program designed to scale. Results will provide insight into the feasibility of the BEAM program and will inform future RCTs. Trial registration {2a} This trial was retrospectively registered with ClinicalTrial.gov ( NCT05398107 ) on May 31st, 2022.Item Open Access Understanding the Relationship Between Health Technology Reassessment and Knowledge Translation(2020-10-18) Esmail, Rosmin; Clement, Fiona M.; Hanson, Heather M.; Holroyd-Leduc, Jayna M.; Niven, Daniel J.Until now, it was not well understood how the field of Knowledge Translation (KT) would be applicable to Health Technology Reassessment (HTR). This thesis reports on three studies to determine how KT approaches are used to translate HTR outputs to achieve the desired outcomes. The first study was a scoping review of full-spectrum (phases of planning/design, evaluation, implementation, sustainability/scalability) KT Theories, Models, Frameworks (KT TMFs). Thirty-six KT TMFs were identified and categorized according to five approaches: process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. It provided a starting point for the selection of KT TMFs for HTR. The second study employed a modified Delphi process and expert survey to review the 36 full-spectrum KT TMFs and determined which may be suitable for HTR. The three-round modified Delphi process resulted in 16 KT TMFs. Twenty-two international experts (11 KT and 11 HTR) were surveyed. None of the 16 KT TMFs reached ≥ 70% agreement when ratings of “yes” were considered. However when ratings of “yes” and “partially yes” were combined, the Consolidated Framework for Implementation Research (CFIR) was considered the most suitable by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: the Knowledge-to-Action framework. HTR experts selected two additional KT TMFs: the co-KT framework and the Plan-Do-Study-Act cycle. The third study involved 13 one-to-one semi-structured interviews on characteristics of KT TMFs that were important to consider for the HTR outputs of decreased use or de-adoption of a technology. Four foundational principles, three levers of change, and five steps for knowledge to action emerged as KT TMF traits for HTR. From the KT TMFs that were mapped onto the characteristics, CFIR had the most characteristics (11/12) missing only the ability to map to the micro, meso, macro levels. This is the first body of work that examines the relationship between HTR and KT. The findings offer guidance to users on the application of KT TMFs to the HTR process and implementation of its outputs. Practical use of these KT TMFs to the HTR process will provide further advancement in this area.Item Open Access Understanding the Role of the Public in Reducing Low-value Care(2019-06-21) Sypes, Emma Elizabeth; Stelfox, Henry Thomas; Niven, Daniel J.; Parsons-Leigh, Jeanna; Clement, Fiona M.Low-value care consists of medical tests and treatments that are unnecessary, potentially harmful, or not cost-effective and contribute to rising healthcare costs, adverse events, and poor quality of care. In recent years there has been a surge in initiatives aiming to identify and reduce low-value care. However, the role of the public in reducing low-value care remains unclear. The research reported in this thesis aimed to understand the role of the public in reducing low-value care through a systematic and comprehensive review of the literature. A scoping review identified 151 relevant articles. The majority of these articles described or evaluated a strategy for involving the public in reducing low-value care; articles that explored stakeholder perspectives about the role of the public were less common. Public involvement most commonly occurred at the level of the patient-clinician interaction, followed by administrative and policy decision-making and low-value care research. Shared decision-making and patient-oriented education were the most frequent and best supported strategies. There was considerably less support for public involvement at the level of administrative and policy decision-making. A follow-up systematic review and meta-analysis was conducted to estimate the impact of patient-targeted interventions to reduce low-value care. This study found a statistically significant association between patient-targeted interventions (i.e., shared decision-making, patient-oriented education) and a decrease in use of the low-value practices (RR 0.75; 95% CI 0.66-0.84), which remained significant when the meta-analysis was restricted to randomized clinical trials with low risk of bias (RR 0.69; 95% CI 0.58-0.83). Collectively, these two studies show a considerable amount of support for engaging the public in reducing low-value care at the level of the patient-clinician interaction through strategies including shared decision-making and patient-oriented education. There is comparably less evidence to support public involvement in research or administrative and policy decision-making. Additional research to explore stakeholder perspectives and evaluate strategies for public involvement within varying contexts is required to further understand the role of the public in reducing low-value care.Item Open Access Validation of a case definition to define chronic dialysis using outpatient administrative data(BioMed Central, 2011-03-01) Clement, Fiona M.; James, Matthew T; Chin, Rick; Klarenbach, Scott W.; Manns, Braden J.; Quinn, Robert R.; Ravani, Pietro; Tonelli, Marcello; Hemmelgarn, Brenda R.; Alberta Kidney Disease Network