Browsing by Author "Manns, Braden J"

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    Attitudes, behaviours and barriers to public health measures for COVID-19: a survey to inform public health messaging
    (2021-04-21) Lang, Raynell; Benham, Jamie L; Atabati, Omid; Hollis, Aidan; Tombe, Trevor; Shaffer, Blake; Burns, Katharina K; MacKean, Gail; Léveillé, Tova; McCormack, Brandi; Sheikh, Hasan; Fullerton, Madison M; Tang, Theresa; Boucher, Jean-Christophe; Constantinescu, Cora; Mourali, Mehdi; Manns, Braden J; Marshall, Deborah A; Hu, Jia; Oxoby, Robert J
    Abstract Background Public support of public health measures including physical distancing, masking, staying home while sick, avoiding crowded indoor spaces and contact tracing/exposure notification applications remains critical for reducing spread of COVID-19. The aim of our work was to understand current behaviours and attitudes towards public health measures as well as barriers individuals face in following public health measures. We also sought to identify attitudes persons have regarding a COVID-19 vaccine and reasons why they may not accept a vaccine. Methods A cross-sectional online survey was conducted in August 2020, in Alberta, Canada in persons 18 years and older. This survey evaluated current behaviours, barriers and attitudes towards public health measures and a COVID-19 vaccine. Cluster analysis was used to identify key patterns that summarize data variations among observations. Results Of the 60 total respondents, the majority of persons were always or often physically distancing (73%), masking (65%) and staying home while sick (67%). Bars/pubs/lounges or nightclubs were visited rarely or never by 63% of respondents. Persons identified staying home while sick to provide the highest benefit (83%) in reducing spread of COVID-19. There were a large proportion of persons who had not downloaded or used a contact tracing/exposure notification app (77%) and who would not receive a COVID-19 vaccine when available (20%) or were unsure (12%). Reporting health authorities as most trusted sources of health information was associated with greater percentage of potential uptake of vaccine but not related to contact tracing app download and use. Individuals with lower concern of getting and spreading COVID-19 showed the least uptake of public health measures except for avoiding public places such as bars. Lower concern regarding COVID-19 was also associated with more negative responses to taking a potential COVID-19 vaccine. Conclusion These results suggest informational frames and themes focusing on individual risks, highlighting concern for COVID-19 and targeting improving trust for health authorities may be most effective in increasing public health measures. With the ultimate goal of preventing spread of COVID-19, understanding persons’ attitudes towards both public health measures and a COVID-19 vaccine remains critical to addressing barriers and implementing targeted interventions and messaging to improve uptake.
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    Catheter-related blood stream infections in hemodialysis patients: a prospective cohort study
    (2017-12-08) Thompson, Stephanie; Wiebe, Natasha; Klarenbach, Scott; Pelletier, Rick; Hemmelgarn, Brenda R; Gill, John S; Manns, Braden J; Tonelli, Marcello
    Abstract Background For people requiring hemodialysis, infectious mortality is independently associated with geographic distance from a nephrologist. We aimed to determine if differential management of catheter-related blood stream infections (CRBSIs) could explain poorer outcomes. Methods We prospectively collected data from adults initiating hemodialysis with a central venous catheter between 2005 and 2015 in Alberta, Canada. We collected indicators of CRBSI management (timely catheter removal, relapsing bacteremia); frequency of CRBSIs; hospitalizations; predictors of CRBSIs, and bacteremia. We evaluated indicators and infectious episodes as a function of the shortest distance by road to the closest nephrologist’s practice: <50 (referent); 50–99; and ≥100 km. Results One thousand one hundred thirty-one participants were followed for a median of 755 days (interquartile range (IQR) 219, 1465) and used dialysis catheters for a median of 565 days (IQR 176, 1288). Compared to the referent group, there was no significant difference in the rate ratio (RR) of CRBSI in the 50–100 and >100 km distance categories: RR 1.63; 95% confidence interval (CI) (0.91, 2.91); RR 0.84 (95% CI 0.44, 1.58); p = 0.87, respectively or in bacteremia: RR 1.42; (95% CI 0.83, 2.45); RR 0.79 (95% CI 0.45,1.39) p = 0.74, respectively. There were no differences in indicators of appropriate CRBSI management or hospitalizations according to distance. The overall incidence of CRBSIs was low (0.19 per 1000 catheter days) as was the frequency of relapse. Only liver disease was independently associated with CRBSI (RR 2.11; 95% CI 1.15, 3.86). Conclusions The frequency and management of CRBSIs did not differ by location; however, event rates were low.
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    Correction to: Methods for identifying 30 chronic conditions: application to administrative data
    (2019-09-04) Tonelli, Marcello; Wiebe, Natasha; Fortin, Martin; Guthrie, Bruce; Hemmelgarn, Brenda R; James, Matthew T; Klarenbach, Scott W; Lewanczuk, Richard; Manns, Braden J; Ronksley, Paul; Sargious, Peter; Straus, Sharon; Quan, Hude
    Following publication of the original manuscript [1], the authors noted several errors in Table 1. Details of the requested corrections are shown below:
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    Cost analysis and efficacy of recruitment strategies used in a large pragmatic community-based clinical trial targeting low-income seniors: a comparative descriptive analysis
    (2019-10-07) Kakumanu, Sravya; Manns, Braden J; Tran, Sophia; Saunders-Smith, Terry; Hemmelgarn, Brenda R; Tonelli, Marcello; Tsuyuki, Ross; Ivers, Noah; Southern, Danielle; Bakal, Jeff; Campbell, David J T
    Abstract Objective One of the most challenging parts of running clinical trials is recruiting enough participants. Our objective was to determine which recruitment strategies were effective in reaching specific subgroups. Study design and setting We assessed the efficacy and costs of the recruitment strategies used in the Assessing Outcomes of Enhanced Chronic Disease Care Through Patient Education and a Value-based Formulary Study (ACCESS) in Alberta, Canada. Results Twenty percent of the study budget ($354,330 CAD) was spent on recruiting 4013 participants, giving an average cost per enrolled of $88 CAD. Pharmacies recruited the most participants (n = 1217), at a cost of $128/enrolled. ”Paid media” had the highest cost ($806/enrolled), whereas ”word of mouth” and ”unpaid media” had the lowest (~$3/enrolled). Participants enrolled from ”seniors outreach” had the lowest baseline quality of life and income, while participants from ”word of mouth” had the lowest educational attainment. Conclusion The ”health care providers” strategies were especially successful — at a moderate cost per enrolled. The "media" strategies were less effective, short lasting, and more costly. No strategy was singularly effective in recruiting our targeted groups, emphasizing the importance of utilizing a variety of strategies to reach recruitment goals. Trial registration ClinicalTrials.gov, NCT02579655 . Registered on 19 October 2015.
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    Exploring structural barriers to diabetes self-management in Alberta First Nations communities
    (2018-12-03) Kulhawy-Wibe, Stephanie; King-Shier, Kathryn M; Barnabe, Cheryl; Manns, Braden J; Hemmelgarn, Brenda R; Campbell, David J T
    Abstract Background Type 2 diabetes is highly prevalent in Canadian First Nations (FN) communities. FN individuals with diabetes are less likely to receive guideline recommended care and access specialist care. They are also less likely to be able to engage in optimal self-management behaviours. While the systemic and racial contributors to this problem have been well described, individuals’ experiences with structural barriers to care and self-management remain under-characterized. Methods We utilized qualitative methods to gain insight into the structural barriers to self-management experienced by FN individuals with diabetes. We conducted a qualitative descriptive analysis of a subcohort of patients with diabetes from FN communities (n = 5) from a larger qualitative study. Using detailed semi-structured telephone interviews, we inquired about participants’ diabetes and barriers to diabetes self-management. Inductive thematic analysis was performed in duplicate using NVivo 10. Results The structural barriers faced by this population were substantial yet distinct from those described by non-FN individuals with diabetes. For example, medication costs, which are usually cited as a barrier to care, are covered for FN persons with status. The barriers to diabetes self-management that were commonly experienced in this cohort included transportation-related difficulties, financial barriers to uninsured health services, and lack of accessible diabetes education and resultant knowledge gaps. Conclusions FN Albertans with diabetes face a myriad of barriers to self-management, which are distinct from the Non-FN population. In addition to the barriers introduced by colonialism and historical injustices, finances, geographic isolation, and lack of diabetes education each impede optimal management of diabetes. Programs targeted at addressing FN-specific barriers may improve aspects of diabetes self-management in this population.
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    Exploring the impact of financial barriers on secondary prevention of heart disease
    (2017-02-14) Dhaliwal, Kirnvir K; King-Shier, Kathryn; Manns, Braden J; Hemmelgarn, Brenda R; Stone, James A; Campbell, David J T
    Abstract Background Patients with coronary artery disease experience various barriers which impact their ability to optimally manage their condition. Financial barriers may result in cost related non-adherence to medical therapies and recommendations, impacting patient health outcomes. Patient experiences regarding financial barriers remain poorly understood. Therefore, we used qualitative methods to explore the experience of financial barriers to care among patients with heart disease. Methods We conducted a qualitative descriptive study of participants in Alberta, Canada with heart disease (n = 13) who perceived financial barriers to care. We collected data using semi-structured face-to-face or telephone interviews inquiring about patients experience of financial barriers and the strategies used to cope with such barriers. Multiple analysts performed inductive thematic analysis and findings were bolstered by member checking. Results The aspects of care to which participants perceived financial barriers included access to: medications, cardiac rehabilitation and exercise, psychological support, transportation and parking. Some participants demonstrated the ability to successfully self-advocate in order to effectively navigate within the healthcare and social service systems. Conclusion Financial barriers impacted patients’ ability to self-manage their cardiovascular disease. Financial barriers contributed to non-adherence to essential medical therapies and health recommendations, which may lead to adverse patient outcomes. Given that it is such a key skill, enhancing patients’ self-advocacy and navigation skills may assist in improving patient health outcomes.
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    Financial barriers and adverse clinical outcomes among patients with cardiovascular-related chronic diseases: a cohort study
    (2017-02-15) Campbell, David J T; Manns, Braden J; Weaver, Robert G; Hemmelgarn, Brenda R; King-Shier, Kathryn M; Sanmartin, Claudia
    Abstract Background Some patients with cardiovascular-related chronic diseases such as diabetes and heart disease report financial barriers to achieving optimal health. Previous surveys report that the perception of having a financial barrier is associated with self-reported adverse clinical outcomes. We sought to confirm these findings using linked survey and administrative data to determine, among patients with cardiovascular-related chronic diseases, if there is an association between perceived financial barriers and the outcomes of: (1) disease-related hospitalizations, (2) all-cause mortality and (3) inpatient healthcare costs. Methods We used ten cycles of the nationally representative Canadian Community Health Survey (administered between 2000 and 2011) to identify a cohort of adults aged 45 and older with hypertension, diabetes, heart disease or stroke. Perceived financial barriers to various aspects of chronic disease care and self-management were identified (including medications, healthful food and home care) from the survey questions, using similar questions to those used in previous studies. The cohort was linked to administrative data sources for outcome ascertainment (Discharge Abstract Database, Canadian Mortality Database, Patient Cost Estimator). We utilized Poisson regression techniques, adjusting for potential confounding variables (age, sex, education, multimorbidity, smoking status), to assess for associations between perceived financial barriers and disease-related hospitalization and all-cause mortality. We used gross costing methodology and a variety of modelling approaches to assess the impact of financial barriers on hospital costs. Results We identified a cohort of 120,752 individuals over the age of 45 years with one or more of the following: hypertension, diabetes, heart disease or stroke. One in ten experienced financial barriers to at least one aspect of their care, with the two most common being financial barriers to accessing medications and healthful food. Even after adjustment, those with at least one financial barrier had an increased rate of disease-related hospitalization and mortality compared to those without financial barriers with adjusted incidence rate ratios of 1.36 (95% CI: 1.29–1.44) and 1.24 (1.16–1.32), respectively. Furthermore, having a financial barrier to care was associated with 30% higher inpatient costs compared to those without financial barriers. Discussion This study, using novel linked national survey and administrative data, demonstrates that chronic disease patients with perceived financial barriers have worse outcomes and higher resource utilization, corroborating the findings from prior self-report studies. The overall exposure remained associated with the primary outcome even in spite of adjustment for income. This suggests that a patient’s perception of a financial barrier might be used in clinical and research settings as an additional measure along with standard measures of socioeconomic status (ie. income, education, social status). Conclusions After adjusting for relevant covariates, perceiving a financial barrier was associated with increased rates of hospitalization and mortality and higher hospital costs compared to those without financial barriers. The demonstrable association with adverse outcomes and increased costs seen in this study may provide an impetus for policymakers to seek to invest in interventions which minimize the impact of financial barriers.
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    How externalities impact an evaluation of strategies to prevent antimicrobial resistance in health care organizations
    (2017-06-02) Leal, Jenine R; Conly, John; Henderson, Elizabeth A; Manns, Braden J
    Abstract Background The rates of antimicrobial-resistant organisms (ARO) continue to increase for both hospitalized and community patients. Few resources have been allocated to reduce the spread of resistance on global, national and local levels, in part because the broader economic impact of antimicrobial resistance (i.e. the externality) is not fully considered when determining how much to invest to prevent AROs, including strategies to contain antimicrobial resistance, such as antimicrobial stewardship programs. To determine how best to measure and incorporate the impact of externalities associated with the antimicrobial resistance when making resource allocation decisions aimed to reduce antimicrobial resistance within healthcare facilities, we reviewed the literature to identify publications which 1) described the externalities of antimicrobial resistance, 2) described approaches to quantifying the externalities associated with antimicrobial resistance or 3) described macro-level policy options to consider the impact of externalities. Medline was reviewed to identify published studies up to September 2016. Main body An externality is a cost or a benefit associated with one person’s activity that impacts others who did not choose to incur that cost or benefit. We did not identify a well-accepted method of accurately quantifying the externality associated with antimicrobial resistance. We did identify three main methods that have gained popularity to try to take into account the externalities of antimicrobial resistance, including regulation, charges or taxes on the use of antimicrobials, and the right to trade permits or licenses for antimicrobial use. To our knowledge, regulating use of antimicrobials is the only strategy currently being used by health care systems to reduce antimicrobial use, and thereby reduce AROs. To justify expenditures on programs that reduce AROs (i.e. to formally incorporate the impact of the negative externality of antimicrobial resistance associated with antimicrobial use), we propose an alternative approach that quantifies the externalities of antimicrobial use, combining the attributable cost of AROs with time-series analyses showing the relationship between antimicrobial utilization and incidence of AROs. Conclusion Based on the findings of this review, we propose a methodology that healthcare organizations can use to incorporate the impact of negative externalities when making resource allocation decisions on strategies to reduce AROs.
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    Joint associations of obesity and estimated GFR with clinical outcomes: a population-based cohort study
    (2019-06-06) Tonelli, Marcello; Wiebe, Natasha; Kovesdy, Csaba P; James, Matthew T; Klarenbach, Scott W; Manns, Braden J; Hemmelgarn, Brenda R
    Abstract Background Despite the interrelationships between obesity, eGFR and albuminuria, few large studies examine how obesity modifies the association between these markers of kidney function and adverse clinical outcomes. Methods We examined the joint associations between obesity, eGFR and albuminuria on four clinical outcomes (death, end-stage renal disease [ESRD], myocardial infarction [MI], and placement in a long-term care facility) using a population-based cohort with procedures from Alberta. Obesity was defined by body mass index ≥35 kg/m2 as defined by a fee modifier applied to an eligible procedure. Results We studied 1,293,362 participants, of whom 171,650 (13.3%) had documented obesity (BMI ≥ 35 kg/m2 based on claims data) and 1,121,712 (86.7%) did not. The association between eGFR and death was J-shaped for participants with and without documented obesity. After full adjustment, obesity tended to be associated with slightly lower odds of mortality (OR range 0.71–1.02; p for interaction between obesity and eGFR 0.008). For participants with and without obesity, the adjusted odds of ESRD were lowest for participants with eGFR > 90 mL/min*1.73m2 and increased with lower eGFR, with no evidence of an interaction with obesity (p = 0.37). Although albuminuria and obesity were both associated with higher odds of ESRD, the excess risk associated with obesity was substantially attenuated at higher levels of albuminuria (p for interaction 0.0006). The excess risk of MI associated with obesity was observed at eGFR > 60 mL/min*1.73m2 but not at lower eGFR (p for interaction < 0.0001). Participants with obesity had a higher adjusted likelihood of placement in long-term care than those without, and the likelihood of such placement was higher at lower eGFR for those with and without obesity (p for interaction = 0.57). Conclusions We found significant interactions between obesity and eGFR and/or albuminuria on the likelihood of adverse outcomes including death and ESRD. Since obesity is common, risk prediction tools for people with CKD might be improved by adding information on BMI or other proxies for body size in addition to eGFR and albuminuria.
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    Patient and provider experience and perspectives of a risk-based approach to multidisciplinary chronic kidney disease care: a mixed methods study
    (2019-03-29) Smekal, Michelle D; Tam-Tham, Helen; Finlay, Juli; Donald, Maoliosa; Thomas, Chandra; Weaver, Robert G; Quinn, Robert R; Tam, Kin; Manns, Braden J; Tonelli, Marcello; Bello, Aminu; Tangri, Navdeep; Hemmelgarn, Brenda R
    Abstract Background The Kidney Failure Risk Equation (KFRE) predicts risk of progression to kidney failure and is used to guide clinical decisions for patients with chronic kidney disease (CKD). Methods The KFRE was implemented to guide access to multidisciplinary care for CKD patients in Alberta, Canada, based on their 2-year risk of kidney failure. We used a mixed methods approach to investigate patients’ and providers’ perspectives and experiences 1 year following KFRE implementation. We conducted post-implementation interviews with multidisciplinary clinic providers and with low-risk patients who transitioned from multidisciplinary to general nephrology care. We also administered pre- and post-implementation patient care experience surveys, targeting both low-risk patients discharged to general nephrology and high-risk patients who remained in the multidisciplinary clinic, and provider job satisfaction surveys. Results Twenty-seven interviews were conducted (9 patients, 1 family member, 17 providers). Five categories were identified among patients and providers: targeted care; access to resources outside the multidisciplinary clinics; self-efficacy; patient reassurance and reduced stress; and transition process for low-risk patients Two additional categories were identified among providers only: anticipated concerns and job satisfaction. Patients and providers reported that the risk-based approach allowed the clinic to target care to those most likely to experience kidney failure and most likely to benefit from multidisciplinary care. While some participants indicated the risk-based model enhanced the sustainability of the clinics, others expressed concern that care for low-risk patients discharged from multidisciplinary care, or those now considered ineligible, may be inadequate. Overall, 413 patients completed the care experience survey and 73 providers completed the workplace satisfaction survey. The majority of patients were satisfied with their care in both periods with no overall differences. When considering the responses “Always” and “Often” together versus not, there were statistically significant improvements in domains of access to care, caring staff, and safety of care. There were no differences in healthcare providers’ job satisfaction following KFRE implementation. Conclusions Patients and healthcare providers reported that the risk-based approach improved the focus of the multidisciplinary CKD clinics by targeting patients at highest risk, with survey results suggesting no difference in patient care experience or healthcare provider job satisfaction.
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    Pharmacist and patient perspectives on recruitment strategies for randomized controlled trials: a qualitative analysis
    (2020-10-31) Fletcher, Jane M; Saunders-Smith, Terry; Manns, Braden J; Tsuyuki, Ross; Hemmelgarn, Brenda R; Tonelli, Marcello; Campbell, David J T
    Abstract Background Although recruitment is a major challenge for most randomized controlled trials, few report on the difficulties of recruitment, or how it might be enhanced. The objective of our study was to qualitatively explore the experiences of both patients and pharmacists related to recruitment for ACCESS, a large trial involving low-income seniors, given that two of our most successful recruitment strategies were direct patient recruitment materials and use of community pharmacists. Methods Using qualitative descriptive methods, we collected data from pharmacists and study participants. Pharmacists were asked about their impressions of the study, as well as challenges they faced and methods they used to recruit potential participants. Focus groups with trial participants centered on the patient recruitment materials. Interviews and focus groups were recorded, transcribed and analyzed using thematic analysis. Results Pharmacists noted that their first impressions of the study were positive as they described being enticed to help the study team by the potential benefit of copayment elimination for their patients and the low time commitment. Pharmacists noted they were more likely to recruit if they were well informed on the study, as they could answer their patients’ questions. Participants noted that their primary motivations for participating were the tangible benefits of free medications and the intrinsic value of participating in research. Conclusions We noted that recruitment through pharmacies was an effective method as most patients have trusting relationships with their pharmacist. To optimize recruitment through pharmacies, study procedures should be straightforward, and pharmacists need to be equipped with good knowledge of the study. When promoting a study to potential participants, messaging should ensure the individuals are aware of the tangible benefits of participation while still presenting a full overview of the trial. Trial registration Trial Registration Number: NCT02579655 – initially registered Oct 19, 2015.
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    Statin use and the risk of acute kidney injury in older adults
    (2019-03-25) Tonelli, Marcello; Lloyd, Anita M; Bello, Aminu K; James, Matthew T; Klarenbach, Scott W; McAlister, Finlay A; Manns, Braden J; Tsuyuki, Ross T; Hemmelgarn, Brenda R
    Abstract Background As more patients at lower cardiovascular (CV) risk are treated with statins, the balance between cardiovascular benefits and the risk of adverse events becomes increasingly important. Methods We did a population-based cohort study (May 1, 2002 to March 30, 2013) using province-wide laboratory and administrative data in Alberta. We studied new statin users aged 66 years of age and older who were not receiving renal replacement therapy at baseline. We assessed statin use at 30-day intervals to allow time-varying assessment of statin exposure in Cox proportional hazards models that examined the relation between statin use and hospitalization with acute kidney injury (AKI). Results Of the 128,140 new statin users, 47 and 46% were prescribed high- and medium-intensity regimens at the index date. During median follow-up of 4.6 years (interquartile range 2.2, 7.4), 9118 individuals were hospitalized for AKI. Compared to non-use, the use of high- and medium-intensity statin regimens was associated with significant increases in the adjusted risks of hospitalization with AKI: hazard ratios 1.16 [95% confidence interval (CI) 1.10, 1.23] and 1.07 (95% CI 1.01, 1.13), respectively. Risks of AKI were higher among women than men, and among users of angiotensin converting enzyme inhibitors/angiotensin receptor blockers than non-users, and among diuretic users (p for interaction 0.002, 0.01, and 0.04 respectively). Conclusions We found a graded, independent association between the intensity of statin use and the risk of hospitalization with AKI, although the absolute magnitude of the excess risk was small.