Browsing by Author "Marshall, Deborah"
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- ItemOpen AccessAn Evaluation of the Primary-to-Specialist Referral System for Elective Hip and Knee Replacements in Alberta(2012-12-04) Fyie, Kenneth Alan; Marshall, DeborahIntroduction: Long waiting times for elective surgical procedures in the Canadian healthcare system are a concern for patients, physicians, and governments. Objective: To measure how changes in elective hip and knee arthroplasty referral processing for primary-to-specialist surgical consultations may impact accessibility, referral appropriateness, and efficiency. Methods: I documented current referral practices by conducting semi-structured interviews with clinical staff at three Alberta hip and knee musculoskeletal clinics, determined accessibility and referral appropriateness outcomes by reviewing 218 patient charts, and efficiency outcomes by conducting time studies at each clinic. Using scenario analyses, I estimated expected system-related improvements from implementing an electronic referral tool. Results: 20-54% of received referrals were incomplete or incorrectly directed, with involuntary waits accounting for 11-15% of waiting times. Implementing electronic referral could reduce inappropriate referrals, waiting time, and reduce staff time to process referrals by 20-25%. Conclusion: An electronic referral tool may reduce waiting times through streamlined referral practices.
- ItemOpen AccessDevelopment and Testing of Cardiovascular Quality Indicators for Rheumatoid Arthritis(2015-12-04) Barber, Claire; Marshall, Deborah; Esdaile, John; Barnabe, Cheryl; Faris, Peter; Martin, LiamRheumatoid arthritis (RA) is an autoimmune inflammatory arthritis with a 50% increased risk of cardiovascular disease (CVD) related deaths. Traditional CVD risk factors including smoking, hypertension and diabetes may be under-identified and/or undertreated in RA, indicating a gap in care. Quality indicators (QIs) are an important tool for quality improvement and are lacking in this area. The objectives of this dissertation were to: (1) identify existing recommendations pertaining to screening and management of CVD risk in RA; (2) to develop a set of CVD QIs for RA based on the best practices; and (3) to test the QIs in clinical practice. A systematic review of existing CVD QIs and guidelines was conducted (Study 1). All CVD recommendations from high quality guidelines and relevant quality measures were abstracted and best practices in RA were identified. In Study 2, a panel of cardiologists and rheumatologists developed a set of CVD QIs for RA based on best the practices identified. The QIs were presented to an international panel of experts through a novel online modified Delphi process where they were rated and discussed over 3 rounds. In the final study, performance on the CVD QIs was evaluated in 170 early and biologic treated RA patients. Based on the process described above, 11 CVD QIs for RA were developed and were rated as highly relevant and valid by our international panel of experts. This was the first time the online platform was used for QI development and it demonstrated many advantages. Performance on the QIs from our cohort suggests under screening and inconsistent management of CVD risk factors. Also evident, was that our patients had a high burden of obesity, hypertension and smoking, suggesting this is a clinically meaningful gap in care. The primary area for future improvement was noted for QIs relating to communication of CVD risk and coordination of care between rheumatology and primary care. Therefore, future efforts should focus on improving coordination of CVD care as well as improving efficiency of QI measurement and reporting for timely and effective improvements in CVD care.
- ItemOpen AccessDoes bearing size influence metal ion levels in large-head metal-on-metal total hip arthroplasty? A comparison of three total hip systems(BioMed Central, 2014-01-28) Smith, James; Lee, David; Bali, Kamal; Railton, Pam; Kinniburgh, David; Faris, Peter; Marshall, Deborah; Burkart, Brian; Powell, James
- ItemOpen AccessEvaluating Yoga Therapy for Irritable Bowel Syndrome(2022-06-21) D'Silva, Adrijana; Raman, Maitreyi; Marshall, Deborah; Nasser, Yasmin; Vallance, JeffBackground: Irritable bowel syndrome (IBS) is a chronic disease of the brain-gut axis. Mind-body therapies such as yoga target the central nervous system, autonomic nervous system, immune and endocrine systems involved in the brain-gut axis to improve IBS symptoms and other patient outcomes such as mental health and quality of life. Virtually delivered yoga programming has not been tested nor have the experiences of participants in these programs been explored. Further, we are unaware of the beliefs and attitudes of IBS patients and gastroenterologists towards yoga. Objectives: This thesis had four objectives and they were to: 1) identify patients’ attitudes, subjective norms, perceived behavioural control for yoga, and underlying beliefs and intentions to practice yoga; 2) identify gastroenterologists’ attitudes, perceived supports, barriers and facilitators and intention to recommend a yoga program as part of routine medical care for patients with IBS; 3) explore the feasibility and efficacy of an eight-week virtual yoga program on IBS symptom severity and other patient-reported outcomes compared to an advice-only control group; and 4) explore and describe participants’ experiences in a virtual yoga program, and its impact. Methods: Using mixed-methods, cross-sectional surveys were used to answer aims 1 and 2. A randomized clinical trial answered objective 3 and semi-structured interviews answered objective 4. Results: Patients (N=109) reported controllability, self-efficacy, and affective attitude predicted their intention to practice yoga. Gastroenterologists (N=79) reported they were ten times more likely to recommend yoga if they agreed yoga improves IBS symptoms, however, most were not recommending yoga due to lack of confidence and scientific evidence. The randomized controlled trial (N=79) found virtually delivered yoga was safe, feasible, and efficacious in improving IBS symptoms, quality of life, stress, and fatigue. The interviews revealed the participants had overwhelmingly positive experiences in the program. Conclusions: Virtually delivered yoga programming is acceptable, safe, feasible, and efficacious in the treatment of IBS. Future research is needed to explore how virtually delivered yoga may be positioned as a therapy in the management of IBS.
- ItemOpen AccessIdentifying strategies that support equitable person-centred osteoarthritis care for diverse women: content analysis of guidelines(2023-09-14) Abuwa, Chidinma; Abbaticchio, Angelina; Theodorlis, Madeline; Marshall, Deborah; MacKay, Crystal; Borkhoff, Cornelia M.; Hazlewood, Glen S.; Battistella, Marisa; Lofters, Aisha; Ahluwalia, Vandana; Gagliardi, Anna R.Abstract Introduction Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access early diagnosis and management, or experience OA care tailored through person-centred approaches to their needs and preferences, particularly racialized women. One way to support clinicians in optimizing OA care is through clinical guidelines. We aimed to examine the content of OA guidelines for guidance on providing equitable, person-centred care to disadvantaged groups including women. Methods We searched indexed databases and websites for English-language OA-relevant guidelines published in 2000 or later by non-profit organizations. We used manifest content analysis to extract data, and summary statistics and text to describe guideline characteristics, person-centred care (PCC) using a six-domain PCC framework, OA prevalence or barriers by intersectional factors, and strategies to improve equitable access to OA care. Results We included 36 OA guidelines published from 2003 to 2021 in 8 regions or countries. Few (39%) development panels included patients. While most (81%) guidelines included at least one PCC domain, guidance was often brief or vague, few addressed exchange information, respond to emotions and manage uncertainty, and none referred to fostering a healing relationship. Few (39%) guidelines acknowledged or described greater prevalence of OA among particular groups; only 3 (8%) noted that socioeconomic status was a barrier to OA care, and only 2 (6%) offered guidance to clinicians on how to improve equitable access to OA care: assess acceptability, availability, accessibility, and affordability of self-management interventions; and employ risk assessment tools to identify patients without means to cope well at home after surgery. Conclusions This study revealed that OA guidelines do not support clinicians in caring for diverse persons with OA who face disadvantages due to intersectional factors that influence access to and quality of care. Developers could strengthen OA guidelines by incorporating guidance for PCC and for equity that could be drawn from existing frameworks and tools, and by including diverse persons with OA on guideline development panels. Future research is needed to identify multi-level (patient, clinician, system) strategies that could be implemented via guidelines or in other ways to improve equitable, person-centred OA care. Patient or public contribution This study was informed by a team of researchers, collaborators, and thirteen diverse women with lived experience, who contributed to planning, and data collection, analysis and interpretation by reviewing study materials and providing verbal (during meetings) and written (via email) feedback.
- ItemOpen AccessMonitoring Quality of Care for Joint Replacements: Assessing Alternative Statistical Methods to Accurately Estimate Time to Revision(2015-02-04) Lacny, Sarah Lynn; Marshall, DeborahWith increased longevity and as younger, more physically active patients are receiving joint replacements, it has become increasingly important to measure the failure rate for joint replacements using the cumulative incidence of revision. The most commonly applied survival analysis technique, the Kaplan-Meier (KM) method, does not account for competing risks (i.e., patient deaths) and consequently overestimates the cumulative incidence. This thesis examines alternative methods for estimating the cumulative incidence of revision using population-based cohorts of hip and knee replacements performed in Alberta and Sweden. In comparing the KM method to the cumulative incidence function, which accounts for competing risks, the KM method overestimated the cumulative incidence at each time point. The magnitude of overestimation increased with follow-up time and higher mortality rates. Application of three regression models demonstrated competing risks models require careful interpretation. Competing risks methods are recommended to accurately estimate revision rates for healthcare planning purposes.
- ItemOpen AccessMulti-level strategies to improve equitable timely person-centred osteoarthritis care for diverse women: qualitative interviews with women and healthcare professionals(2023-10-07) Gagliardi, Anna R.; Abbaticchio, Angelina; Theodorlis, Madeline; Marshall, Deborah; MacKay, Crystal; Borkhoff, Cornelia M.; Hazlewood, Glen S.; Battistella, Marisa; Lofters, Aisha; Ahluwalia, VandanaAbstract Background Women are more likely to develop osteoarthritis (OA), and have greater OA pain and disability compared with men, but are less likely to receive guideline-recommended management, particularly racialized women. OA care of diverse women, and strategies to improve the quality of their OA care is understudied. The purpose of this study was to explore strategies to overcome barriers of access to OA care for diverse women. Methods We conducted qualitative interviews with key informants and used content analysis to identify themes regarding what constitutes person-centred OA care, barriers of OA care, and strategies to support equitable timely access to person-centred OA care. Results We interviewed 27 women who varied by ethno-cultural group (e.g. African or Caribbean Black, Chinese, Filipino, Indian, Pakistani, Caucasian), age, region of Canada, level of education, location of OA and years with OA; and 31 healthcare professionals who varied by profession (e.g. family physician, nurse practitioner, community pharmacist, physio- and occupational therapists, chiropractors, healthcare executives, policy-makers), career stage, region of Canada and type of organization. Participants within and across groups largely agreed on approaches for person-centred OA care across six domains: foster a healing relationship, exchange information, address emotions, manage uncertainty, share decisions and enable self-management. Participants identified 22 barriers of access and 18 strategies to overcome barriers at the patient- (e.g. educational sessions and materials that accommodate cultural norms offered in different languages and formats for persons affected by OA), healthcare professional- (e.g. medical and continuing education on OA and on providing OA care tailored to intersectional factors) and system- (e.g. public health campaigns to raise awareness of OA, and how to prevent and manage it; self-referral to and public funding for therapy, greater number and ethno-cultural diversity of healthcare professionals, healthcare policies that address the needs of diverse women, dedicated inter-professional OA clinics, and a national strategy to coordinate OA care) levels. Conclusions This research contributes to a gap in knowledge of how to optimize OA care for disadvantaged groups including diverse women. Ongoing efforts are needed to examine how best to implement these strategies, which will require multi-sector collaboration and must engage diverse women.
- ItemOpen AccessPatient and Rheumatologist Perspectives on Tapering DMARDs in Rheumatoid Arthritis: A Qualitative Study(British Society for Rheumatology, Oxford University Press [University Publisher, 2021-04-20) Hazlewood, Glen S; Loyola-Sanchez, Adalberto; Bykerk, Vivian; Hull, Pauline M; Marshall, Deborah; Pham, Tram; Barber, Claire E H; Barnabe, Cheryl; Sirois, Alexandra; Pope, Janet; Schieir, Orit; Richards, Dawn; Proulx, Laurie; Bartlett, Susan JObjectives: To understand the perspectives of patients and rheumatologists for tapering DMARDs in RA. Methods: Using semi-structured interview guides, we conducted individual interviews and focus groups with RA patients and rheumatologists, which were audiotaped and transcribed. We conducted a pragmatic thematic analysis to identify major themes, comparing and contrasting different views on DMARD tapering between patients and rheumatologists. Results: We recruited 28 adult patients with RA (64% women; disease duration 1-54 years) and 23 rheumatologists (52% women). Attitudes across both groups towards tapering DMARDs were ambivalent, ranging from wary to enthusiastic. Both groups expressed concerns, particularly the inability to ‘recapture’ the same level of disease control, while also acknowledging potential positive outcomes such as reduced drug harms. Patient tapering perspectives (whether to and when) changed over time and commonly included non-biologic DMARDs. Patient preferences were influenced by lived experiences, side effects, previous tapering experiences, disease trajectory, remission duration, and current life roles. Rheumatologists’ perspectives varied on timing and patient profile to initiate tapering, and were informed by both data and clinical experience. Patients expressed interest in shared decision making (SDM) and close monitoring during tapering, with ready access to their healthcare team if problems arose. Rheumatologists were generally open to tapering (not stopping), though sometimes only when requested by their patients. Conclusion: The perspectives of patients and rheumatologists on tapering DMARDs in RA vary and evolve over time. Rheumatologists should periodically discuss DMARD tapering with patients as part of SDM, and ensure monitoring and flare management plans are in place.
- ItemOpen AccessPatient preferences to value health outcomes in rheumatology clinical trials: Report from the OMERACT special interest group(Oxford University Press, British Society for Rheumatology, 2021-05-24) Thomas, Megan; Fraenkel, Liana; Boonen, Annelies; Bansback, Nick; Buchbinder, Rachelle; Marshall, Deborah; Proulx, Laurie; Voshaar, Marieke; Richards, Pamela; Richards, Dawn P; Hiligsmann, Mickael; Guillemin, Francis; Shea, Beverly; Tugwell, Peter; Hazlewood, GlenObjective. To inform a research plan for future studies by obtaining stakeholder input on the application of preference-based methods to clinical trial design. Methods. We conducted a virtual OMERACT session to encourage stakeholder engagement. We developed materials for the session to facilitate discussion based on identified case examples and feedback sessions. Results. Participants prioritized incorporating patient preferences in all aspects of trial design with an emphasis on outcome selection. Participants highlighted the need for careful consideration around preference heterogeneity and equity factors. Conclusion. Including patient preferences in trial design was considered a priority requiring further exploration to develop comprehensive guidance.
- ItemOpen AccessPolicies in Canada fail to address disparities in access to person-centred osteoarthritis care: a content analysis(2024-04-25) Abbaticchio, Angelina; Theodorlis, Madeline; Marshall, Deborah; MacKay, Crystal; Borkhoff, Cornelia M.; Hazlewood, Glen S.; Battistella, Marisa; Lofters, Aisha; Ahluwalia, Vandana; Gagliardi, Anna R.Abstract Background Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access OA care, particularly racialized women. One way to reduce inequities is through policies that can influence healthcare services. We examined how OA-relevant policies in Canada address equitable, person-centred OA care for women. Methods We used content analysis to extract data from English-language OA-relevant documents referred to as policies or other synonymous terms published in 2000 or later identified by searching governmental and other web sites. We used summary statistics to describe policy characteristics, person-centred care using McCormack’s six-domain framework, and mention of OA prevalence, barriers and strategies to improve equitable access to OA care among women. Results We included 14 policies developed from 2004 to 2021. None comprehensively addressed all person-centred care domains, and few addressed individual domains: enable self-management (50%), share decisions (43%), exchange information (29%), respond to emotions (14%), foster a healing relationship (0%) and manage uncertainty (0%). Even when mentioned, content offered little guidance for how to achieve person-centred OA care. Few policies acknowledged greater prevalence of OA among women (36%), older (29%) or Indigenous persons (29%) and those of lower socioeconomic status (14%); or barriers to OA care among those of lower socioeconomic status (50%), in rural areas (43%), of older age (37%) or ethno-cultural groups (21%), or women (21%). Four (29%) policies recommended strategies for improving access to OA care at the patient (self-management education material in different languages and tailored to cultural norms), clinician (healthcare professional education) and system level (evaluate OA service equity, engage lay health leaders in delivering self-management programs, and offer self-management programs in a variety of formats). Five (36%) policies recommended research on how to improve OA care for equity-seeking groups. Conclusions Canadian OA-relevant policies lack guidance to overcome disparities in access to person-centred OA care for equity-seeking groups including women. This study identified several ways to strengthen policies. Ongoing research must identify the needs and preferences of equity-seeking persons with OA, and evaluate the impact of various models of service delivery, knowledge needed to influence OA-relevant policy.
- ItemOpen AccessThe Need, Value and Affordability of First-line Treatments for Hip and Knee Osteoarthritis in Alberta(2024-04-24) Mazzei, Darren Randell; Marshall, Deborah; Whittaker, Jackie; Faris, Peter; Wasylak, TracyClinical guidelines have recommended exercise and education as first-line treatments for hip and knee osteoarthritis (OA) for 25 years, but these proven treatments are underused globally. In Alberta, joint replacements are publicly funded. Meanwhile, first-line treatments are funded with private insurance or out-of-pocket which reduces access. We sought to inform the policy-making process in Alberta by addressing three objectives: 1) Describe “usual care” (UC) patterns of education, exercise, weight management, pain medication and other nonsurgical treatments for knee OA in a cohort of people recommended for nonsurgical care by an orthopaedic surgeon; 2) Estimate the real-world incremental net monetary benefit (INMB) of a standardized education and exercise therapy program (GLA:D®) compared to usual care for people managing hip and/or knee OA; 3) Estimate the budget impact of funding GLA:D® for people with hip and knee OA waiting for total joint replacement (TJR) consultation in a universal publicly insured healthcare system. We surveyed 250 people over the telephone and found that only 20% of people used treatments consistent with international clinical guidelines during a three-to-six-year period after an orthopaedic surgeon recommended nonsurgical care. Our prospective matched cohort study (GLA:D® n=127, UC n=127) showed that GLA:D® had a positive INMB compared to UC from the Ministry of Health perspective over 12-months. The INMB of GLA:D® was still positive but less certain over a lifetime as well as when out-of-pocket and private insurance costs were considered. Our budget impact analysis model showed that publicly funding GLA:D® for everyone waiting for TJR consultation could be an affordable solution to avoid surgeries, improve equitable access to evidence-based treatments and save more than the program costs. Our research shows that publicly funding GLA:D® would increase use of first-line treatments in Alberta by filling an important care gap, offer more equitable access to evidence-based care, reduce significant out-of-pocket expenses for people living with OA and improve health system performance.