Browsing by Author "McCaughey, Deirdre"
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- ItemOpen AccessA 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, DeirdreAbstract 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.
- ItemOpen AccessEvaluation of the Effect of Hospital and Physician Factors on Likelihood of Revision After Mid-Urethral Sling Placement(2020-01) Brennand, Erin Alexandra; Quan, Hude; Metcalfe, Amy; Peng, Mingkai; McCaughey, DeirdreObjective: To estimate rates of revision surgery after insertion of mesh midurethral slings (MUS) and explore if healthcare attributes such as physician specialty, annual operative volume, or hospital type are risk factors for this outcome. Methods: This study used a population-based retrospective cohort of women who underwent MUS insertion over a 13-year interval (2004–2017) in Alberta, Canada. The main outcome was subsequent surgery for revision of MUS, defined by a composite of surgical procedures. Exposures included annual number of MUS procedures performed by the surgeon, facility type, surgeon specialty, patient age, and concomitant prolapse repair. Mixed-effects logistic regression utilizing linear spines was used to test the a priori hypothesis that annual surgical volume would be inversely related in a non-linear fashion to risk of revision. Results: In a cohort of 19,511 women, cumulative rates of revision surgery were 3.36% (95% CI 3.06–3.68) at 5 years and 4.57% (95% CI 4.00–5.21) at 10 years. The first year after MUS insertion was the most vulnerable window, with 0.39% (95% CI 0.31–0.49) undergoing revision within 30 days and 2.05% (95% CI 1.85–2.26) within a year. Concomitant prolapse repairs (OR = 1.24, 95% CI 1.04–1.48) and surgeon’s annual volume were associated with revision. After 50 cases per year, odds of revision declined with each additional case (OR = 0.991 per case, 95% CI 0.983–0.999; OR = 0.91 per 10 cases, 95% CI 0.84–0.98) and plateaued at 110 cases per year. Surgeon specialty, hospital type, and patient age were not associated with outcome. Conclusions and relevance: Within 10 years, nearly 1 in 20 women underwent revision surgery after MUS insertion. Physician annual surgical volume appears to be a risk factor, with a decline in risk of revision surgery occurring at an annual threshold of >50 cases. Given that annual case volume is a potentially modifiable risk factor, development of policies regarding minimum caseload parameters for surgeons performing MUS procedures may hold potential to improve the quality of MUS surgery.
- ItemOpen AccessExamining End-of-Life Experiences of Family Caregivers for People Living with Dementia During Covid-19: An Interpretive Description Study(2021-08) Mithani, Sameer Ashraf; McGhan, Gwen; McCaughey, Deirdre; Venturato, LorraineFamily caregivers of people living with dementia (PLWD) are key participants in determining and carrying out end-of-life care for PLWD. In an effort to contain the spread of Covid-19, public health restrictions, such as no visitation in care settings, were enacted which had the potential to severely impede the family caregiver’s role in providing end-of-life care. This study aims to determine the experiences of family caregivers who provided end-of-life care to PLWD during Covid-19. To examine these experiences, the qualitative method of interpretive description was utilized. Family caregivers in Alberta, Canada were invited to participate in an online survey to examine their caregiving experiences during the Covid-19 pandemic, with the option of participating in a follow-up focus group. Sixteen FCGs whose family members with dementia died during the pandemic participated in the survey. A follow-up focus group (n=3) was conducted virtually to further examine how Covid-19 policies impacted their role as a caregiver for the PLWD in long-term care and affected the family caregiver’s ability to grieve. The results of the survey and virtual focus group suggest that a lack of role clarity and inadequate communication channels between the family caregivers and long-term care centers due to Covid-19 increased the strain family caregivers faced during end-of-life care. Participants also expressed frustration regarding their inability to communicate with the PLWD due to public health restrictions. Additionally, participants felt that protocols related to visitation were unclear. At the end of life, public policies, such as reduced or no visitation, led to feelings of chronic grief. Several participants also expressed appreciation for having previously completing advance care planning documentation prior to Covid-19. Family caregivers also felt that the limitation on gatherings negatively impacted their ability to grieve and organize adequate funeral services for the PLWD. Based on these results, policymakers can help ease the increased challenges faced by family caregivers during end-of-life care in future public health emergencies by involving family caregivers of PLWD in the decision-making process. The completion of advance care planning documentation can also ease the burden family caregivers may experience prior to and during end-of-life care.
- ItemOpen AccessMortality and cardiovascular events in adults with kidney failure after major non-cardiac surgery: a population-based cohort study(2021-11-04) Harrison, Tyrone G.; Ronksley, Paul E.; James, Matthew T.; Ruzycki, Shannon M.; Tonelli, Marcello; Manns, Braden J.; Zarnke, Kelly B.; McCaughey, Deirdre; Schneider, Prism; Wick, James; Hemmelgarn, Brenda R.Abstract Background People with kidney failure have a high incidence of major surgery, though the risk of perioperative outcomes at a population-level is unknown. Our objective was to estimate the proportion of people with kidney failure that experience acute myocardial infarction (AMI) or death within 30 days of major non-cardiac surgery, based on surgery type. Methods In this retrospective population-based cohort study, we used administrative health data to identify adults from Alberta, Canada with major surgery between April 12,005 and February 282,017 that had preoperative estimated glomerular filtration rates (eGFRs) < 15 mL/min/1.73m2 or received chronic dialysis. The index surgical procedure for each participant was categorized within one of fourteen surgical groupings based on Canadian Classification of Health Interventions (CCI) codes applied to hospitalization administrative datasets. We estimated the proportion of people that had AMI or died within 30 days of the index surgical procedure (with 95% confidence intervals [CIs]) following logistic regression, stratified by surgery type. Results Overall, 3398 people had a major surgery (1905 hemodialysis; 590 peritoneal dialysis; 903 non-dialysis). Participants were more likely male (61.0%) with a median age of 61.5 years (IQR 50.0–72.7). Within 30 days of surgery, 272 people (8.0%) had an AMI or died. The probability was lowest following ophthalmologic surgery at 1.9% (95%CI: 0.5, 7.3) and kidney transplantation at 2.1% (95%CI: 1.3, 3.2). Several types of surgery were associated with greater than one in ten risk of AMI or death, including retroperitoneal (10.0% [95%CI: 2.5, 32.4]), intra-abdominal (11.7% [8.7, 15.5]), skin and soft tissue (12.1% [7.4, 19.1]), musculoskeletal (MSK) (12.3% [9.9, 15.5]), vascular (12.6% [10.2, 15.4]), anorectal (14.7% [6.3, 30.8]), and neurosurgical procedures (38.1% [20.3, 59.8]). Urgent or emergent procedures had the highest risk, with 12.1% experiencing AMI or death (95%CI: 10.7, 13.6) compared with 2.6% (1.9, 3.5) following elective surgery. Conclusions After major non-cardiac surgery, the risk of death or AMI for people with kidney failure varies significantly based on surgery type. This study informs our understanding of surgery type and risk for people with kidney failure. Future research should focus on identifying high risk patients and strategies to reduce these risks.
- ItemOpen AccessPrediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models(2023-03-10) Harrison, Tyrone G.; Hemmelgarn, Brenda R.; James, Matthew T.; Sawhney, Simon; Manns, Braden J.; Tonelli, Marcello; Ruzycki, Shannon M.; Zarnke, Kelly B.; Wilson, Todd A.; McCaughey, Deirdre; Ronksley, Paul E.Abstract Background People with kidney failure often require surgery and experience worse postoperative outcomes compared to the general population, but existing risk prediction tools have excluded those with kidney failure during development or exhibit poor performance. Our objective was to derive, internally validate, and estimate the clinical utility of risk prediction models for people with kidney failure undergoing non-cardiac surgery. Design, setting, participants, and measures This study involved derivation and internal validation of prognostic risk prediction models using a retrospective, population-based cohort. We identified adults from Alberta, Canada with pre-existing kidney failure (estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73m2 or receipt of maintenance dialysis) undergoing non-cardiac surgery between 2005–2019. Three nested prognostic risk prediction models were assembled using clinical and logistical rationale. Model 1 included age, sex, dialysis modality, surgery type and setting. Model 2 added comorbidities, and Model 3 added preoperative hemoglobin and albumin. Death or major cardiac events (acute myocardial infarction or nonfatal ventricular arrhythmia) within 30 days after surgery were modelled using logistic regression models. Results The development cohort included 38,541 surgeries, with 1,204 outcomes (after 3.1% of surgeries); 61% were performed in males, the median age was 64 years (interquartile range [IQR]: 53, 73), and 61% were receiving hemodialysis at the time of surgery. All three internally validated models performed well, with c-statistics ranging from 0.783 (95% Confidence Interval [CI]: 0.770, 0.797) for Model 1 to 0.818 (95%CI: 0.803, 0.826) for Model 3. Calibration slopes and intercepts were excellent for all models, though Models 2 and 3 demonstrated improvement in net reclassification. Decision curve analysis estimated that use of any model to guide perioperative interventions such as cardiac monitoring would result in potential net benefit over default strategies. Conclusions We developed and internally validated three novel models to predict major clinical events for people with kidney failure having surgery. Models including comorbidities and laboratory variables showed improved accuracy of risk stratification and provided the greatest potential net benefit for guiding perioperative decisions. Once externally validated, these models may inform perioperative shared decision making and risk-guided strategies for this population.
- ItemOpen AccessQuality Improvement Training in Medical Education(2020-05-06) Brown, Allison J.; Kassam, Aliya; Hecker, Kent; Sharma, Nishan; McCaughey, DeirdreProblem: Training healthcare professionals in Quality Improvement (QI) has been highlighted as a potential strategy to reduce the prevalence of error and harm in healthcare. As a result, various health professions education programs have integrated QI into the competency frameworks that inform the core curriculum, including those used in the training of medical doctors. However, QI has been integrated, emphasized, and taught to medical trainees (i.e., medical students and residents) in a variety of ways across countries, programs, and stages of training. As contemporary medical education increasingly adapts outcomes-oriented, competency-based models of training, medical trainees may be required to demonstrate competency in QI during their training. Method of Study: This research considered how best to train future physicians in QI during their core medical training. First, methods for examining complex social phenomena were analyzed through a thought experiment exploring the methodological intersections of realist inquiry (RI) with structural equation modelling (SEM). Next, a realist synthesis examined the literature for teaching QI at the undergraduate and postgraduate levels of medical training. This generated an explanatory program theory that highlighted common associations between contexts, mechanisms, and outcomes of QI training in undergraduate and postgraduate medical training. Finally, a collective case study of four postgraduate programs at the University of Calgary examined how residents learned about QI during their training using four data sources. The combinations of RI and SEM were re-visited and operationalized as the program theory informed the specification of structural models using the quantitative data in the case study. This resulted in a novel, realist-informed SEM that statistically modelled elements associated with resident self-assessments of QI knowledge, skills, and attitudes. Conclusions: Explicit training in QI might ensure that all physicians enter practice equipped with the fundamental knowledge and skills to not only recognize areas for improvement, but implement sustainable solutions that improve the quality and safety of care. The conscientious design of QI curricula in the core medical curriculum that considers integrating features commonly associated with successful QI curricula may be beneficial to optimize training in this domain, and ultimately, catalyze the development of QI competencies amongst future physicians.
- ItemOpen AccessTeaching Mental Health in the Classroom: A Mixed-Methods Investigation of a Mental Health Literacy Program in Elementary Schools(2023-06) Sadler, Daniel; Ronksley, Paul; McCaughey, Deirdre; Metcalfe, Amy; Milaney, KatrinaBackground: Mental illnesses are the largest disease burden for adolescents, affecting 20% of youth in Canada. As mental health needs arise earlier and with greater prevalence it is essential to work upstream and prepare youth before psychological distress emerges. When implemented in the classroom as part of the educational curriculum, Mental Health Literacy (MHL) fulfills these goals as a universal response to the myriad of societal and development stressors experienced by youth. Aim: The overall aim of this program evaluation was to investigate the experience of educators in delivering the Elementary Mental Health Literacy Resources (EMHLR) program during a 4-month trial. The specific objectives were to identify the individual (educator) and organizational (district) level barriers and facilitators to delivery of the EMHLR to improve future implementation of the program. Design and Setting: An explanatory sequential design collected educator experience through a feedback survey which informed group interviews. Participants were elementary school educators primarily from the provinces of British Columbia and New Brunswick. Methods: The feedback survey collected demographics and feedback on each module taught using five-point Likert scales. The feedback survey also included multiple solicitations for qualitative feedback. Group interviews were held to further explore survey responses. Findings were integrated using the RE-AIM framework to identify barriers and facilitators and develop considerations for implementation. Results: System level barriers included preexisting stigma around mental health, competing priorities for classroom time and access, and cultivating buy-in from educational leadership. Individual level barriers included the time required to teach the EMHLR curriculum and to develop the skills and knowledge to teach MHL. The flexible design of the EMHLR curriculum alongside key implementation strategies of advocacy, practice champions, and professional development were seen as facilitators. Conclusion: Adolescents are ready to engage in their mental health. Mental Health Literacy offers the language to communicate about their experience clearly and accurately. The EMHLR curriculum offers an evidence-based and adaptable means to build the MHL of youth across Canada. This could result in significant improvements in adolescent mental health but requires intentional implementation strategies to be successful.
- ItemOpen AccessA Value Driven, Co-designed Framework for Sustained Patient Engagement(2019-04-22) McCarron, Tamara L.; Marlett, Nancy J.; Noseworthy, Tom W.; Hassay, Derek N.; White, Deborah Elizabeth; Lorenzetti, Diane L.; Bryan, Stirling; McCaughey, DeirdrePatient involvement in various aspects of healthcare, from improving healthcare quality to promoting patient safety, has emerged as a critical priority, but understanding how best to engage patients is not well-understood. This knowledge gap results in frustrating barriers for decision-makers looking to draw transferable lessons to inform the design of patient engagement programs and processes. Coupled with challenges to the sustainability of health care and the need for innovative solutions, patient engagement has become central to improving both quality and delivery of services. This thesis is comprised of three independent studies that form an overarching program of research. The first study reports the results of a scoping review to understand how health systems are investing in building the capacity and ability of patients. In the second study, we build on the findings from the scoping review and a series of qualitative interviews to inform a provincial survey tool to understand the motivations of individuals who chose to give their time and talents to health organizations. In the third study, we co-designed a framework for patient engagement, grounded in market choice behaviour theory and informed by the literature, a province-wide survey and four provincial stakeholder workshops. While significant research exists that highlights the motivations of the public who choose to participate in decision-making, a limited number of studies have explored these concepts within healthcare. As the roles of patient and family members in the context of healthcare decision-making continue to evolve, the importance of effective and sustainable engagement programs will become increasingly important. A deeper knowledge of patient motivations will not only create meaningful engagement opportunities for patients but will also enable health organizations to gain from the experience of these individuals. While further research is needed to support the engagement of diverse groups of stakeholders, the findings from this study have developed an understanding of how patients are motivated to make engagement decisions. This knowledge will help focus patient engagement efforts, thereby improving the efficiency and cost effectiveness of these programs, ensuring their relative sustainability.