Browsing by Author "Nelson, Gregg"

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    Defining the short-term disease recurrence after loop electrosurgical excision procedure (LEEP)
    (2020-02-26) Papalia, Nicholas; Rohla, Amanda; Tang, Selphee; Nation, Jill; Nelson, Gregg
    Abstract Background The goal of cervical cancer screening is to identify dysplastic lesions for subsequent excision in order to prevent invasive disease. There is clinical equipoise, on how to best follow women for disease surveillance after treatment with some Canadian provinces exclusively performing colposcopy and some utilizing Human Papilloma Virus (HPV) testing in addition to cervical cytology. Loop Electrosurgical Excision Procedure (LEEP) is used to treat pre-invasive HPV-mediated disease and patients are typically followed for 12 months after disease excision. This study aims to quantify the prevalence of high-grade disease at the time of the second follow-up colposcopy visit, in a practice setting that utilizes laser ablation in addition to LEEP. Methods In a retrospective cohort study, consecutive patient charts were accessed through the electronic medical record system, ARIA, at the Tom Baker Cancer Centre, in Calgary, Alberta, from January 2010 to December 2015. Data was extracted and a REDCap database was used to compile pertinent information from charts meeting inclusion criteria. Descriptive and analytic statistics were performed. Results Of the 303 patients identified, 221 patients met inclusion criteria. 86% of these patients met discharge criteria from colposcopy after the second follow up visit. 31 (14%) were seen in a subsequent visit for abnormal findings. Of these, 7 (3.2%) underwent further treatment for high-grade disease/Cervical Intraepithelial Neoplasia (CIN 2/3). Of the 31, 23 (10.6%) had a third – negative – visit, resulting in discharge from colposcopy. One patient had a repeat LEEP for persistent Low-Grade Squamous Intraepithelial Lesion (LSIL). Conclusion In summary, our data demonstrates a prevalence of 3.2% of high-grade disease at the time of a second colposcopic follow up visit after treatment, in a setting which frequently utilizes laser ablation in combination with LEEP, for large lesions. This recurrence rate is consistent with most published literature on recurrence rates of CIN2/3.
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    Exploring How Men and Women Approach Patient Educational Resources: How this Impacts Patient Experience
    (2020-10-13) Viceer, Nazia; Jacobsen, D. Michelle; Nelson, Gregg; Groen, Janet Elizabeth
    Patient education (PE) resources are provided to patients with the aim of engaging them in their health outcomes. Medicine, and as a result patient education, has evolved over many decades but has been skewed to favor one gender. This emphasis on representation of one gender has upheld a hegemonic status quo, excluding almost half of the patient population. Thus, there is a need for a more inclusive approach to patient education. This research used a case study methodology to investigate patient education as part of the Enhanced Recovery After Surgery (ERAS) protocol. ERAS is a set of clinical practice changes that have contributed to patients being discharged from hospital sooner with fewer re-admissions and complications after colorectal surgery when compared to traditional surgical practices. In process of the development of ERAS patient education for the surgery process, differences that men and women may experience have not been well considered in the development of the patient education. This research was conducted with patients who underwent a colorectal ERAS surgical procedure. This study considers patient and healthcare provider (HCP) perspectives in regard to engagement with PE to determine if there are biological sex and gender specific considerations or processes that may result in improved patient outcomes and/or satisfaction. Participants identified gaps in the PE pertaining to sex and gender as well as other areas of personalization such as nutritional and post-care instructions. Participants indicated that involving patients as partners in development of PE may be a way to address gaps and improve outcomes. Study findings may be used to help design patient educational tools that consider a sex and gender approach, in order to be more inclusive and prioritize the needs of the patient populations that HCP aim to engage with ERAS.
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    Hospital and Individual Variations of Surgical Errors and Complications in Caesarean Section in the United States
    (2018-06-04) Sheikh, Manal Salim; Metcalfe, Amy; Nelson, Gregg; Wood, Stephen L.
    Background: Caesarean Section (CS) is the most common inpatient surgery performed internationally. Although CS is typically performed to prevent adverse maternal and fetal outcomes, there is still a risk of surgical errors and complications. This study examined maternal and hospital risk factors associated with errors and complications following CS in the United States (US). Methods: Data were obtained from the 2012-2014 National Inpatient Sample, a deidentified database containing a random sample of 20% of hospital discharges in the US. Surgical errors (e.g. foreign body retained during surgery) can be the result of human error, while complications (e.g. infection) can be due to external factors such as preexisting comorbidities. The overall incidence of surgical errors and complications in CS was calculated. Bivariate analysis examined the association between surgical errors and complications in CS, and potential individual and hospital level covariates. Multilevel logistic modelling examined the association between individual (e.g. race) and hospital (e.g. CS volume), and errors and complications. Results: Among 648,584 CS hospitalizations, 1.98% (95%CI: 1.95%-2.01%) and 9.67% (95%CI: 9.59%-9.74%) of women had an error or complication, respectively. The odds of developing a complication were 15.90 (95%CI: 15.33-16.49) if an error also occurred. Both individual- and hospital-level factors were associated with errors and complications. Women with Medicaid had increased odds of errors (OR: 1.40 (95%CI:1.37-1.43)) but lower odds of complications (OR: 0.89 (95%CI:0.88-0.90)), compared to women with private insurance. Compared to non-Hispanic white women, iii all races had lower odds of error, and only non-Hispanic black women had greater odds of complications (OR: 1.14 (95%CI:1.13-1.16)). Delivering prior to 37 weeks of gestation decreased the odds of errors (OR: 0.73 (95%CI:0.71-0.76)) and maternal complications (OR: 0.73 (95%CI:0.72-0.74)). Similarly, rural hospitals had lower odds of surgical errors (OR: 0.59 (95%CI: 0.56-0.62)) and complications (OR: 0.61 (95%CI: 0.59-0.62)) while hospitals with a large bed size had greater odds of errors and complications than medium bed size hospitals, at 1.13 (95%CI:1.09-1.17), and 1.13 (95%CI:1.11-1.15), respectively. Conclusions: This study identified specific risk factors for errors and complications that can be further examined through quality improvement frameworks to reduce the incidence of adverse maternal events during CS.
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    Implementation of Enhanced Recovery After Surgery: a strategy to transform surgical care across a health system
    (2017-05-19) Gramlich, Leah M; Sheppard, Caroline E; Wasylak, Tracy; Gilmour, Loreen E; Ljungqvist, Olle; Basualdo-Hammond, Carlota; Nelson, Gregg
    Abstract Background Enhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS). Methods ERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation. Results Compliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time. Conclusions Using the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.
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    Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives
    (2020-04-26) Gramlich, Leah; Nelson, Gregg; Nelson, Alison; Lagendyk, Laura; Gilmour, Loreen E; Wasylak, Tracy
    Abstract Background Knowledge Translation evidence from health care practitioners and administrators implementing Enhanced Recovery After Surgery (ERAS) care has allowed for the spread and scale of the health care innovation. There is a need to identify at a health system level, what it takes from a leadership perspective to move from implementation to sustainability over time. The purpose of this research was to systematically synthesize feedback from health care leaders to inform further spread, scale and sustainability of ERAS care across a health system. Methods Alberta Health Services (AHS) is the largest Canadian health system with approximately 280,000 surgeries annually at more than 50 surgical sites. In 2013 to 2014, AHS used a structured approach to successfully implement ERAS colorectal guidelines at six sites. Between 2016 and 2018, three of the six sites expanded ERAS to other surgical areas (gynecologic oncology, hepatectomy, pancreatectomy/Whipple’s, and cystectomy). This research was designed to explore and learn from the experiences of health care leaders involved in the AHS ERAS implementation expansion (eg. surgical care unit, hospital site or provincial program) and build on the model for knowledge mobilization develop during implementation. Following informed consent, leaders were interviewed using a structured interview guide. Data were recorded, coded and analyzed qualitatively through a combination of theory-driven immersion and crystallization, and template coding using NVivo 12. Results Forty-four individuals (13 physician leaders, 19 leading clinicians and hospital administrators, and 11 provincial leaders) were interviewed. Themes were identified related to Supportive Environments including resources, data, leadership; Champion and Nurse coordinator role; and Capacity Building through change management, education, and teams. The perception and role of leaders changed through initiation and implementation, spread, and sustainability. Barriers and enablers were thematically aligned relative to outcome assessment, consistency of implementation, ERAS care compliance, and the implementation of multiple guidelines. Conclusions Health care leaders have unique perspectives and approaches to support spread, scale and sustainability of ERAS that are different from site based ERAS teams. These findings inform us what leaders need to do or need to do differently to support implementation and to foster spread, scale and sustainability of ERAS.
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    A Prospective Cohort Study of Metabolic Syndrome and Endometrial Cancer Survival
    (2020-07-24) Kokts-Porietis, Renee L.; Friedenreich, Christine M.; Nelson, Gregg; Cook, Linda S.; Courneya, Kerry S.
    Background: Metabolic syndrome has been previously associated with increased endometrial cancer risk, but the relationship with metabolic syndrome and endometrial cancer survival remains unclear. Objectives: To determine the associations between metabolic syndrome using the harmonized criteria with disease-free survival, overall survival, endometrial cancer-specific survival and time to recurrence among endometrial cancer survivors. Second, to determine the association between the number of metabolic syndrome components as well as each individual metabolic syndrome component with these prognostic outcomes. Methods: A prospective cohort of 540 endometrial cancer survivors diagnosed between 2002 and 2006 participated in the Alberta Endometrial Cancer Cohort and were followed until death or March 20, 2019. Baseline in-person interviews, direct anthropometric measurements and fasting blood samples were used to assess metabolic syndrome. Recurrence and survival data were obtained via medical chart abstraction and vital status updates. Results: Compared to endometrial cancer survivors without metabolic syndrome, survivors with metabolic syndrome had worse overall survival when assessed with the harmonized criteria. Of the individual metabolic syndrome components, only waist circumference was associated with recurrence and survival outcomes. Lifetime recreational physical activity prior to diagnosis was observed to modify the associations between metabolic syndrome and its components with overall survival and disease-free survival. Conclusion: The metabolic syndrome, especially waist circumference, was associated with worse overall and disease-free survival among endometrial cancer survivors. Future research should aim to confirm these results and improve our understanding of the role lifestyle factors such as physical activity have in the association between metabolic syndrome and endometrial cancer survivors’ prognosis.