Ainsley Moore

Monitoring physical functioning as the sixth vital sign: evaluating patient and practice engagement in chronic illness care in a primary care setting--a quasi-experimental design

BackgroundIn Canada, one in three adults or almost 9 million people report having a chronic condition. Over two thirds of total deaths result from cardiovascular disease, diabetes, cancer and respiratory illness and 77% of persons ≥65 years have at least one chronic condition. Persons with chronic disease are at risk for functional decline; as a result, there is an increased awareness of the significance of functional status as an important health outcome. The purpose of this study was to determine whether patients who receive a multi-component rehabilitation intervention, including online monitoring of function with feedback and self-management workshops, showed less functional decline than case matched controls who did not receive this intervention. In addition, we wanted to determine whether capacity building initiatives within the Family Health Team promote a collaborative approach to Chronic Disease Management.MethodsA population-based multi-component rehabilitation intervention delivered to persons with chronic illnesses (≥ 44 yrs) (n = 60) was compared to a group of age and sex matched controls (n = 60) with chronic illnesses receiving usual care within a primary healthcare setting. The population-based intervention consisted of four main components: (1) function-based individual assessment and action planning, (2) rehabilitation self-management workshops, (3) on-line self-assessment of function and (4) organizational capacity building. T-tests and chi-square tests were used for continuous and categorical variables respectively in baseline comparison between groups.ResultsTwo MANOVA showed significant between group differences in patient reported physical functioning (Λ = 0.88, F = (2.86) = 5.97. p = 0.004) and for the physical performance measures collectively as the dependent variable (Λ = 0.80, F = (6.93) = 3.68. p = 0.0025). There were no within group differences for the capacity measures.ConclusionIt is feasible to monitor physical functioning as a health outcome for persons with chronic illness in primary care. The timeline for this study was not sufficient to show an increase in the capacity within the team; however there were some differences in patient outcomes. The short timeline was likely not sufficient to build the capacity required to support this approach.Trial registrationNCT00859638

Using patient values and preferences to inform the importance of health outcomes in practice guideline development following the GRADE approach

BackgroundThere are diverse opinions and confusion about defining and including patient values and preferences (i.e. the importance people place on the health outcomes) in the guideline development processes. This article aims to provide an overview of a process for systematically incorporating values and preferences in guideline development.MethodsIn 2013 and 2014, we followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to adopt, adapt and develop 226 recommendations in 22 guidelines for the Ministry of Health of the Kingdom of Saudi Arabia. To collect context-specific values and preferences for each recommendation, we performed systematic reviews, asked clinical experts to provide feedback according to their clinical experience, and consulted patient representatives.ResultsWe found several types of studies addressing the importance of outcomes, including those reporting utilities, non-utility measures of health states based on structured questionnaires or scales, and qualitative studies. Guideline panels used the relative importance of outcomes based on values and preferences to weigh the balance of desirable and undesirable consequences of alternative intervention options. However, we found few studies addressing local values and preferences.ConclusionsCurrently there are different but no firmly established processes for integrating patient values and preferences in healthcare decision-making of practice guideline development. With GRADE Evidence-to-Decision (EtD) frameworks, we provide an empirical strategy to find and incorporate values and preferences in guidelines by performing systematic reviews and eliciting information from guideline panel members and patient representatives. However, more research and practical guidance are needed on how to search for relevant studies and grey literature, assess the certainty of this evidence, and best summarize and present the findings.

The Saudi clinical practice guideline for the management of overweight and obesity in adults

Objective: To assist healthcare providers in evidence-based clinical decision-making for the management of overweight and obese adults in Saudi Arabia. Methods: The Ministry of Health, Riyadh, Kingdom of Saudi Arabia assembled an expert Saudi panel to produce this clinical practice guideline in 2015. In collaboration with the methodological working group from McMaster University, Hamilton, Canada, using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, which describes both the strength of recommendation and the quality of evidence Results: After identifying 11 questions, corresponding recommendations were agreed upon as guidance for the management of overweight and obese adults. These included strong recommendations in support of lifestyle interventions rather than usual care alone, individualized counseling interventions rather than generic educational pamphlets, physical activity rather than no physical activity, and physical activity in addition to diet rather than diet alone. Metformin and orlistat were suggested as conditional recommendations for the management of overweight and obesity in adults. Bariatric surgery was recommended, conditionally, for the management of obese adults (body mass index of ≥40 or ≥35 kg/m2 with comorbidities). Conclusions: The current guideline includes recommendation for the non-pharmacological, pharmacological, and surgical management of overweight and obese adults. In addition, the panel recommends conducting research priorities regarding lifestyle interventions and economic analysis of drug therapy within the Saudi context, as well as long term benefits and harms of bariatric surgery.

The Public Health Implications of Water in Disasters

Disasters are becoming more frequent worldwide and water figures prominently in many of them. Disasters can result from a severe shortage of water (drought, famine) or too much of it (floods, tsunamis). The recent earthquake and tsunami in Japan offers an excellent example of the critical role water can play, given that the Fukushima Daiichi nuclear power plant weathered the 9.0 moment magnitude earthquake well but suffered catastrophic failure from the resulting tsunami. After disasters, water contamination can compound an already miserable situation. This article will discuss the most current literature on the public health implications of water in disasters and offer recommendations for public policy changes to improve water security. Key policy implications include: reestablishment of water and sanitation are top priorities in the immediate post-disaster period; shelters must not be overcrowded and should have adequate latrines; public health education about personal hygiene is critically important along with liquid soap and safe water to clean hands; supplies of water chlorination products and covered water storage receptacles need to be adequately stockpiled before a disaster.

Patients’ Attitudes Toward Nonphysician Screening of Low Back and Low Back Related Leg Pain Complaints Referred for Surgical Assessment

Study Design. A questionnaire survey. Objective. The aim of this study was to explore patient attitudes toward screening to assess suitability for low back surgery by nonphysician health care providers. Summary of Background Data. Canadian spine surgeons have shown support for nonphysician screening to assess and triage patients with low back pain and low back related leg pain. However, patients’ attitudes toward this proposed model are largely unknown. Methods. We administered a 19-item cross-sectional survey to adults with low back and/or low back related leg pain who were referred for elective surgical assessment at one of five spine surgeons’ clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician health care providers. Results. Eighty low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a nonphysician health care provider to establish whether they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician health care provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons’ and nonphysicians’ determination of surgical candidates. Conclusion. Patients referred for surgical consultation for low back or low back related leg pain are largely willing to accept screening by nonphysician health care providers. Future research should explore the concordance of screening results between surgeon and nonphysician health care providers. Level of Evidence: 3

Minding the gap: Prioritization of care issues among nurse practitioners, family physicians and geriatricians when caring for the elderly

Abstract Accumulating health problems of the elderly requires recognition of geriatric syndromes, while shifting away from a conventional disease-specific approach. We surveyed 179 practitioners representing Family Physicians (FPs), Nurse Practitioners (NPs) and geriatricians in Ontario, in order to quantify how they prioritize syndromes, diseases and conditions in the elderly. Identifying differences may inform opportunities for interprofessional sharing of expertise among professionals pursuing a common goal, which is expected to improve interprofessional collaboration. Our survey (response rate 36%) identifies that NP, FP and geriatrician respondents all recognize co-occurrence of “multiple morbidities” as one of the most frequently encountered issues when serving the elderly, however FPs and NPs place higher priority on managing individual chronic diseases than explicitly prioritizing geriatric syndromes. Our findings identify a need for a more clearly defined role for the geriatrician as syndrome-educator and implies further need for collaborative approaches to caring for seniors that values different professional’s expertise.

Gathering, strategizing, motivating and celebrating: the team huddle in a teaching general practice

Abstract Objectives: To understand how implementing a daily team huddle affected the function of a complex interprofessional team including learners. Design: A qualitative descriptive study using semi-structured interviews in focus groups. Setting: An academic general practice teaching practice. Participants: All members of one interprofessional team, including nurses, general practitioners, junior doctors, and support staff. Method: Focus group interviews using semi-structured guidance were transcribed and the results analysed using qualitative content analysis. Main findings: Four interrelated themes were identified: communication and knowledge sharing; efficiency of care; relationship and team building; and shared responsibility for team function. The implementation of the daily team huddle was seen by participants to enhance the collaboration within the team and to contribute to work life enjoyment. Participants perceived that problems were anticipated and solved quickly. Clinical updates and information about patients benefited the team including learners. Junior doctors quickly understood the scope of practice of other team members, but some felt reluctant to offer clinical opinions. Conclusion: The implementation of a daily team huddle was viewed as worthwhile by this large interprofessional general practice team. The delivery of patient care was more efficient, knowledge was readily distributed, and problem solving was shared across the team, including junior doctors.

Recommendations on screening for asymptomatic bacteriuria in pregnancy

KEY POINTS This guideline from the Canadian Task Force on Preventive Health Care focuses on screening for asymptomatic bacteriuria in pregnancy and re-examines the evidence supporting this routine practice in prenatal care. Asymptomatic bacteriuria is defined as a quantitative count of > 100 × 106

Primary Health Care Providers' Perspectives: Facilitating Older Patients' Access to Community Support Services

RÉSUMÉ: Le but de l’étude examiné dans cet article était de comprendre comment les professionnels des soins de santé qui ne sont pas médecins, mais travaillent dans des milieux primaires canadiens de soins de santé, facilitent l’accès des personnes âgées aux services de soutien communautaire (SSC). L’utilisation de SSC a un impact positif pour les clients, mais ils restent sous-utilisés en raison du manque de prise de conscience. En utilisant une approche descriptive qualitative, nous avons interrogé 20 professionnels de la santé de diverses disciplines et modèles de soins de santé primaires sur les processus qu’ils utilisent pour lier les patients âgés à SSC. Les participants ont collaboré intensivement avec des collègues professionnels au sein et à l’extérieur de leurs organisations pour trouver SSC pertinents. Ils faisaient participer activement les patients et leurs familles à faire ces liens et ont assuré le suivi. Il est troublant de constater qu’ils comptaient sur les ressources périmées et des stratégies de recherche inefficaces pour trouver les SSC. Nos résultats peuvent être utilisés pour développer des ressources et des approches afin de mieux soutenir les fournisseurs de soins de santé primaires en reliant les adultes âgés à des CSS pertinents. ABSTRACT: The purpose of the study examined in this article was to understand how non-physician health care professionals working in Canadian primary health care settings facilitate older persons’ access to community support services (CSSs). The use of CSSs has positive impacts for clients, yet they are underused from lack of awareness. Using a qualitative description approach, we interviewed 20 health care professionals from various disciplines and primary health care models about the processes they use to link older patients to CSSs. Participants collaborated extensively with interprofessional colleagues within and outside their organizations to find relevant CSSs. They actively engaged patients and families in making these linkages and ensured follow-up. It was troubling to find that they relied on out-of-date resources and inefficient search strategies to find CSSs. Our findings can be used to develop resources and approaches to better support primary health care providers in linking older adults to relevant CSSs.