Joshua Shadd

Understanding Palliative Care on the Heart Failure Care Team: An Innovative Research Methodology

CONTEXT There is a growing call to integrate palliative care for patients with advanced heart failure (HF). However, the knowledge to inform integration efforts comes largely from interview and survey research with individual patients and providers. This work has been critically important in raising awareness of the need for integration, but it is insufficient to inform solutions that must be enacted not by isolated individuals but by complex care teams. Research methods are urgently required to support systematic exploration of the experiences of patients with HF, family caregivers, and health care providers as they interact as a care team. OBJECTIVES To design a research methodology that can support systematic exploration of the experiences of patients with HF, caregivers, and health care providers as they interact as a care team. METHODS This article describes in detail a methodology that we have piloted and are currently using in a multisite study of HF care teams. RESULTS We describe three aspects of the methodology: the theoretical framework, an innovative sampling strategy, and an iterative system of data collection and analysis that incorporates four data sources and four analytical steps. CONCLUSION We anticipate that this innovative methodology will support groundbreaking research in both HF care and other team settings in which palliative integration efforts are emerging for patients with advanced nonmalignant disease.

Pulling together and pulling apart: influences of convergence and divergence on distributed healthcare teams

Effective healthcare requires both competent individuals and competent teams. With this recognition, health professions education is grappling with how to factor team competence into training and assessment strategies. These efforts are impeded, however, by the absence of a sophisticated understanding of the the relationship between competent individuals and competent teams . Using data from a constructivist grounded theory study of team-based healthcare for patients with advanced heart failure, this paper explores the relationship between individual team members’ perceived goals, understandings, values and routines and the collective competence of the team. Individual interviews with index patients and their healthcare team members formed Team Sampling Units (TSUs). Thirty-seven TSUs consisting of 183 interviews were iteratively analysed for patterns of convergence and divergence in an inductive process informed by complex adaptive systems theory. Convergence and divergence were identifiable on all teams, regularly co-occurred on the same team, and involved recurring themes. Convergence and divergence had nonlinear relationships to the team’s collective functioning. Convergence could foster either shared action or collective paralysis; divergence could foster problematic incoherence or productive disruption. These findings advance our understanding of the complex relationship between the individual and the collective on a healthcare team, and they challenge conventional narratives of healthcare teamwork which derive largely from acute care settings and emphasize the importance of common goals and shared mental models. Complex adaptive systems theory helps us to understand the implications of these insights for healthcare teams’ delivery of care for the complex, chronically ill.

Neuropathic pain in a primary care electronic health record database

Neuropathic pain (NP) is common in the adult population but is difficult to study in electronic health record (EHR) databases because it is a symptom rather than a pathologic diagnosis. The first step in studying NP in EHR databases is to develop methods for identifying patients with NP. The objectives of this study were to develop estimates of the prevalence of NP among patients in a primary care EHR database and describe these patients’ demographic characteristics and health‐care utilization.

Prevalence and indications for bladder catheterization on a palliative care unit: A prospective, observational study

The transition from walking to the bathroom to using a bedside commode, bedpan, brief, or bladder catheter can be difficult for both patients and nurses. Though bladder management is a common concern in palliative care units (PCU), the only study found on this topic determined that 72% of terminally ill cancer patients required a catheter before death.1 The goal of this prospective, observational study was to describe the use of bladder catheters among patients on a 14-bed, non-acute hospital-based PCU that serves approximately 180 patients annually in London, Canada. Specifically, the study aims were to determine the incidence of and indications for bladder catheterization among PCU patients with a view to understanding why PCU patients were catheterized.

Institutional non-participation in assisted dying: Changing the conversation

Whether institutions and not just individual doctors have a right to not participate in medical assistance in dying (MAID) is controversial, but there is a tendency to frame the issue of institutional non-participation in a particular way. Conscience is central to this framing. Non-participating health centres are assumed to be religious and full participation is expected unless a centre objects on conscience grounds. In this paper we seek to reframe the issue. Institutional non-participation is plausibly not primarily, let alone exclusively, about conscience. We seek to reframe the issue by making two main points. First, institutional non-participation is primarily a matter of institutional self-governance. We suggest that institutions have a natural right of self-governance which, in the case of health centres such as hospitals or hospices, includes the right to choose whether or not to offer MAID. Second, there are various legitimate reasons unrelated to conscience for which a health centre might not offer MAID. These range from considerations such as institutional capacity and expertise to a potential contradiction with palliative care and a concern to not conflate palliative care and MAID in public consciousness. It is a mistake to frame the conversation simply in terms of conscience-based opposition to MAID or full participation. Our goal is to open up new space in the conversation, for reasons unrelated to conscience as well as for non-religious health centres who might nonetheless have legitimate grounds for not participating in MAID.

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data

Background A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. Objective To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. Method Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location. Proportion of variance in referral rates attributable to the patient and practice levels. Results On average, males had 0.26 and females had 0.31 referrals in a 12-month period. Referrals were significantly higher for females, increased with age, FP visits and the number of chronic conditions (p < 0.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. Conclusions Both the patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilise count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time.

Urinary Retention and Medication Utilization on a Palliative Care Unit: A Retrospective Observational Study

ABSTRACT Urinary retention is a common problem at end-of-life that may be a result of medications used to control other symptoms. To determine whether use of retention-causing drugs was associated with catheterization for urinary retention among palliative care unit (PCU) patients, the authors reviewed charts of 91 consecutively admitted patients to a hospital-based PCU. Utilization of eight classes of retention-causing medications (opioids, antidopaminergics, benzodiazepines, anticholinergics, antidepressants, calcium channel antagonists, nonsteroidal anti-inflammatory drugs [NSAIDs], and H1 histamine antagonists) was compared between those catheterized for urinary retention (n = 34) and those never catheterized (n = 31). All patients used medication from more than one class of retention-causing medication. A statistically significant association with urinary retention occurred for antidopaminergic medications, but not other drug classes. The total number of classes of retention-causing medications was not associated with catheterization. These findings question whether urinary retention need hinder medication use for symptom management at end-of-life. Tapering of antidopaminergic medications, compared with other drug classes studied, may be more likely to resolve retention.