Ricardo Angeles

The Effectiveness of Web-Based Tools for Improving Blood Glucose Control in Patients with Diabetes Mellitus: A Meta-Analysis

ABSTRACT OBJECTIVES: Health promotion using web-based tools may provide some benefit to patients with diabetes mellitus. This meta-analysis assessed the effectiveness of web-based tools in improving blood glucose control. METHODS: Randomized, controlled trials (web-based tools vs. usual care) were identified from research databases using the following criteria: participants were patients with diabetes (type 1 or 2) who had suboptimal blood glucose control (glycated hemoglobin [A1C] >7%), and outcomes included A1C. Two reviewers independently screened and extracted data. Study quality was evaluated based on randomization; concealment of allocation; blinding; accounting for dropouts and losses to follow-up; and overall quality based on the Grading of Recommendations Assessment, Development and Evaluation scale. RESULTS: Nine studies were included. Pooled estimates showed a significant mean difference in A1C favouring webbased tools. The mean differences were –0.71% (95% CI –1.00, -0.43) after 3 months, -0.52% (95% CI –0.75, –0.29) after 6 months and –0.55% (95% CI –0.70, -0.39) after 12 months. There was heterogeneity among studies with 12 months of intervention (I 2 =78%). There was also a significant mean difference in low-density lipoprotein cholesterol (LDL-C) favouring web-based tools (–0.23 mmol/L, 95% CI –0.28, –0.19). CONCLUSION: This study showed that web-based tools were better than usual care in improving A1C and LDL-C. Future studies should assess the cost benefit of web-based tools and further improve their effectiveness.

Developing a Theoretical Framework for Complex Community-Based Interventions

Applying existing theories to research, in the form of a theoretical framework, is necessary to advance knowledge from what is already known toward the next steps to be taken. This article proposes a guide on how to develop a theoretical framework for complex community-based interventions using the Cardiovascular Health Awareness Program as an example. Developing a theoretical framework starts with identifying the intervention’s essential elements. Subsequent steps include the following: (a) identifying and defining the different variables (independent, dependent, mediating/intervening, moderating, and control); (b) postulating mechanisms how the independent variables will lead to the dependent variables; (c) identifying existing theoretical models supporting the theoretical framework under development; (d) scripting the theoretical framework into a figure or sets of statements as a series of hypotheses, ifthen logic statements, or a visual model; (e) content and face validation of the theoretical framework; and (f) revising the theoretical framework. In our example, we combined the “diffusion of innovation theory” and the “health belief model” to develop our framework. Using the Cardiovascular Health Awareness Program as the model, we demonstrated a stepwise process of developing a theoretical framework. The challenges encountered are described, and an overview of the strategies employed to overcome these challenges is presented.

Rationale and methods of a multicentre randomised controlled trial of the effectiveness of a Community Health Assessment Programme with Emergency Medical Services (CHAP-EMS) implemented on residents aged 55 years and older in subsidised seniors' housing buildings in Ontario, Canada

Introduction Chronic diseases and falls substantially contribute to morbidity/mortality among seniors, causing this population to frequently seek emergency medical care. Research suggests the paramedic role can be successfully expanded to include community-based health promotion and prevention. This study implements a community paramedicine programme targeting seniors in subsidised housing, a high-risk population and frequent users of emergency medical services (EMS). The aims are to reduce EMS calls, improve health outcomes and healthcare utilisation. Methods/analysis This is a pragmatic clustered randomised control trial in four communities across Ontario, Canada. Within each, four to eight seniors’ apartment buildings will be paired and within each pair one building will be randomly assigned to receive the Community Health Assessment Programme through EMS (CHAP-EMS) intervention, while the other building receives no intervention. During the 1-year intervention, paramedics will run weekly sessions in a common area of the building, assessing risk factors for cardiovascular disease, diabetes and falls; providing health education and referrals to community programmes; and communicating results to the participants primary physician. The primary outcomes are rate of emergency calls per 100 residents, change in blood pressure and change in Canadian Diabetes Risk (CANRISK) score, as collected by the local EMS and study databases. The secondary outcomes are change in health behaviours, measured using a preintervention and postintervention survey and healthcare utilisation, available through administrative databases. Analysis will mainly consist of descriptive statistics and generalised estimating equations, including subgroup cluster analysis. Ethics/dissemination This study is approved by the Hamilton Integrated Research Ethics Board and will follow the Tri-Council Policy Statement. Findings will be disseminated through reports to local stakeholders, publication in peer-reviewed journals and conference presentations. Trial registration number NCT02152891.

Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial

BACKGROUND: Low-income older adults who live in subsidized housing have higher mortality and morbidity. We aimed to determine if a community paramedicine program — in which paramedics provide health care services outside of the traditional emergency response — reduced the number of ambulance calls to subsidized housing for older adults. METHODS: We conducted an open-label pragmatic cluster-randomized controlled trial (RCT) with parallel intervention and control groups in subsidized apartment buildings for older adults. We selected 6 buildings using predefined criteria, which we then randomly assigned to intervention (Community Paramedicine at Clinic [CP@clinic] for 1 yr) or control (usual health care) using computer-generated paired randomization. CP@clinic is a paramedic-led, community-based health promotion program to prevent diabetes, cardiovascular disease and falls for residents 55 years of age and older. The primary outcome was building-level mean monthly ambulance calls. Secondary outcomes were individual-level changes in blood pressure, health behaviours and risk of diabetes assessed using the Canadian Diabetes Risk Questionnaire. We analyzed the data using generalized estimating equations and hierarchical linear modelling. RESULTS: The 3 intervention and 3 control buildings had 455 and 637 residents, respectively. Mean monthly ambulance calls in the intervention buildings (3.11 [standard deviation (SD) 1.30] calls per 100 units/mo) was significantly lower (−0.88, 95% confidence interval [CI] −0.45 to −1.30) than in control buildings (3.99 [SD 1.17] calls per 100 units/mo), when adjusted for baseline calls and building pairs. Survey participation was 28.4% (n = 129) and 20.3% (n = 129) in the intervention and control buildings, respectively. Residents living in the intervention buildings showed significant improvement compared with those living in control buildings in quality-adjusted life years (QALYs) (mean difference 0.09, 95% CI 0.01 to 0.17) and ability to perform usual activities (odds ratio 2.6, 95% CI 1.2 to 5.8). Those who received the intervention had a significant decrease in systolic (mean change 5.0, 95% CI 1.0 to 9.0) and diastolic (mean change 4.8, 95% CI 1.9 to 7.6) blood pressure. INTERPRETATION: A paramedic-led, community-based health promotion program (CP@clinic) significantly lowered the number of ambulance calls, improved QALYs and ability to perform usual activities, and lowered systolic blood pressure among older adults living in subsidized housing. Trial registration: Clinicaltrials.gov, no. NCT02152891

Group interprofessional chronic pain management in the primary care setting: a pilot study of feasibility and effectiveness in a family health team in Ontario.

BACKGROUND Approximately 18.9% of Canadians live with chronic pain. Primary care reform in Ontario presents unique opportunities to assess approaches to help these patients. OBJECTIVE To assess the feasibility of an interprofessional primary care-based program for patients living with chronic pain, and to examine the potential impact of such a program on quality of life and health resource utilization. METHODS An embedded mixed-methods evaluation (randomized controlled trial with waiting list control and semistructured interviews) of an eight-week series of small group sessions exploring multifactoral aspects of pain management was performed. Participants were randomly assigned to early intervention (EI) or delayed intervention (DI) groups. All participants received the intervention; the DI group served as a control group for comparison with the EI group. Outcomes included the Short Form-36 Health Survey version 2 (SF-36v2), medication use and health care utilization. Qualitative interviews were conducted to identify areas for program improvement. RESULTS A total of 240 patients were recruited and 63 agreed to participate. The mean (± SD) age of the participants was 55±14.1 years and 62.3% were female. There was no significant difference in the mean change in SF-36v2 summary scores between the EI and DI groups. However, the SF-36v2 subscale score for bodily pain was significantly improved in the EI group compared with the DI group after six months of observation (mean difference = 13.1 points; P<0.05). There was also significant improvement in this score when both groups were pooled and aggregate preintervention and postintervention scores were compared. There was a significant decrease in the mean number of clinic visits in the six-month period following the intervention compared with the six-month period before the intervention (P=0.043). CONCLUSION An interprofessional program in primary care for patients living with chronic pain may lead to improvements in quality of life and health resource utilization. The challenges to the feasibility of the program and its evaluation are recruitment and retention of patients, leading to the conclusion that the program, as it was conducted in the present study, is not appropriate for this setting.

Understanding Why Frequent Users of EMS Call 9-1-1: A Grounded Theory Study

Introduction. Frequent users of emergency medical services (EMS) have disproportionately high 9-1-1 call frequency. Evidence suggests that this small group burdens the health care system, leading to misallocation of already-limited health resources. Aim. To understand frequent users’ perceptions and experiences regarding EMS, as well as the driving factors underlying their frequent use. Method. A grounded theory approach guided our qualitative research process. Participants older than 17 years who called EMS five or more times in the past year were consecutively sampled where each participant was contacted in the order they appeared on our list of potential participants for interviews until data saturation was achieved. Transcripts were analyzed to derive common themes among frequent EMS callers. Results. Frequent EMS calls often resulted from chronic medical conditions creating recurrent crisis situations, mental health issues as well as mobility issues, frequent noninjurious falls, and social isolation. Combined with these factors, perceptions of the purpose of EMS and social circumstances also contributed to the creation of complex health issues that influenced frequent EMS use. These findings can advise the development of future paramedicine programs and health promotion interventions.

Choosing the optimal method of blood pressure measurement for limited‐resource rural communities in the “Community Health Assessment Program—Philippines”

The Community Health Assessment Program—Philippines (CHAP‐P) is an international collaboration of investigators whose aim is to adapt a previously proven Canadian community‐based cardiovascular awareness and prevention intervention to the Philippines and other low‐middle–income countries. Choosing a method of blood pressure measurement for the research program presents a challenge. There is increasing consensus globally that blood pressure measurement with automated devices is preferred. Recommendations from low‐middle–income countries, including the Philippines, are less supportive of automated blood pressure devices. The value placed on factors including device accuracy, durability, cost, energy source, and complexity differ with local context. Our goal was to support the progress of local policy concerning blood pressure measurement while testing a comprehensive approach to community‐based screening for cardiovascular risk. The authors describe the challenges in making a choice of blood pressure device and the approach to determine optimal method of measurement for our research program.

EXAMINING HYPERTENSION RATES, SEVERITY, KNOWLEDGE, AND MODIFIABLE RISK FACTORS IN OLDER ADULTS RESIDING IN ONTARIO SUBSIDISED HOUSING

referral to a pediatric cardiologist who then decided if a patient would receive an echocardiogram while Strategy 2 used a hypothetical situation where any physician could refer patients with heart murmurs for an echocardiogram. DESIGN: Pre-existing clinical data from a previous study consisting of 252 new, outpatient consultations to the IWK Children’s Heart Centre between August 1, 2011 and August 17, 2012 were obtained to determine what types of tests were ordered for patients with heart murmurs, in what proportions, and their final diagnoses. Costs of the different strategies were calculated using multiple hospital resources, the public physician billing manual and other publically available online resources. Descriptive statistics were used to describe observed and estimated costs and a Wilcoxon matched-pairs signed rank test assessed the significance of pair-wise differences in cost between the two approaches. RESULTS: Strategy 2, which requires performing echocardiograms on all patients, resulted in a

Primary health care needs for a priority population: A survey of professional truck drivers

77.30 increase in median total costs per patient over the current Strategy 1, which required all patients to be first examined by a pediatric cardiologist before any specialized tests could be performed. The difference was significant (p<0.001). CONCLUSION: The cost of initial referral to a pediatric specialist is less costly than direct referral of patients with murmurs for echocardiography in the patient group and caregiver group studied. The percentage of echoes ordered for innocent murmurs at which the “crossover point” in cost occurs, remains to be determined. CIHR