Completion of Preventive Health Care Actions by Older Women with HIV/AIDS

The widespread use of highly active antiretroviral therapy (HAART) has resulted in longer lifespans for HIV seropositive women in the United States, during which preventive health care is recommended. Failing to complete recommended cancer screening tests can result in cancer being diagnosed at a later stage with a poorer prognosis. The purpose of the study, based on the ecosocial theory, was to describe the sociodemographic and clinical variables of HIV seropositive women who failed to complete recommended screening tests for breast, cervical, and colorectal cancers, and determine if the presence of hypertension, obesity, diabetes, depression, or tobacco use impacted the completion of these screening tests. The electronic medical records of 142 HIV seropositive women were reviewed. Univariate analysis, bivariate analysis, and logistic regression were conducted to create a model associated with the completion of preventive health care screening tests. For breast cancer, cervical cancer, and colorectal cancer, 69%, 71.8%, and 69.7% failed to complete screening, respectively. Number of years living with HIV infection and HIV stage were associated with breast cancer screening; distance between residence and health care facility, and HIV stage were associated with cervical cancer screening; and age and marital status were associated with colorectal cancer screening. Addressing issues related to the completion of cancer screening tests over the lifespans of HIV seropositive women can result in positive social change by preventing disease and disability, which can negatively impact these women, their families, and their communities

L'usage secondaire des données médico-administratives afin d’optimiser l’usage des médicaments chez les patients atteints de maladies respiratoires chroniques : adhésion aux médicaments, identification de cas et intensification du traitement

Medication adherence in patients with asthma and chronic obstructive pulmonary disease (COPD) is notoriously low and is associated with suboptimal therapeutic outcomes. To intervene effectively, family physicians need to assess medication adherence efficiently and accurately. Otherwise, failure to detect nonadherence may further reduce patient disease control and result in unnecessary treatment escalation that can increase the risk of adverse events and lead to more complex and costly drug regimens. The overarching goal of this thesis was to investigate how the use of secondary healthcare data can be leveraged to optimize medication adherence in clinical practice. Methodological considerations to facilitate our understanding of treatment escalation in asthma using secondary healthcare data were also examined. In the first part of my doctoral research program, I led a project which aimed at developing e-MEDRESP, a novel web-based tool built from pharmacy claims data that provides to family physicians with objective and easily interpretable information on patient adherence to asthma/COPD medications. This tool was developed in collaboration with family physicians and patients using a framework inspired by user-centered design principles. As part of a feasibility study, e-MEDRESP was subsequently implemented in electronic medical records across several family medicine clinics in Quebec (346 patients, 19 physicians). Findings showed that its integration within physician workflow was feasible. Physicians reported that the tool helped to: 1) better evaluate their patients’ medication adherence; and 2) adjust prescribed therapies, with mean ± sd ratings (5-point Likert scale) of 4.8±0.7 and 4.3±0.9, respectively. A pre-post analysis did not reveal improvement in adherence among patients whose physician consulted e-MEDRESP during a medical visit. However, significant improvements in adherence for inhaled corticosteroids (Proportion of days covered (PDC): 26.4% (95% CI: 14.3-39.3%)) and long-acting muscarinic agents (PDC: 26.4% (95% CI: 12.4-40.2%)) were observed among patients whose adherence level was less than 80% in the 6-month period prior to the medical visit. The second part of this research program consisted of two studies which laid the groundwork to estimate the association between medication adherence and treatment escalation in asthma using Canadian healthcare administrative data, a phenomenon that is currently under-explored in the literature. Prior to embarking in this study, it is important to ensure that healthcare administrative databases can be used to identify asthma patients and treatment escalations in an adequate manner. First, a systematic review was conducted to obtain an overview of the available evidence supporting the validity of algorithms to identify asthma patients in healthcare administrative databases. The algorithm developed by Gershon et al. (Canadian Respiratory Journal, 2009;16(6):183-188) comprising ≥2 ambulatory medical visits or ≥1 hospitalization for asthma over two years had the best trade-off between sensitivity (84 %) and specificity (77%). Second, an operational definition of treatment escalation was developed through a Delphi study that incorporated an expert consensus process. This definition includes 7 steps and was inspired by the 2020 Global for Initiative for Asthma treatment guidelines. I plan to integrate the definitions obtained from these two studies in a future cohort study which aims to examine the association between medication adherence and treatment escalation in asthma. My research provides compelling evidence on the importance of developing and evaluating the feasibility of implementing tools which can aid physicians in assessing medication adherence in clinical practice and extends the literature on treatment escalation in asthma.L’adhésion aux médicaments chez les patients présentant un asthme ou une maladie pulmonaire obstructive chronique (MPOC) est reconnue pour être faible. Pour intervenir efficacement, les médecins de famille doivent évaluer de manière précise l’adhésion aux médicaments. Ne pas détecter la non-adhésion peut réduire davantage la maîtrise de la maladie, entraîner une intensification non-nécessaire du traitement, mener à des schémas pharmacologiques plus complexes et coûteux et par conséquent, augmenter le risque d’événements indésirables. La présente thèse vise à approfondir les connaissances sur l'usage secondaire des données médico-administratives afin d’optimiser l’adhésion et l’usage des médicaments chez les patients atteints de maladies respiratoires chronique, au moyen d’une approche méthodologique mixte de recherche. Plusieurs questions méthodologiques cruciales concernant l’étude de l’intensification du traitement en asthme ont également été abordées. Le premier axe porte sur le développement de l’outil e-MEDRESP, qui s’appuie sur les renouvellements d’ordonnances et qui est conçu pour donner rapidement accès aux médecins de famille à une mesure objective et facilement interprétable de l’adhésion aux médicaments utilisés dans le traitement de l’asthme et de la MPOC. L’outil a été développé en collaboration avec des médecins de famille et des patients à l’aide de groupes de discussion et d’entrevues individuelles. Dans le cadre d’une étude de faisabilité, l’outil e-MEDRESP a été par la suite implanté dans les dossiers médicaux électroniques de plusieurs cliniques de médecine familiale au Québec (346 patients, 19 médecins). Les résultats ont montré que l’intégration de d’e-MEDRESP dans le flux de travail des médecins était faisable. Les médecins ont indiqué que l’outil leur a permis de : 1) mieux évaluer l’adhésion aux médicaments de leurs patients (cote moyenne et écart-type sur une échelle de Likert à 5 points [perception d’accord] de 4,8±0,7); et 2) ajuster les traitements prescrits (4,8±0,7 et 4.3±0,9). Une analyse pré-post n’a pas révélé d’amélioration au niveau de l’adhésion aux médicaments chez les patients dont le médecin a consulté e-MEDRESP lors d’une visite médicale. Toutefois, une amélioration statistiquement significative a été observée chez les patients dont le niveau d’adhésion était inférieur à 80 % au cours de la période de six mois précédant la visite et qui étaient traités par des corticostéroïdes inhalés (Proportion of days covered (PDC) = 26,4 % (IC à 95 % : 14,3-39,3 %) ou des antagonistes muscariniques à action prolongée (PDC = 26,9 % (IC à 95 % : 12,4-40,2 %)). Le deuxième axe présente des travaux préparatoires à la conduite d’une cohorte qui sera réalisée à partir de bases de données médico-administratives et qui aura comme objectif d’estimer l’association entre l’adhésion aux médicaments et l’intensification du traitement de l’asthme, une question peu explorée à ce jour. Avant de débuter une telle étude, il est important de s’assurer que les bases de données médico-administratives peuvent être utilisées pour identifier de manière adéquate les patients asthmatiques et l’intensification du traitement. Dans un premier temps, une revue systématique a été effectuée pour identifier les données probantes disponibles concernant la validité des algorithmes permettant d’identifier les patients asthmatiques dans les bases de données médico-administratives. L’algorithme qui a été développé par Gershon et coll. (Revue canadienne de pneumologie, 2009; vol. 16, no 6, p. 183-188), qui comprenait deux visites médicales ambulatoires ou une hospitalisation pour asthme sur deux ans, présentait le meilleur compromis entre la sensibilité (84 %) et la spécificité (77 %). Dans un second temps, une définition opérationnelle de l’intensification du traitement a été élaborée dans le cadre d’une étude Delphi qui incorporait un processus consensuel d’experts. Cette définition comprend sept étapes et s’inspire des lignes directrices 2020 de l'initiative mondiale de lutte contre l'asthme. Les définitions obtenues à partir de ces deux études seront intégrées dans l’étude de cohorte. Les études constituant cette thèse démontrent l’importance de développer des outils qui permettent aux médecins d’évaluer l’adhésion aux médicaments dans leur pratique clinique, en plus d’enrichir la littérature scientifique médicale sur l’intensification du traitement chez les patients asthmatiques

The Gezira Family Medicine Project (GFMP). A scientific evaluation of a Master program for family physicians in Gezira, Sudan

Background: Family medicine based health systems are accepted worldwide as the best suitable model to provide integrated, high quality health services. In Sub-Saharan Africa, there is a recent movement towards implementing family medicine in health system; consequently, high up scaling of family medicine training is targeted and is going on like a fast track. Sudan faces the same challenges found in other Sub-Saharan African countries including the predominance of the tropical diseases that over-shadow the emerging problem of Non-Communicable Diseases (NCDs). The Gezira Family Medicine Project (GFMP) was established in 2010 as a collaboration project between several local partners including the State Ministry of Health and the University of Gezira. The project aimed to train qualified family physicians who can participate in providing high quality, accessible, and affordable primary health care services in Gezira. A twoyear Master curriculum was designed as an “in-service” model of training to meet both service provision and training's goals. A total of 207 candidates were enrolled in the first batch of the program in 2010. The project used information and communication technology (ICT) in a comprehensive way; it is used to provide health care in a distance (telemedicine), to facilitate and increase the accessibility in medical education (e-learning) and to manage patients' information (Electronic Medical Records- EMR). Study objectives: This study aimed to: Describe the GFMP during its first batch (2010-2012), its implementation, curriculum structure, baseline data of the trainees and their health centres. Assess the candidates' utilization of information and communication technology at the GFMP, and their perception of its use. Assess the impact of the Master programme on candidates' confidence to perform certain manual and cognitive clinical skills. Assess the impact of the GFMP on candidates' adherence to the core values of family medicine including patient-centeredness. Methods: Three comprehensive questionnaires were used to collect data both at the start of the Master program for the first batch and again at its end. The first questionnaire included background data regarding the candidates and their self-assessment of confidence to perform certain skills. The second questionnaire was a checklist for the health centres including the buildings, available equipment and provided services. The third questionnaire aimed to assess candidates' practice including adhesion to the core values of family medicine during patient consultations. A cross sectional, questionnaire and administrative data based observational design was used in paper 1 and paper 2. Self-evaluation questionnaire was used to collect data about the trainees' skills, while a checklist was used to collect data from the health centres. Administrative data was used to describe the project implementation, its curriculum design and candidates' utilization of ICT during the master period. A prospective cross sectional study with a before-and-after design was used in paper 3 and paper 4 to assess the progress change of the trainees during the Master period 2010-2012 (cohort observational design). Self-evaluation questionnaire and practicebased data were used to assess trainees' confidence in performing certain clinical skills and to assess their adhesion to some family medicine core values. The Patient- Practitioner Orientation Scale (PPOS) was used to assess patient-centeredness. Results: The 2-year in-service Master program at the GFMP could recruit 207 physicians to be trained in family medicine and to provide health services in 158 health centres, of which, 84 centres had never been served by a doctor before. The mean age of the enrolled trainees was 32.5 years, 57% were males and one third of them were graduated from the University of Gezira. Self-evaluation in confidence to perform certain clinical skills showed significant variations between individual skills, between medical disciplines, and between genders. Health centres were generally equipped to deal with tropical diseases, but poorly equipped to deal with Non Communicable Diseases (NCDs) Information and communication (ICT) reports showed a performance of 3808 online telemedicine consultations in the period April 2011 to December 2012. Over 165000 new patients' electronic medical records (EMRs) were established by the candidates at their graduation (N: 125 candidate). Candidates were generally highly satisfied with the use of ICT during their master period. They highlighted some patients' concerns regarding the use of EMR and telemedicine during consultations. To assess candidate’s improvement after the Master program, self-assessment of 46 clinical skills was done before and after the master program using a five-grade Likert scale (1-5). It showed an overall improvement of 21.7% from 3.23 (before) to 3.92 (after). Improvement variation is observed between the different medical disciplines. Males have constantly scored higher confidence than females, while females showed higher progress percentage in improvement compared with males. Statistically significant improvement is also detected regarding candidates' development in certain role skills like leadership, health promotion, and communication with colleagues and the community. In contrast, there was an overall significant decrease in orientation towards patient-centred care by 4% using the Patient-Practitioner Orientation Scale (PPOS). Conclusion: GFMP represented a good model for local collaboration, which resulted in performing training goals and providing high quality primary health care services. The in-service model of training was attractive for trainees (207 joined the program) and promising for health service provision (158 health centres were served by GFMP, of which 84 had never been served by physicians before). Information and communication technology (ICT) supported both training goals and service provision goals at the GFMP. The GFMP curriculum had a positive impact on candidates' confidence to perform the targeted clinical skills. Practice data showed a positive impact of the Master program on candidates' adherence to family medicine core values. Patient centred care was a weak point in candidates' training that needs more attention in future curriculum planning and implementation. Recent assessment of the status of the GFMP and family medicine training in Sudan as a whole done in Apr 2018, showed still high up-scaling of family medicine training in the whole country, presented by several institutes including the University of Gezira and the National Public Health Institute (PHI). The development of the GFMP as a project is affected by economical challenges and a decline in the political commitment, which affected the partnership between the University of Gezira and the State Ministry of Health

The Retrospective Evaluation of the Effectiveness of Implementing Standard of Care Best Practices on Fear of Hypoglycemia (FOH) in Insulin Requiring Diabetics

The population of individuals with diabetes is expected to rise along with a rise in the use of insulin therapy to control hyperglycemia and prevent diabetic complications. Insulin therapy is implicated as one of the leading causes of hypoglycemia, a potentially life-threatening adverse drug event. Hypoglycemia is recognized by patients and clinicians as the greatest barrier to achieving adequate glycemic control and it causes physical, psychosocial, financial, and safety concerns for individuals, their families, communities and health care systems. Hypoglycemia often causes insulin requiring diabetics to develop a fear of hypoglycemia, a complex phenomenon that manifests as avoidance of hypoglycemia or near normal euglycemia thus triggering hyperglycemia and increasing risk. The fear and risk of hypoglycemia requires attention by clinicians in order to assist patients in self-management. The purpose of this evidence based project was to add to clinical knowledge and demonstrate how the application of best practice strategies can be translated into real world clinical practice to improve quality and safety. All insulin requiring adults evaluated by the advanced practice nurse were provided education in accordance to best practice standards. Sixty participants were queried pre-intervention and post-intervention with the FH-15 Survey and a hypoglycemia incidence survey. The data was comparatively analyzed. Outcomes demonstrated that self-management education effectively reduced fear of hypoglycemia and incidence of hypoglycemia; however, the intervention was statistically significant in reducing fear of hypoglycemia only. Additional scholarly inquiry regarding the topic is recommended

An initial case study of a readmission and emergency department revisit reduction program for high utilizer patients at a large community hospital system in Massachusetts

BACKGROUND: This dissertation presents an initial, mixed-methods case study of a hospital-based multidisciplinary care team (MCT) program designed to reduce hospital readmissions and emergency department (ED) revisits among patients with high hospital utilization without restrictions in a large, not-for-profit, non-teaching, community hospital system. METHODS: High utilizers were defined by either ≥10 ED visits or ≥4 inpatient stays within the past 12 months on a rolling basis. Electronic medical records and retrospective patient-level surveys completed by MCT staff provided insight into program reach and implementation, as well as initial impacts on hospital-based outcomes, non-hospital based outcomes, and staff-perceived impacts of MCT services on patients. Interviews with MCT patients, program staff, hospital administrators, community partners, and field experts were analyzed to understand the key challenges, best practices, and lessons learned to help inform transferability and sustainability of this type of program. RESULTS: Of the 1,680 patients who were identified as eligible high utilizers, about half received ≥2 telephone calls or face-to-face visits with the MCT. There were significant delays to patients receiving MCT services, especially for patients who met eligibility criteria within the first few months of the program initiation. Data reflected the high number of MCT encounters and breadth of services provided to MCT participants. On average, changes in post-period ED revisit and inpatient readmission rates were not significantly different from pre-period rates for MCT participants overall, or when broken down by initial classification as an inpatient or ED high utilizer. MCT staff reported improvements in housing stability, usual source of care, and substance use treatment or recovery for MCT participants. Staff perceived positive overall and specific impacts of MCT services for a large portion of patients, with greater perceived positive impacts on all outcomes with increasing program duration. Salient themes from the qualitative data analysis included the heterogeneity of the high utilizer population, internal communication and support, community integration, and financing. CONCLUSION: This initial study, conducted prior to the conclusion of the full MCT program, provided insight into the strengths, challenges, and early lessons learned from a hospital-based multidisciplinary care team program designed to reduce high readmission and revisit rates among high utilizers. This study also lays the groundwork for a full post-program evaluation in the future.2019-11-08T00:00:00

HIV Associated Neurocognitive Disorder: Exploring the complexity

Background Human Immunodeficiency Virus (HIV) infection is now a chronic disease. As people living with HIV (PLHIV) age they are at risk of a neurological co-morbid disease called HIV associated Neurocognitive Disorder (HAND), which causes varied levels of disability affecting quality of life. Early identification and diagnosis is important, as HAND is potentially treatable. Informal and professional caregivers may assist in identification of HAND. Aim To explore the complexities of identifying HAND by PLHIV, their informal or professional caregivers. Objectives: • Explore whether PLHIV and their informal caregivers can identify HAND. • Explore the experience of HAND in PLHIV. • Explore whether community based health care professionals can identify HAND. Design A pragmatic explanatory sequential design. Method A mixed method approach explored the complexities of identifying HAND through a preliminary observational multisite pilot study followed by three subsequent study phases, an online survey, a cross sectional file audit of two community based HIV teams and a modified Delphi study. Results The pilot study noted that both PLHIV and informal caregivers can identify signs and symptoms of HAND leading to diagnosis of HAND. The online survey noted PLHIV were concerned about HAND; were experiencing signs and symptoms of HAND and additionally wanted support in discussing HAND with others. The file audit noted that community based professionals were not collecting the appropriate information to identify HAND. The modified Delphi method lead to development of an initial and monitoring tool for community-based professionals to use to identify those PLHIV at risk of HAND who should be referred for formal assessment. Conclusion HAND is a potentially treatable condition. Early recognition can have a positive impact on health and quality of life of PLHIV as they age. Diagnosis of HAND is complex, but the observational and other experiences of PLHIV and their caregivers, can offer unique insights into cognitive changes in PLHIV. For those PLHIV without the support of an informal caregiver and/or who live alone, professional caregivers can act as an alternative to an informal caregiver, being well placed to observe changes in cognitive behaviour over time

Engineering an EMR System in the Developing WorldNecessity is the Mother of Invention

While Electronic Medical Record (EMR) systems continue to improve the efficacy of healthcare delivery in the West, they have yet to be widely deployed in the developing world, where more than 90% of the global disease burden exists. The benefits afforded by an EMR notwithstanding, there is some skepticism regarding the feasibility of operationalizing an EMR system in a low-resource setting. This dissertation challenges these preconceptions and advances the understanding of the problems faced when implementing EMR systems to support healthcare delivery in a developing-world setting.Our methodology relies primarily on eight years of in-field experimentation and study. To facilitate a better understanding of the needs and challenges, we created a pilot system in a large government central hospital in Malawi, Africa. Learning from the pilot we developed and operationalized a point-of-care EMR system for managing the care and treatment of patients receiving antiretroviral therapy, which we put forth as a demonstration of feasibility in a developing-world setting.The pilot identified many unique challenges of healthcare delivery in the developing world, and reinforced the need to engineer solutions from scratch rather than blindly transplant systems developed in and for the West. Three novel technologies were developed over the course of our study, the most significant of which is the touchscreen clinical workstation appliance. Each of the novel technologies and their contribution towards successful implementation are described in the context of both an engineering and a risk management framework. A small comparative study to address data quality concerns associated with a point-of-care approach concluded that there was no significant difference in the accuracy of data collected through the use of a prototype point-of-care system compared to that of data entered retrospectively from paper records. We conclude by noting that while feasibility has been demonstrated the greatest challenge to sustainability is the lack of financial resources to monitor and support EMR systems once in place