Developing clinical decision tools to implement chronic disease prevention and screening in primary care: the BETTER 2 program (building on existing tools to improve chronic disease prevention and screening in primary care).

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial demonstrated the effectiveness of an approach to chronic disease prevention and screening (CDPS) through a new skilled role of a 'prevention practitioner'(PP). The PP has appointments with patients 40-65 years of age that focus on primary prevention activities and screening of cancer (breast, colorectal, cervical), diabetes and cardiovascular disease and associated lifestyle factors. There are numerous and occasionally conflicting evidence-based guidelines for CDPS, and the majority of these guidelines are focused on specific diseases or conditions; however, primary care providers often attend to patients with multiple conditions. To ensure that high-level evidence guidelines were used, existing clinical practice guidelines and tools were reviewed and integrated into blended BETTER tool kits. Building on the results of the BETTER trial, the BETTER tools were updated for implementation of the BETTER 2 program into participating urban, rural and remote communities across Canada.MethodsA clinical working group consisting of PPs, clinicians and researchers with support from the Centre for Effective Practice reviewed the literature to update, revise and adapt the integrated evidence algorithms and tool kits used in the BETTER trial. These resources are nuanced, based on individual patient risk, values and preferences and are designed to facilitate decision-making between providers across the target diseases and lifestyle factors included in the BETTER 2 program. Using the updated BETTER 2 toolkit, clinicians 1) determine which CDPS actions patients are eligible to receive and 2) develop individualized 'prevention prescriptions' with patients through shared decision-making and motivational interviewing.ResultsThe tools identify the patients' risks and eligible primary CDPS activities: the patient survey captures the patient's health history; the prevention visit form and integrated CDPS care map identify eligible CDPS activities and facilitate decisions when certain conditions are met; and the 'bubble diagram' and 'prevention prescription' promote shared decision-making.ConclusionThe integrated clinical decision-making tools of BETTER 2 provide resources for clinicians and policymakers that address patients' complex care needs beyond single disease approaches and can be adapted to facilitate CDPS in the urban, rural and remote clinical setting.Trial registrationThe registration number of the original RCT BETTER trial was ISRCTN07170460

Human hippocampal theta power indicates movement onset and distance travelled

Rodent hippocampal theta-band oscillations are observed throughout translational movement, implicating theta in the encoding of self-motion. Interestingly, increases in theta power are particularly prominent around movement onset. Here, we use intracranial recordings from epilepsy patients navigating in a desktop virtual reality environment to demonstrate that theta power is also increased in the human hippocampus around movement onset and throughout the remainder of movement. Importantly, these increases in theta power are greater both before and during longer paths, directly implicating human hippocampal theta in the encoding of translational movement. These findings help to reconcile previous studies of rodent and human hippocampal theta oscillations and provide additional insight into the mechanisms of spatial navigation in the human brain

Patient–Provider Rapport in the Health Care of People Who Inject Drugs

Little research has described determinants and consequences of patient–provider rapport among people who inject drugs (PWIDs). This mixed-method study (a) qualitatively described facilitators, barriers, and consequences to rapport development between PWIDs and their health care providers and (b) quantitatively tested the hypothesis that quality of rapport is associated with positive patterns of service use. Two exploratory focus groups with PWIDs and care providers were conducted. Subsequently, 89 PWIDs completed a survey interview; of those, eight completed a follow-up qualitative interview. Qualitative results indicated that rapport is influenced by drug-related behaviors, addiction severity, provider expertise, patient-centered care, and perceived discrimination and that rapport then influences patient compliance, timing of care, and criminal activity. Quantitative results indicated that rapport predicted PWID satisfaction with care as well as frequency and timing of emergency department presentations. Results suggest that PWID–provider rapport has several unique determinants and is associated with positive health care outcomes

Moderate mental illness as a predictor of chronic disease prevention and screening

Abstract Background Primary care plays a pivotal role in the provision of both mental health care and chronic disease prevention and screening (CDPS). Unfortunately, moderate mental illness (MMI) is associated with poorer general health outcomes. Part of this burden of illness may be due to reduced CDPS uptake. The Building on the Existing Tools to Improve Chronic Disease Prevention in Primary Care (BETTER) trial recruited 777 participants ages 40–65 from 32 family practice panels, of whom 135 (18.2%) had elevated GAD scores, 118 (16.4%) had elevated PHQ scores, and 264 (34.0%) had electronic medical record (EMR)-documented MMI. We hypothesized that patients with screen-positive or chart-documented MMI are 1) eligible for more CDPS actions, and 2) able to complete a lower proportion of CDPS actions than patients unaffected by MMI. Methods This study was a secondary analysis of data from the BETTER trial. Participants were stratified by both EMR-documented MMI and screen-positive evidence of MMI (using the General Anxiety Disorders (GAD-7) and Patient Health Questionnaire (PHQ-9) instruments for anxiety and depression screening, respectively). The primary outcome was the proportion of CDPS actions for which the patient was eligible completed at follow-up, using a composite index. Results After adjusting for age, gender, and social support, patients with evidence of MMI had a lower composite index than patients without evidence of MMI (p < 0.05). The lower composite index is primarily due to higher eligibility for CDPS at baseline; ability to complete CDPS was not statistically different. Conclusions Patients affected by MMI are eligible for more CDPS actions than their unaffected counterparts. Although they are able to complete a similar number of CDPS actions, they are not able to eliminate their baseline CDPS gap. Primary care teams need to be aware of this increased CDPS eligibility for patients with MMI and ensure best practices in CDPS supports are available to this patient population. Further study is needed to determine the ideal suite of targeted supports

Development of the Inner City attitudinal assessment tool (ICAAT) for learners across Health care professions

Abstract Background Many health professions learners report feeling uncomfortable and underprepared for professional interactions with inner city populations. These learners may hold preconceptions which affect therapeutic relationships and provision of care. Few tools exist to measure learner attitudes towards these populations. This article describes the development and validity evidence behind a new tool measuring health professions learner attitudes toward inner city populations. Methods Tool development consisted of four phases: 1) Item identification and generation informed by a scoping review of the literature; 2) Item refinement involving a two stage modified Delphi process with a national multidisciplinary team (n = 8), followed by evaluation of readability and response process validity with a focus group of medical and nursing students (n = 13); 3) Pilot testing with a cohort of medical and nursing students; and 4) Analysis of psychometric properties through factor analysis and reliability. Results A 36-item online version of the Inner City Attitudinal Assessment Tool (ICAAT) was completed by 214 of 1452 undergraduate students (67.7% from medicine; 32.3% from nursing; response rate 15%). The resulting tool consists of 24 items within a three-factor model – affective, behavioural, and cognitive. Reliability (internal consistency) values using Cronbach alpha were 0.87, 0.82, and 0.82 respectively. The reliability of the whole 24-item ICAAT was 0.90. Conclusions The Inner City Attitudinal Assessment Tool (ICAAT) is a novel tool with evidence to support its use in assessing health care learners’ attitudes towards caring for inner city populations. This tool has potential to help guide curricula in inner city health

Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital.

BackgroundPeople who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.MethodsWe utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.ResultsParticipants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.ConclusionsAcute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary

Additional file 2 of Social service providers’ perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study

Additional file 2. Semi-structured interview guide

Additional file 1 of Social service providers’ perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study

Additional file 1. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist