Case 12 : Policy Meets Practice – People Who Inject Drugs (PWID)

Dr. Silverman is the Chief of Infectious Diseases at London Health Sciences Centre (LHSC) and St. Joseph’s Health Care in London, Ontario. He is concerned about the increasing prevalence of people who inject drugs (PWID) in London, and the risk to PWID of bacterial infections due to contamination (e.g., improperly or unsterilized injection equipment, skin not being sterilized before injection). Of primary concern is the risk of infective endocarditis (IE), an infection in a patient’s heart. Treatment for IE entails antibiotics administered through the intravenous (IV) route. IE is generally treated through home care; in London, the South West Community Care Access Centre (CCAC) is responsible for delivering home care. To treat IE at home, a patient would need a peripherally inserted central catheter (a PICC-line) and assistance from a CCAC nurse to administer the antibiotics. This option, however, is not viable for some patients, including those who fall under the category of PWID or who may not have a fixed address. In the case of PWID, the PICC-line, in effect, becomes a “highway” for injecting other drugs; in instances where a patient may not have secure housing or be homeless, the CCAC nurse may not be able to track down the individual. When a patient in one of these situations is being treated for IE, it puts the care team in a difficult position. The alternatives to home care are hospital admittance or no treatment at all, neither of which are ideal solutions. Dr. Silverman is currently in this position, as he must decide on a treatment plan for Mr. W., a patient who has IE, has struggled with drug addiction (the likely cause of his IE), and who does not have stable housing. In making his decision, Dr. Silverman has included on Mr. W.’s care team two other physicians from LHSC, a representative from the CCAC, and the managing director of London CAReS, a community-based housing-first organization. The care team must determine the best treatment plan for Mr. W

Case 17 : Can Hospitals do Health Promotion? Making Hospitals a Place for both Care and Health through Health Promotion

Lauren Kitsman trained as a health promoter and is now working for a hospital. She has been tasked with implementing a health promotion approach in her hospital and has tried to understand the health issues at the hospital and identified potential areas to inform health promotion action. She turned to the ‘health promoting hospitals (HPH) approach’ in order to bridge the gap between acute care and health promotion in the hospital setting. As she looked deeper into HPHs in Ontario, she discovered an advocacy network, the Ontario Health Promoting Hospitals Network (OHPHN). While the initiative had largely been unsuccessful in Ontario, Health Promoting Hospital Networks had been successful and continue to have momentum in Europe and around the world. There seemed to be success stories from other provinces (Quebec, in particular). Why is Ontario so different, and what could be done to overcome the barriers to make the work of this network successful? What can Lauren learn from international HPH efforts to apply in her local context? Lauren wants to make changes that are sustainable and in-line with HPH approaches but needs to remain true to the acute mandate of her hospital. She is unsure of next steps

Case 14 : Development of an Electronic Health Record Strategy at the Glenburn Public Health Unit

Medical or electronic health records (EHR) are electronic databases that capture an individual’s health and care history throughout their life. EHRs are often used as a single repository of patient information that is shared among multiple health care providers (such as hospitals, laboratories, and family physicians). The Ontario Ministry of Health and Long-Term Care requires all EHR systems in public health units be provincially certified; however, their budget does not provide units with the necessary funding for EHR implementation. The Glenburn Public Health Unit (GPHU) is conducting a review of their recordkeeping practices and has identified a need to streamline their methods for client documentation. There are currently inconsistencies across the unit’s many health teams that result in communication, logistical, and technical issues with respect to document storage and delivery. To address these issues, GPHU must develop an EHR strategy that seeks to improve current recordkeeping practices and, as a result, improves client service delivery

Evaluating the implementation of a chronic obstructive pulmonary disease management program using the Consolidated Framework for Implementation Research: a case study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a prevalent chronic disease that requires comprehensive approaches to manage; it accounts for a significant portion of Canada\u27s annual healthcare spending. Interprofessional teams are effective at providing chronic disease management that meets the needs of patients. As part of an ongoing initiative, a COPD management program, the Best Care COPD program was implemented in a primary care setting. The objectives of this research were to determine site-specific factors facilitating or impeding the implementation of a COPD program in a new setting, while evaluating the implementation strategy used. METHODS: A qualitative case study was conducted using interviews, focus groups, document analysis, and site visits. Data were deductively analyzed using the Consolidated Framework for Implementation Research (CFIR) to assess the impact of each of its constructs on Best Care COPD program implementation at this site. RESULTS: Eleven CFIR constructs were determined to meaningfully affect implementation. Five were identified as the most influential in the implementation process. Cosmopolitanism (partnerships with other organizations), networks and communication (amongst program providers), engaging (key individuals to participate in program implementation), design quality and packaging (of the program), and reflecting and evaluating (throughout the implementation process). A peer-to-peer implementation strategy included training of registered respiratory therapists (RRT) as certified respiratory educators and the establishment of a communication network among RRTs to discuss experiences, collectively solve problems, and connect with the program lead. CONCLUSIONS: This study provides a practical example of the various factors that facilitated the implementation of the Best Care COPD program. It also demonstrates the potential of using a peer-to-peer implementation strategy. Focusing on these factors will be useful for informing the continued spread and success of the Best Care COPD program and future implementation of other chronic care programs

Men’s Experiences with the Hockey Fans in Training Weight Loss and Healthy Lifestyle Program

Background: Increasing rates of chronic disease, especially in men, have led to an increased effort to implement lifestyle interventions focusing on healthy eating and physical activity. Men are underrepresented in lifestyle programs and some studies have observed that males prefer men-only programs that occur in the context of sports. This paper reviews men’s feedback regarding motivation for joining and overall experience in a 12-week lifestyle intervention in the context of junior level ice hockey teams. Methods: Men age 35-65 with a BMI ?28 were recruited from local ice hockey team fan bases in London and Sarnia Ontario, Canada and randomized to the 12-week lifestyle intervention or control group. Those who attended at least 6 of the 12 weekly sessions, including at least one session in the final six weeks (n=30) were asked to complete an online questionnaire upon finishing the active phase of the intervention. The questionnaire elicited reasons for joining the program, changes seen following their participation, and the usefulness of specific components of the program. Results: For the 27 men who completed the questionnaire, weight loss and a desire to increase physical activity were the two main reasons cited for joining the program. After the intervention, 100% of the men reported eating a healthier diet and 78% increased their activity level. Program satisfaction was high and 96% of men believed both the classroom and exercise components were useful. Conclusion: Our results support previous research showing increased levels of satisfaction in men when lifestyle interventions are run in...

Hockey Fans in Training (Hockey FIT) Pilot Study Protocol: A Gender-Sensitized Weight Loss and Healthy Lifestyle Program for Overweight and Obese Male Hockey Fans

Background: Effective approaches that engage men in weight loss and lifestyle change are important because of worldwide increases, including in Canada, in obesity and chronic diseases. Football Fans in Training (FFIT), developed in Scotland, successfully tackled these problems by engaging overweight/obese male football fans in sustained weight loss and positive health behaviours, through program deliveries at professional football stadia. Methods: Aims: 1) Adapt FFIT to hockey within the Canadian context and integrate with HealtheSteps™ (evidence-based lifestyle program) to develop Hockey Fans in Training (Hockey FIT); 2) Explore potential for Hockey FIT to help overweight/obese men lose weight and improve other outcomes by 12 weeks, and retain these improvements to 12 months; 3) Evaluate feasibility of recruiting and retaining overweight/obese men; 4) Evaluate acceptability of Hockey FIT; and 5) Conduct program optimization via a process evaluation. We conducted a two-arm pilot pragmatic randomized controlled trial (pRCT) whereby 80 overweight/obese male hockey fans (35–65 years; body-mass index ≥28 kg/m2 ) were recruited through their connection to two junior A hockey teams (London and Sarnia, ON) and randomized to Intervention (Hockey FIT) or Comparator (Wait-List Control). Hockey FIT includes a 12-week Active Phase (classroom instruction and exercise sessions delivered weekly by trained coaches) and a 40-week Maintenance Phase. Data collected at baseline and 12 weeks (both groups), and 12 months (Intervention only), will inform evaluation of the potential of Hockey FIT to help men lose weight and improve other health outcomes. Feasibility and acceptability will be assessed using data from self-reports at screening and baseline, program fidelity (program observations and coach reflections), participant focus group discussions, coach interviews, as well as program questionnaires and interviews with participants. This information will be analyzed to inform program optimization. Discussion: Hockey FIT is a gender-sensitive program designed to engage overweight/obese male hockey fans to improve physical activity and healthy eating choices, thereby leading to weight loss and other positive changes in health outcomes. We expect this study to provide evidence for a full-scale confirmatory pRCT. Trial registration: NCT02396524 (Clinicaltrials.gov). Date of registration: Feb 26, 2015

Family physician leadership during the COVID-19 pandemic: roles, functions and key supports.

PURPOSE: Strong leadership in primary care is necessary to coordinate an effective pandemic response; however, descriptions of leadership roles for family physicians are absent from previous pandemic plans. This study aims to describe the leadership roles and functions family physicians played during the COVID-19 pandemic in Canada and identify supports and barriers to formalizing these roles in future pandemic plans. DESIGN/METHODOLOGY/APPROACH: This study conducted semi-structured qualitative interviews with family physicians across four regions in Canada as part of a multiple case study. During the interviews, participants were asked about their roles during each pandemic stage and the facilitators and barriers they experienced. Interviews were transcribed and a thematic analysis approach was used to identify recurring themes. FINDINGS: Sixty-eight family physicians completed interviews. Three key functions of family physician leadership during the pandemic were identified: conveying knowledge, developing and adapting protocols for primary care practices and advocacy. Each function involved curating and synthesizing information, tailoring communications based on individual needs and building upon established relationships. PRACTICAL IMPLICATIONS: Findings demonstrate the need for future pandemic plans to incorporate formal family physician leadership appointments, as well as supports such as training, communication aides and compensation to allow family physicians to enact these key roles. ORIGINALITY/VALUE: The COVID-19 pandemic presents a unique opportunity to examine the leadership roles of family physicians, which have been largely overlooked in past pandemic plans. This study\u27s findings highlight the importance of these roles toward delivering an effective and coordinated pandemic response with uninterrupted and safe access to primary care

Escherichia coli O157 Exposure in Wyoming and Seattle: Serologic Evidence of Rural Risk

We tested the hypothesis that rural populations have increased exposure to Escherichia coli O157:H7. We measured circulating antibodies against the O157 lipopolysaccharide in rural Wyoming residents and in blood donors from Casper, Wyoming, and Seattle, Washington, by enzyme immunoassay (EIA). EIA readings were compared by analysis of variance and the least squares difference multiple comparison procedure. Rural Wyoming residents had higher antibody levels to O157 LPS than did Casper donors, who, in turn, had higher levels than did Seattle donors (respective least squares means: 0.356, 0.328, and 0.310; p<0.05, Seattle vs. Casper, p<0.001, rural Wyoming vs. either city). Lower age was significantly correlated with EIA scores; gender; and, in rural Wyoming, history of bloody diarrhea, town, duration of residence, and use of nontreated water at home were not significantly correlated. These data suggest that rural populations are more exposed to E. coli O157:H7 than urban populations

Evaluating priority setting success in healthcare: a pilot study

<p>Abstract</p> <p>Background</p> <p>In healthcare today, decisions are made in the face of serious resource constraints. Healthcare managers are struggling to provide high quality care, manage resources effectively, and meet changing patient needs. Healthcare managers who are constantly making difficult resource decisions desire a way to improve their priority setting processes. Despite the wealth of existing priority setting literature (for example, program budgeting and marginal analysis, accountability for reasonableness, the 'describe-evaluate-improve' strategy) there are still no tools to evaluate how healthcare resources are prioritised. This paper describes the development and piloting of a process to evaluate priority setting in health institutions. The evaluation process was designed to examine the procedural and substantive dimensions of priority setting using a multi-methods approach, including a staff survey, decision-maker interviews, and document analysis.</p> <p>Methods</p> <p>The evaluation process was piloted in a mid-size community hospital in Ontario, Canada while its leaders worked through their annual budgeting process. Both qualitative and quantitative methods were used to analyze the data.</p> <p>Results</p> <p>The evaluation process was both applicable to the context and it captured the budgeting process. In general, the pilot test provided support for our evaluation process and our definition of success, (i.e., our conceptual framework).</p> <p>Conclusions</p> <p>The purpose of the evaluation process is to provide a simple, practical way for an organization to better understand what it means to achieve success in its priority setting activities and identify areas for improvement. In order for the process to be used by healthcare managers today, modification and contextualization of the process are anticipated. As the evaluation process is applied in more health care organizations or applied repeatedly in an organization, it may become more streamlined.</p

Priority setting: what constitutes success? A conceptual framework for successful priority setting

BACKGROUND: The sustainability of healthcare systems worldwide is threatened by a growing demand for services and expensive innovative technologies. Decision makers struggle in this environment to set priorities appropriately, particularly because they lack consensus about which values should guide their decisions. One way to approach this problem is to determine what all relevant stakeholders understand successful priority setting to mean. The goal of this research was to develop a conceptual framework for successful priority setting. METHODS: Three separate empirical studies were completed using qualitative data collection methods (one-on-one interviews with healthcare decision makers from across Canada; focus groups with representation of patients, caregivers and policy makers; and Delphi study including scholars and decision makers from five countries). RESULTS: This paper synthesizes the findings from three studies into a framework of ten separate but interconnected elements germane to successful priority setting: stakeholder understanding, shifted priorities/reallocation of resources, decision making quality, stakeholder acceptance and satisfaction, positive externalities, stakeholder engagement, use of explicit process, information management, consideration of values and context, and revision or appeals mechanism. CONCLUSION: The ten elements specify both quantitative and qualitative dimensions of priority setting and relate to both process and outcome components. To our knowledge, this is the first framework that describes successful priority setting. The ten elements identified in this research provide guidance for decision makers and a common language to discuss priority setting success and work toward improving priority setting efforts