Primary care-based integrated disease management for heart failure: a study protocol for a cluster randomised controlled trial

INTRODUCTION

Heart failure (HF) is a common chronic disease that increases in prevalence with age. It is associated with high hospitalisation rates, poor quality of life and high mortality. Management is complex with most interactions occurring in primary care. Disease management programmes implemented during or after an HF hospitalisation have been shown to reduce hospitalisation and mortality rates. Evidence for integrated disease management (IDM) serving the primary care HF population has been investigated but is less conclusive. The aim of this study is to evaluate the efficacy of IDM, focused on, optimising medication, self-management and structured follow-up, in a high-risk primary care HF population.

METHODS AND ANALYSIS

100 family physician clusters will be recruited in this Canadian primary care multicentre cluster randomised controlled trial. Physicians will be randomised to IDM or to care as usual. The IDM programme under evaluation will include case management, medication management, education, and skills training delivered collaboratively by the family physician and a trained HF educator. The primary outcome will measure the combined rate (events/patient-years) of all-cause hospitalisations, emergency department visits and mortality over a 12-month follow-up. Secondary outcomes include other health service utilisation, quality of life, knowledge assessments and acute HF episodes. Two to three HF patients will be recruited per physician cluster to give a total sample size of 280. The study has 90% power to detect a 35% reduction in the primary outcome. The difference in primary outcome between IDM and usual care will be modelled using a negative binomial regression model adjusted for baseline, clustering and for individuals experiencing multiple events.

ETHICS AND DISSEMINATION

The study has obtained approval from the Research Ethics Board at the University of Western Ontario, London, Canada (ID 114089). Findings will be disseminated through local reports, presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04066907.

Confronting complexity and supporting transformation through health systems mapping: a case study

INTRODUCTION

Health systems are a complex web of interacting and interconnected parts; introducing an intervention, or the allocation of resources, in one sector can have effects across other sectors and impact the entire system. A prerequisite for effective health system reorganisation or transformation is a broad and common understanding of the current system amongst stakeholders and innovators. Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are common chronic diseases with high health care costs that require an integrated health system to effectively treat.

STUDY DESCRIPTION

This case study documents the first phase of system transformation at a regional level in Ontario, Canada. In this first phase, visual representations of the health system in its current state were developed using a collaborative co-creation approach, and a focus on COPD and HF. Multiple methods were used including focus groups, open-ended questionnaires, and document review, to develop a series of graphical and visual representations; a health care ecosystem map.

RESULTS

The ecosystem map identified key sectoral components, inter-component interactions, and care requirements for patients with COPD and HF and inventoried current programs and services available to deliver this care. Main findings identified that independent system-wide navigation for this vulnerable patient group is limited, primary care is central to the accessibility of nearly half of the identified care elements, and resources are not equitably distributed. The health care ecosystem mapping helped to identify care gaps and illustrates the need to resource the primary care provider and the patient with system navigation resources and interdisciplinary team care.

CONCLUSION

The co-created health care ecosystem map brought a collective understanding of the health care system as it applies to COPD and HF. The map provides a blueprint that can be adapted to other disease states and health systems. Future transformation will build on this foundational work, continuing the robust interdisciplinary co-creation strategies, exploring predictive health system modelling and identifying areas for integration.

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

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.

Promoting deceased organ and tissue donation registration in family physician waiting rooms (RegisterNow-1 trial): study protocol for a pragmatic, stepped-wedge, cluster randomized controlled registry

Background

There is a worldwide shortage of organs available for transplant, leading to preventable mortality associated with end-stage organ disease. While most citizens in many countries with an intent-to-donate “opt-in” system support organ donation, registration rates remain low. In Canada, most Canadians support organ donation but less than 25% in most provinces have registered their desire to donate their organs when they die. The family physician office is a promising yet underused setting in which to promote organ donor registration and address known barriers and enablers to registering for deceased organ and tissue donation. We developed a protocol to evaluate an intervention to promote registration for organ and tissue donation in family physician waiting rooms.

Methods/design

This protocol describes a planned, stepped-wedge, cluster randomized registry trial in six family physician offices in Ontario, Canada to evaluate the effectiveness of reception staff providing patients with a pamphlet that addresses barriers and enablers to registration including a description of how to register for organ donation. An Internet-enabled tablet will also be provided in waiting rooms so that interested patients can register while waiting for their appointments. Family physicians and reception staff will be provided with training and/or materials to support any conversations about organ donation with their patients. Following a 2-week control period, the six offices will cross sequentially into the intervention arm in randomized sequence at 2-week intervals until all offices deliver the intervention. The primary outcome will be the proportion of patients visiting the office who are registered organ donors 7 days following their office visit. We will evaluate this outcome using routinely collected registry data from provincial administrative databases. A post-trial qualitative evaluation process will assess the experiences of reception staff and family physicians with the intervention and the stepped-wedge trial design.

Discussion

Promoting registration for organ donation in family physician offices is a potentially useful strategy for increasing registration for organ donation. Increased registration may ultimately help to increase the number of organs available for transplant. The results of this trial will provide important preliminary data on the effectiveness of using family physician offices to promote registration for organ donation.

Trial registration

ClinicalTrials.gov, ID: NCT03213171. Registered on 11 July 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2333-5) contains supplementary material, which is available to authorized users.

Understanding bladder management on a palliative care unit: a grounded theory study

BACKGROUND

Research regarding factors associated with nursing-initiated changes to bladder management at end-of-life is sparse.

OBJECTIVES

To explore the process of Palliative Care Unit (PCU) nurses' approach to bladder management changes.

METHODS

Nursing staff from one PCU in London, Canada were interviewed regarding bladder management care practices. A constructivist grounded theory was generated.

RESULTS

Four interconnected themes emerged: humanity (compassionate support of patients); journey (making the most of a finite timeline); health condition (illness, functional decline); and context (orders, policies, supplies). These overlapping themes must be considered in light of ongoing changes which prompt recycling through the framework. While bladder management necessitates shared decision-making and individualised care, nurses' phronetic experience may serve to detect the presence of change and the need to consider other alternatives.

CONCLUSION

End-of-life bladder management requires nurses to continually reconsider the significance of humanity, journey, health condition and context in light of ongoing changes.

Novel approaches to the biosynthesis of vanillin

Microorganisms able to produce vanillin in excess of 6g/l from ferulic acid have now been isolated. In Pseudomonas strains, the metabolic pathway from eugenol via ferulic acid to vanillin has been characterised at the enzymic and molecular genetic levels. Attempts to introduce vanillin production into other organisms by genetic engineering have begun.

A modular esterase from Pseudomonas fluorescens subsp. cellulosa contains a non-catalytic cellulose-binding domain

The 5' regions of genes xynB and xynC, coding for a xylanase and arabinofuranosidase respectively, are identical and are reiterated four times within the Pseudomonas fluorescens subsp. cellulosa genome. To isolate further copies of the reiterated xynB/C 5' region, a genomic library of Ps. fluorescens subsp. cellulosa DNA was screened with a probe constructed from the conserved region of xynB. DNA from one phage which hybridized to the probe, but not to sequences upstream or downstream of the reiterated xynB/C locus, was subcloned into pMTL22p to construct pFG1. The recombinant plasmid expressed a protein in Escherichia coli, designated esterase XYLD, of M(r) 58,500 which bound to cellulose but not to xylan. XYLD hydrolysed aryl esters, released acetate groups from acetylxylan and liberated 4-hydroxy-3-methoxycinnamic acid from destarched wheat bran. The nucleotide sequence of the XYLD-encoding gene, xynD, revealed an open reading frame of 1752 bp which directed the synthesis of a protein of M(r) 60,589. The 5' 817 bp of xynD and the amino acid sequence between residues 37 and 311 of XYLD were almost identical with the corresponding regions of xynB and xynC and their encoded proteins XYLB and XYLC. Truncated derivatives of XYLD lacking the N-terminal conserved sequence retained the capacity to hydrolyse ester linkages, but did not bind cellulose. Expression of truncated derivatives of xynD, comprising the 5' 817 bp sequence, encoded a non-catalytic polypeptide that bound cellulose. These data indicate that XYLD has a modular structure comprising of a N-terminal cellulose-binding domain and a C-terminal catalytic domain.