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Petrie S, Laur C, Rios P, Suarez A, Makanjuola O, Burke E, Bhattacharyya O, Mukerji G. Quality measures of virtual care in ambulatory healthcare environments: a scoping review. BMJ Open 2024; 14:e078214. [PMID: 38569716 PMCID: PMC10989112 DOI: 10.1136/bmjopen-2023-078214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 03/22/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVES Delivery of virtual care increased throughout the COVID-19 pandemic and persisted after physical distancing measures ended. However, little is known about how to measure the quality of virtual care, as current measures focus on in-person care and may not apply to a virtual context. This scoping review aims to understand the connections between virtual care modalities used with ambulatory patient populations and quality measures across the Quintuple Aim (provider experience, patient experience, per capita cost, population health and health equity). DESIGN Virtual care was considered any interaction between patients and/or their circle of care occurring remotely using any form of information technology. Five databases (MEDLINE, Embase, PsycInfo, Cochrane Library, JBI) and grey literature sources (11 websites, 3 search engines) were searched from 2015 to June 2021 and again in August 2022 for publications that analysed virtual care in ambulatory settings. Indicators were extracted, double-coded into the Quintuple Aim framework; patient and provider experience indicators were further categorised based on the National Academy of Medicine quality framework (safety, effectiveness, patient-centredness, timeliness, efficiency and equity). Sustainability was added to capture the potential for continued use of virtual care. RESULTS 13 504 citations were double-screened resulting in 631 full-text articles, 66 of which were included. Common modalities included video or audio visits (n=43), remote monitoring (n=11) and mobile applications (n=11). The most common quality indicators were related to patient experience (n=58 articles), followed by provider experience (n=25 articles), population health outcomes (n=23 articles) and health system costs (n=19 articles). CONCLUSIONS The connections between virtual care modalities and quality domains identified here can inform clinicians, administrators and other decision-makers how to monitor the quality of virtual care and provide insights into gaps in current quality measures. The next steps include the development of a balanced scorecard of virtual care quality indicators for ambulatory settings to inform quality improvement.
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Affiliation(s)
- Samuel Petrie
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Celia Laur
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Patricia Rios
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Ally Suarez
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Oluwatoni Makanjuola
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Emeralda Burke
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Onil Bhattacharyya
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Ahmad SZ, Ivers N, Zenlea I, Parsons JA, Shah BR, Mukerji G, Punthakee Z, Shulman R. An assessment of adaptation and fidelity in the implementation of an audit and feedback-based intervention to improve transition to adult type 1 diabetes care in Ontario, Canada. Implement Sci Commun 2024; 5:25. [PMID: 38500183 PMCID: PMC10946155 DOI: 10.1186/s43058-024-00563-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/03/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND The fit between an intervention and its local context may affect its implementation and effectiveness. Researchers have stated that both fidelity (the degree to which an intervention is delivered, enacted, and received as intended) and adaptation to the local context are necessary for high-quality implementation. This study describes the implementation of an audit and feedback (AF)-based intervention to improve transition to type 1 diabetes adult care, at five sites, in terms of adaptation and fidelity. METHODS An audit and feedback (AF)-based intervention for healthcare teams to improve transition to adult care for patients with type 1 diabetes was studied at five pediatric sites. The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) was used to document the adaptations made during the study. Fidelity was determined on three different levels: delivery, enactment, and receipt. RESULTS Fidelity of delivery, receipt, and enactment were preserved during the implementation of the intervention. Of the five sites, three changed their chosen quality improvement initiative, however, within the parameters of the study protocol; therefore, fidelity was preserved while still enabling participants to adapt accordingly. CONCLUSIONS We describe implementing a multi-center AF-based intervention across five sites in Ontario to improve the transition from pediatric to adult diabetes care for youth with type 1 diabetes. This intervention adopted a balanced approach considering both adaptation and fidelity to foster a community of practice to facilitate implementing quality improvement initiatives for improving transition to adult diabetes care. This approach may be adapted for improving transition care for youth with other chronic conditions and to other complex AF-based interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.
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Affiliation(s)
- Syed Zain Ahmad
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- SickKids Research Institute, Toronto, Canada
| | - Noah Ivers
- Women's College Institute for Health System Solutions and Virtual Care, Toronto, Canada
- Department of Family Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Ian Zenlea
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
| | - Janet A Parsons
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Baiju R Shah
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Canada
- ICES, Toronto, Canada
| | - Geetha Mukerji
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Women's College Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
| | - Zubin Punthakee
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Rayzel Shulman
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- SickKids Research Institute, Toronto, Canada.
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Canada.
- Department of Pediatrics, University of Toronto, Toronto, Canada.
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Wright E, Martinovic J, de Camps Meschino D, Barker LC, Philipp DA, Israel A, Hussain-Shamsy N, Mukerji G, Wang V, Chatterjee A, Vigod SN. A virtual mother-infant postpartum psychotherapy group for mothers with a history of adverse childhood experiences: open-label feasibility study. BMC Psychiatry 2023; 23:950. [PMID: 38110902 PMCID: PMC10726650 DOI: 10.1186/s12888-023-05444-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVES Mothers with a history of adverse childhood experiences (ACE) are at elevated risk for postpartum mental illness and impairment in the mother-infant relationship. Interventions attending to maternal-infant interactions may improve outcomes for these parents and their children, but barriers to accessing in-person postpartum care limit uptake. We adapted a postpartum psychotherapy group for mothers with mental illness (e.g., mood, anxiety, trauma-related disorders) and ACE for live video-based delivery, and evaluated feasibility, acceptability, and preliminary efficacy in an open-label pilot study. METHODS We recruited adults with children (6-18 months) from a perinatal psychiatry program in Toronto, Canada. The intervention was a live video-based 12-week interactive psychotherapy group focused on maternal symptoms and maternal-infant relationships. The primary outcome was feasibility, including feasibility of recruitment and retention, fidelity of the intervention, and acceptability to patients and group providers. Maternal clinical outcomes were compared pre- to post-intervention, as secondary outcomes. RESULTS We recruited 31 participants (mean age 36.5 years (SD 3.9)) into 6 groups; 93.6% (n = 29) completed post-group questionnaires, and n = 20 completed an optional post-group acceptability interview. Mean weekly group attendance was 83% (IQR 80-87); one participant (3.2%) dropped out. All group components were implemented as planned, except for dyadic exercises where facilitator observation of dyads was replaced with unobserved mother-infant exercises followed by in-group reflection. Participant acceptability was high (100% indicated the virtual group was easy to access, beneficial, and reduced barriers to care). Mean maternal depressive [Edinburgh Postnatal Depression Scale: 14.6 (SD 4.2) vs. 11.8 (SD 4.2), paired t, p = 0.005] and post-traumatic stress [Posttraumatic Stress Disorder Checklist for DSM-5: 35.5 (SD 19.0) vs. 27.1 (SD 16.7)], paired t, p = 0.01] symptoms were significantly lower post vs. pre-group. No differences were observed on mean measures of anxiety, emotion regulation or parenting stress. CONCLUSIONS Recruitment and retention met a priori feasibility criteria. There were significant pre- to post-group reductions in maternal depressive and post-traumatic symptoms, supporting proceeding to larger-scale implementation and evaluation of the intervention, with adaptation of dyadic exercises.
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Affiliation(s)
- Elisabeth Wright
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada.
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
| | - Jovana Martinovic
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Diane de Camps Meschino
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Lucy C Barker
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Diane A Philipp
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
- Garry Hurvitz Centre for Community Mental Health at Sickkids, Toronto, ON, Canada
| | - Aliza Israel
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Neesha Hussain-Shamsy
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 3M6, Canada
| | - Geetha Mukerji
- Department of Medicine, Temerty Faculty of Medicine, Sunnybrook Health Sciences Center, King's College Circle, University of Toronto, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, Canada
| | - Vivienne Wang
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Antara Chatterjee
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Simone N Vigod
- Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 3M6, Canada
- Department of Psychiatry, Women's College Hospital and Research Institute, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
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Wu N, Wang SJ, Brazeau AS, Chan D, Mussa J, Nakhla M, Elkeraby M, Ell M, Prevost M, Lepine L, Panagiotopoulos C, Mukerji G, Butalia S, Henderson M, Da Costa D, Rahme E, Dasgupta K. Supporting and Incentivizing Peer Leaders for an Internet-Based Private Peer Community for Youths With Type 1 Diabetes: Social Network and Directed Content Analysis. J Med Internet Res 2023; 25:e48267. [PMID: 38085568 PMCID: PMC10751631 DOI: 10.2196/48267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/04/2023] [Accepted: 10/27/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Youths with type 1 diabetes (T1D) frequently experience stigma. Internet-based peer communities can mitigate this through social support but require leaders to catalyze exchange. Whether nurturing potential leaders translates into a central role has not been well studied. Another issue understudied in such communities is lurking, the viewing of exchanges without commenting or posting. OBJECTIVE We aimed to assess the centrality of the peer leaders we selected, trained, and incentivized within the Canadian Virtual Peer Network (VPN)-T1D. This is a private Facebook (Meta Platforms, Inc) group that we created for persons aged 14 to 24 years with T1D. We specifically sought to (1) compare a quantitative estimate of network centrality between peer leaders and regular members, (2) assess the proportions of network exchanges that were social support oriented, and (3) assess proportions of high engagement (posts, comments, reactions, and votes) and low engagement (lurking) exchanges. METHODS We recruited peer leaders and members with T1D from prior study cohorts and clinics. We trained 10 leaders, provided them with a monthly stipend, and encouraged them to post on the private Facebook group we launched on June 21, 2017. We extracted all communications (posts, messages, reactions, polls, votes, and views) that occurred until March 20, 2020. We calculated each member's centrality (80% of higher engagement communications comprising posts, comments, and reactions plus 20% of members with whom they connected). We divided each member's centrality by the highest centrality to compute the relative centrality, and compared the mean values between leaders and members (linear regression). We calculated the proportions of communications that were posts, comments, reactions, and views without reaction. We performed content analysis with a social support framework (informational, emotional, esteem-related, network, and tangible support), applying a maximum of 3 codes per communication. RESULTS VPN-T1D gained 212 regular members and 10 peer leaders over 33 months; of these 222 members, 26 (11.7%) exited. Peer leaders had 10-fold higher relative centrality than regular members (mean 0.53, SD 0.26 vs mean 0.04, SD 0.05; 0.49 difference; 95% CI 0.44-0.53). Overall, 91.4% (203/222) of the members connected at least once through posts, comments, or reactions. Among the 75,051 communications, there were 5109 (6.81%) posts, comments, and polls, 6233 (8.31%) reactions, and 63,709 (84.9%) views (lurking). Moreover, 54.9% (3430/6253) of codes applied were social support related, 66.4% (2277/3430) of which were informational (eg, insurance and travel preparation), and 20.4% (699/3430) of which were esteem related (eg, relieving blame). CONCLUSIONS Designating, training, and incentivizing peer leaders may stimulate content exchange and creation. Social support was a key VPN-T1D deliverable. Although lurking accounted for a high proportion of the overall activity, even those demonstrating this type of passive participation likely derived benefits, given that the network exit rate was low. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/18714.
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Affiliation(s)
- Nancy Wu
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Susan Joanne Wang
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Anne-Sophie Brazeau
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Ste Anne de Bellevue, QC, Canada
| | - Deborah Chan
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Joseph Mussa
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Meranda Nakhla
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mariam Elkeraby
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Patient partner, Montreal, QC, Canada
| | - Maryna Ell
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Patient partner, Montreal, QC, Canada
| | - Melinda Prevost
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Patient partner, Montreal, QC, Canada
| | - Laurie Lepine
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Patient partner, Montreal, QC, Canada
| | - Constadina Panagiotopoulos
- Endocrinology & Diabetes Unit, British Columbia Children's Hospital and Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Geetha Mukerji
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, Toronto, ON, Canada
| | - Sonia Butalia
- Department of Medicine, Cumming School of Medicine, Health Sciences Centre, Foothills Campus, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mélanie Henderson
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche CHU Sainte-Justine, Montreal, QC, Canada
- School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, Montreal, QC, Canada
| | - Deborah Da Costa
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Elham Rahme
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Kaberi Dasgupta
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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Holmes S, Sarma S, Campbell S, Azab A, Qiang J, Mukerji G. Gaps in Referral to Bariatric Surgery for Patients With Type 2 Diabetes Seen in Endocrinology Clinics. Can J Diabetes 2022; 46:835-842.e1. [PMID: 36088215 DOI: 10.1016/j.jcjd.2022.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES One-third of adults in Canada are overweight and 26.8% experience obesity. Bariatric surgery confers effective weight loss and reduces obesity-related complications, including type 2 diabetes, but remains an underutilized treatment. Our objective in this study was to determine whether a gap exists in bariatric program referrals for patients with type 2 diabetes seen in endocrinology clinics at an ambulatory tertiary care hospital in Toronto, Canada. METHODS A retrospective chart review was conducted of 843 consecutive patients with type 2 diabetes in endocrinology clinics between January 1, 2015 and December 31, 2020. Inclusion criteria were age ≥18 years, type 2 diabetes and body mass index (BMI)>35 kg/m2. Exclusion criteria were recent active cancer, uncontrolled psychiatric disease or active substance use disorder within 6 months of the initial visit. Referrals to bariatric surgery were assessed within a 5-year follow-up period and compared with baseline referral rates from the Ontario Bariatric Network (OBN). An online survey of 48 endocrinologists in Toronto, Ontario, was also conducted to assess physician-level barriers to referral. RESULTS The proportion of patients with class II obesity (BMI>35 kg/m2) and type 2 diabetes meeting the eligibility criteria for bariatric referral was 4.6% (n=38). A documented discussion about bariatric surgery occurred with 7 (18.0%) of these eligible patients, and 1 patient (2.6%) was referred for surgery. Aside from surgical referrals, only 2.6% of eligible patients were referred to cognitive-behavioural therapy, 36.8% were initiated on obesity pharmacotherapy and 42.1% were referred to a dietitian. Baseline OBN data demonstrated that most surgical referrals (n=6,360) were from family physicians (65.0%) and only 8.8% were from a medical specialist. Eight percent of surveyed endocrinologists reported that they discussed bariatric surgery with at least half of their eligible patients. The most frequent barrier to discussing bariatric surgery during visits was time constraints. Physicians identified that simplifying the referral process and providing bariatric surgery handouts would be helpful interventions to improve referral rates. CONCLUSIONS Our gap analysis demonstrated a low bariatric surgery referral rate by tertiary care endocrinologists. Our study also identified a large gap in the appropriate treatment of obesity with poor utilization of behavioural, lifestyle and pharmacotherapy practices. As obesity and diabetes rates increase, better education, training and knowledge translation will be necessary to overcome weight bias and prioritize obesity management.
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Affiliation(s)
- Sheila Holmes
- Division of Endocrinology and Metabolism, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shohinee Sarma
- Division of Endocrinology and Metabolism, Sinai Leadership Centre for Diabetes, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sara Campbell
- Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Abdulrahman Azab
- Division of Endocrinology and Metabolism, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Judy Qiang
- Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Division of Endocrinology and Metabolism, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada.
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Hsu AT, Mukerji G, Levy AM, Iaboni A. Pandemic Preparedness and Beyond: Person-Centred Care for Older Adults Living in Long-Term Care during the COVID-19 Pandemic. Healthc Q 2022; 25:13-19. [PMID: 36562579 DOI: 10.12927/hcq.2022.26983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The increasing complexity of residents' needs, emphasis on social distancing and limited access to high-quality support presented challenges to patient-centred care during the pandemic. Yet the pandemic created an opportunity to explore novel approaches to achieving person-centred care within long-term care (LTC). We share three projects designed to enhance care delivery in the context of the pandemic: to address personhood needs during outbreaks, to improve the quality of medical care and to deliver personalized palliative and end-of-life care using a prediction algorithm. These projects enabled better care during the pandemic and will continue to advance person-centred care beyond the pandemic.
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Affiliation(s)
- Amy T Hsu
- Investigator at the Bruyère Research Institute and a lecturer in the Department of Family Medicine at the University of Ottawa in Ottawa, ON. She holds the University of Ottawa Brain and Mind-Bruyère Research Institute Chair in Primary Health Care in Dementia. Her research uses population-level health administrative data at ICES to examine older adults' health and healthcare needs, especially those living with Alzheimer's disease and dementia
| | - Geetha Mukerji
- Clinician in Quality and Innovation at the Women's College Hospital Institute of Health Systems Solutions and Virtual Care and an associate professor in the Department of Medicine at the University of Toronto in Toronto, ON. Her research interests include the development and evaluation of innovative models of care delivery including virtual models
| | - Anne-Marie Levy
- Research associate in the Lazaridis School of Business & Economics at Wilfrid Laurier University in Waterloo, ON, and a clinical research coordinator in the Geriatric Psychiatry Department, University Health Network in Toronto, ON. Her research centres on the use of technologies and interventions to improve the quality of life for people living with cognitive impairments
| | - Andrea Iaboni
- Geriatric psychiatrist based at the Toronto Rehabilitation Institute, University Health Network, and an associate professor in the Department of Psychiatry, University of Toronto, in Toronto, ON. Her research focuses on developing new models of dementia care by making use of physiological and behavioural data from environmental sensors, work around mobility and falls prevention, the treatment of neuropsychiatric symptoms of dementia and the prevention of injury through rational use of psychotropic medications in frail older adults
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Wang XS, Marani H, Harris‐Taylor C, Drazek L, Rusen J, Farnell N, Lipscombe L, Mukerji G. Quality gaps in care delivery among emerging adults with type 1 diabetes: A retrospective cohort study. Health Sci Rep 2022; 5:e823. [PMID: 36210875 PMCID: PMC9528951 DOI: 10.1002/hsr2.823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 07/29/2022] [Accepted: 08/24/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Xinye S. Wang
- Faculty of MedicineUniversity of TorontoTorontoOntarioCanada,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Husayn Marani
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada,Women's College Hospital Institute for Health System Solutions and Virtual CareWomen's College HospitalTorontoOntarioCanada
| | - Cheryl Harris‐Taylor
- Division of Endocrinology and MetabolismWomen's College HospitalTorontoOntarioCanada
| | - Leah Drazek
- Division of Endocrinology and MetabolismWomen's College HospitalTorontoOntarioCanada
| | - Janis Rusen
- Division of Endocrinology and MetabolismWomen's College HospitalTorontoOntarioCanada
| | - Nicola Farnell
- Division of Endocrinology and MetabolismWomen's College HospitalTorontoOntarioCanada
| | - Lorraine Lipscombe
- Faculty of MedicineUniversity of TorontoTorontoOntarioCanada,Division of Endocrinology and MetabolismWomen's College HospitalTorontoOntarioCanada,Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
| | - Geetha Mukerji
- Faculty of MedicineUniversity of TorontoTorontoOntarioCanada,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada,Women's College Hospital Institute for Health System Solutions and Virtual CareWomen's College HospitalTorontoOntarioCanada,Division of Endocrinology and MetabolismWomen's College HospitalTorontoOntarioCanada
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Langendoen-Gort M, Groeneveld L, Prinsen CAC, Beulens JW, Elders PJM, Halperin I, Mukerji G, Terwee CB, Rutters F. Patient-reported outcome measures for assessing health-related quality of life in people with type 2 diabetes: A systematic review. Rev Endocr Metab Disord 2022; 23:931-977. [PMID: 35779199 PMCID: PMC9515038 DOI: 10.1007/s11154-022-09734-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 11/26/2022]
Abstract
Patient-Reported Outcome Measures (PROMs) are important tools to assess outcomes relevant to patients, with Health-Related Quality Of Life (HRQOL) as an important construct to be measured. Many different HRQOL PROMs are used in the type 2 diabetes field, however a complete overview of these PROMs is currently lacking. We therefore aimed to systematically describe and classify the content of all PROMs that have specifically been developed or validated to measure (aspects of) HRQOL in people with type 2 diabetes. A literature search was performed in PubMed and EMBASE until 31 December 2021. Studies on the development or validation of a PROM measuring HRQOL, or aspects of HRQOL, in people with type 2 diabetes were included. Title and abstract and full-text screening were conducted by two independent researchers and data extraction was performed independently by one of the researchers. Data were extracted on language in which the PROM was developed, target population, construct(s) being measured, names of (sub)scales and number of items per (sub)scale. In addition, all PROMs and subscales were classified according to specific aspects of HRQOL based on the Wilson & Cleary model (symptom status, functional status, general health perceptions) to aid researchers in PROM selection. In total 220 studies were identified that developed or validated PROMs that measure (aspects of) HRQOL in people with type 2 diabetes. Of the 116 unique HRQOL PROMs, 91 (of the subscales) measured symptom status, 60 measured functional status and 26 measured general health perceptions. In addition, 16 of the PROMs (subscales) measured global quality of life. 61 of the 116 PROMs (subscales) also include characteristics of the individual (e.g. aspects of personality, coping) or environment (e.g. social or financial support) and patient-reported experience measures (PREMs, e.g. measure of a patient's perception of their personal experience of the healthcare they have received, e.g. treatment satisfaction), which are not part of the HRQOL construct. Only 9 of the 116 PROMs measure all aspects of HRQOL based on the Wilson & Cleary model. Finally, 8 of the 116 PROMs stating to measure HRQOL, measured no HRQOL construct. In conclusion, a large number of PROMs are available for people with type 2 diabetes, which intend to measure (aspects of) HRQOL. These PROMs measure a large variety of (sub)constructs, which are not all HRQOL constructs, with a small amount of PROMs not measuring HRQOL at all. There is a need for consensus on which aspects of HRQOL should be measured in people with type 2 diabetes and which PROMs to use in research and daily practice. PROSPERO: CRD42017071012. COMET database: http://www.comet-initiative.org/studies/details/956 .
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Affiliation(s)
- Marlous Langendoen-Gort
- General Practice, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
- Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, The Netherlands
| | - Lenka Groeneveld
- Epidemiology and Data Science, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
- Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, The Netherlands
| | - Cecilia A C Prinsen
- Epidemiology and Data Science, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Joline W Beulens
- Epidemiology and Data Science, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
- Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Petra J M Elders
- General Practice, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
- Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands
| | - Ilana Halperin
- Department of Medicine, Temerty Faculty of Medicine, Sunnybrook Health Sciences Center, King's College Circle, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Department of Medicine, Temerty Faculty of Medicine, Sunnybrook Health Sciences Center, King's College Circle, University of Toronto, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, Canada
| | - Caroline B Terwee
- Epidemiology and Data Science, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Femke Rutters
- Epidemiology and Data Science, Amsterdam UMC, Location Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands.
- Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences, Diabetes & Metabolism, Amsterdam, The Netherlands.
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9
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Nayyar D, Pendrith C, Kishimoto V, Chu C, Fujioka J, Rios P, Sacha Bhatia R, Lyons OD, Harvey P, O'Brien T, Martin D, Agarwal P, Mukerji G. Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences. Int J Med Inform 2022; 165:104812. [PMID: 35691260 PMCID: PMC9366328 DOI: 10.1016/j.ijmedinf.2022.104812] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/28/2022] [Accepted: 06/05/2022] [Indexed: 11/21/2022]
Abstract
Background The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs). Objective To characterize patients’ and providers’ experiences with the quality and sustainability of virtual care for ACSCs. Design This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma. Main measures Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain. Key results Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care. Conclusions In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.
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Affiliation(s)
- Dhruv Nayyar
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ciara Pendrith
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vanessa Kishimoto
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Cherry Chu
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Jamie Fujioka
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Patricia Rios
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - R Sacha Bhatia
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Owen D Lyons
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Paula Harvey
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Tara O'Brien
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Danielle Martin
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Payal Agarwal
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada.
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10
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Laur C, Agarwal P, Thai K, Kishimoto V, Kelly S, Liang K, Bhatia RS, Bhattacharyya O, Martin D, Mukerji G. Implementation and Evaluation of COVIDCare@Home, a Family Medicine Led Remote Monitoring Program for COVID-19 Patients: a multi-method cross-sectional study. JMIR Hum Factors 2022; 9:e35091. [PMID: 35499974 PMCID: PMC9239565 DOI: 10.2196/35091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 04/26/2022] [Accepted: 05/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background COVIDCare@Home (CC@H) is a multifaceted, interprofessional team-based remote monitoring program led by family medicine for patients diagnosed with COVID-19, based at Women’s College Hospital (WCH), an ambulatory academic center in Toronto, Canada. CC@H offers virtual visits (phone and video) to address the clinical needs and broader social determinants of the health of patients during the acute phase of COVID-19 infection, including finding a primary care provider (PCP) and support for food insecurity. Objective The objective of this evaluation is to understand the implementation and quality outcomes of CC@H within the Quadruple Aim framework of patient experience, provider experience, cost, and population health. Methods This multimethod cross-sectional evaluation follows the Quadruple Aim framework to focus on implementation and service quality outcomes, including feasibility, adoption, safety, effectiveness, equity, and patient centeredness. These measures were explored using clinical and service utilization data, patient experience data (an online survey and a postdischarge questionnaire), provider experience data (surveys, interviews, and focus groups), and stakeholder interviews. Descriptive analysis was conducted for surveys and utilization data. Deductive analysis was conducted for interviews and focus groups, mapping to implementation and quality domains. The Ontario Marginalization Index (ON-Marg) measured the proportion of underserved patients accessing CC@H. Results In total, 3412 visits were conducted in the first 8 months of the program (April 8-December 8, 2020) for 616 discrete patients, including 2114 (62.0%) visits with family physician staff/residents and 149 (4.4%) visits with social workers/mental health professionals. There was a median of 5 (IQR 4) visits per patient, with a median follow-up of 7 days (IQR 27). The net promoter score was 77. In addition, 144 (23.3%) of the patients were in the most marginalized populations based on the residential postal code (as per ON-Marg). Interviews with providers and stakeholders indicated that the program continued to adapt to meet the needs of patients and the health care system. Conclusions Future remote monitoring should integrate support for addressing the social determinants of health and ensure patient-centered care through comprehensive care teams.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA
| | - Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA.,Department of Family and Community Medicine, University of Toronto, Toronto, CA
| | - Kelly Thai
- Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA
| | - Vanessa Kishimoto
- Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA
| | | | | | - R Sacha Bhatia
- Population Health and Values Based Health Systems, Ontario Health, Toronto, CA.,Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA.,Temerty Faculty of Medicine, University of Toronto, Toronto, CA.,Peter Munk Cardiac Centre, University Health Network, Toronto, CA
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA.,Department of Family and Community Medicine, University of Toronto, Toronto, CA
| | - Danielle Martin
- Women's College Hospital Institute for Health System Solutions and Virtual Care, University of Toronto, 76 Grenville Street, Toronto, CA.,Department of Family and Community Medicine, University of Toronto, Toronto, CA.,Women's College Hospital, Toronto, CA.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, CA
| | - Geetha Mukerji
- Women's College Hospital, Toronto, CA.,Temerty Faculty of Medicine, University of Toronto, Toronto, CA.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, CA
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11
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Chu C, Nayyar D, Bhattacharyya O, Martin D, Agarwal P, Mukerji G. Patient and provider experience with virtual care in a large, ambulatory care hospital in Ontario, Canada during the COVID-19 pandemic: An observational study (Preprint). J Med Internet Res 2022; 24:e38604. [PMID: 36194862 PMCID: PMC9605083 DOI: 10.2196/38604] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/25/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Virtual care use increased during the COVID-19 pandemic. The impact of that shift on patient and provider experiences is unclear. Objective We evaluated patient and provider experiences with virtual visits across an academic, ambulatory hospital in Toronto, Canada and assessed predictors of positive experience with virtual care. Methods Survey data were analyzed from consenting patients who attended at least one virtual visit (video or telephone) and from consenting providers who delivered at least one virtual visit. Distributions for demographic variables and responses to survey questions are reported, with statistical significance assessed using chi-square tests and t tests. Ordinal logistic regression analysis was used to identify any patient predictors of responses. Results During the study period, 253 patients (mean age 45.1, SD 15.6 years) completed 517 video visit surveys, and 147 patients (mean age 41.6, SD 16.4 years) completed 209 telephone visit surveys. A total of 75 and 94 providers completed the survey in June 2020 and June 2021, respectively. On a scale from 1 to 10 regarding likelihood to recommend virtual care to others, fewer providers rated a score of 8 or above compared with patients (providers: 62/94, 66% for video and 49/94, 52% for telephone; patients: 415/517, 80% for video and 150/209, 72% for telephone). Patients of non-White ethnicity had lower odds of rating a high score of 9 or 10 compared with White patients (odds ratio 0.52, 95% CI 0.28-0.99). Conclusions Patient experiences with virtual care were generally positive, but provider experiences were less so. Findings suggest potential differences in patient experience by ethnicity, warranting further investigation into equity concerns with virtual care.
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Affiliation(s)
- Cherry Chu
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Dhruv Nayyar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Martin
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Payal Agarwal
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
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12
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Hussain-Shamsy N, McMillan I, Cook S, Furfaro-Argier A, Sadler A, Delos-Reyes F, Wasserman L, Bhatia S, Martin D, Seto E, Vigod SN, Zaheer J, Agarwal P, Mukerji G. Operationalizing and Evaluating Synchronous Virtual Group Health Interventions: Wide-Scale Implementation at a Tertiary Care Academic Hospital. J Med Internet Res 2022; 24:e29841. [PMID: 35389350 PMCID: PMC9030913 DOI: 10.2196/29841] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/24/2021] [Accepted: 12/17/2021] [Indexed: 12/03/2022] Open
Abstract
Group-based health interventions are an important component of health promotion and management. To provide continuity of care throughout the COVID-19 pandemic, our institution undertook a rapid pivot to delivering group-based health interventions via a videoconferencing service which was securely embedded into both the electronic medical record and the patient portal to sustainably address immediate health service delivery needs during the pandemic and beyond. In this paper, we (1) describe the institutionally driven operationalization of a system to provide integrated synchronous video group visits across our hospital and (2) present a proposed strategy to comprehensively evaluate outcomes regarding their implementation, quality, and impact. Lessons for other institutions and the potential future role of synchronous video group visits to enhance how care can be scaled for delivery are discussed.
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Affiliation(s)
- Neesha Hussain-Shamsy
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Ian McMillan
- Women's Virtual, Women's College Hospital, Toronto, ON, Canada
| | | | - Alyssa Furfaro-Argier
- Department of Information Management and Technology, Women's College Hospital, Toronto, ON, Canada
| | - Andrea Sadler
- Department of Psychiatry, Women's College Hospital, Toronto, ON, Canada
| | - Faith Delos-Reyes
- Department of Cardiology, Women's College Hospital, Toronto, ON, Canada
| | - Lori Wasserman
- Reproductive Life Stages Program, Women's College Hospital, Toronto, ON, Canada
| | - Sacha Bhatia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Danielle Martin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Emily Seto
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Centre for Global eHealth Innovation, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Simone N Vigod
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juveria Zaheer
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Payal Agarwal
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Family Practice Health Centre, Women's College Hospital, Toronto, ON, Canada
| | - Geetha Mukerji
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Women's College Hospital, Toronto, ON, Canada
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13
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Loutfy M, Kennedy VL, Riazi S, Lena S, Kazemi M, Bawden J, Wright V, Richardson L, Mills S, Belsito L, Mukerji G, Bhatia S, Gupta M, Barrett C, Martin D. Development and assessment of a hospital-led, community-partnering COVID-19 testing and prevention program for homeless and congregate living services in Toronto, Canada: a descriptive feasibility study. CMAJ Open 2022; 10:E483-E490. [PMID: 35672043 PMCID: PMC9177196 DOI: 10.9778/cmajo.20210105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Outbreaks of SARS-CoV-2 in shelters and congregate living settings are a major concern because of overcrowding and because resident populations are often at high risk for infection. The objective of this study was to describe the development, implementation and assessment of the COVID-19 Community Response Team, a program that enabled Women's College Hospital in Toronto, Ontario, to work in partnership with shelters and congregate living settings to prevent outbreaks. METHODS The Community Response Team, associated with Women's College Hospital, an academic ambulatory hospital, carried out mobile testing for SARS-CoV-2, supported outbreak management and prevention through ongoing onsite partnership with medical staff, and conducted infection prevention and control (IPC) training to shelter staff. We conducted a descriptive analysis of the sites supported by the program between Apr. 20, 2020, and Aug. 15, 2020. We also assessed the program's feasibility (number of completed needs assessments, mobile testing events and IPC training events, and median time from referral to service delivery), adoption (number of nasopharyngeal swabs, number of pre- and post-program outbreaks and IPC uptake) and acceptability or satisfaction. RESULTS The Community Response Team supported 32 sites. Of those, 30 completed an intake needs assessment, 24 completed mobile testing for SARS-CoV-2 and 15 received IPC support. Mobile testing resulted in the collection of 1566 nasopharyngeal swabs, of which 64 were positive for SARS-CoV-2 infection. Three sites had confirmed outbreaks. The median time from referral to needs assessment was 4 days (interquartile range [IQR] 1-13 days), and the median time to the testing day was 9 days (IQR 1-49 days). The median time from referral to IPC staff training was 14 days (IQR 4-79 days), and 100% of respondents reported being pleased or very pleased with the training. During the follow-up period, the 3 facilities with outbreaks overcame those outbreaks. Three sites supported by the Community Response Team had further single cases, but no site reported subsequent or secondary outbreaks. INTERPRETATION The Community Response Team program led to the transfer of IPC knowledge, allowed for the management and prevention of SARS-CoV-2 outbreaks, and demonstrated feasibility. Collaborative supports between hospitals and the community housing sector may serve as models for ongoing system integration beyond the COVID-19 pandemic.
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Affiliation(s)
- Mona Loutfy
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont.
| | - V Logan Kennedy
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Sheila Riazi
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Suvendrini Lena
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Mina Kazemi
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Jessica Bawden
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Vanessa Wright
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Lisa Richardson
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Selena Mills
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Laura Belsito
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Geetha Mukerji
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Sacha Bhatia
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Meenakshi Gupta
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Cristina Barrett
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
| | - Danielle Martin
- Department of Medicine (Loutfy, Lena, Mukerji, Bhatia, Barrett), Women's College Hospital; Temerty Faculty of Medicine (Loutfy, Richardson, Bhatia, Martin), University of Toronto; Women's College Research Institute (Kennedy, Kazemi, Gupta), Women's College Hospital; Women's College Institute of Health Systems Solutions and Virtual Care (Mukerji, Bhatia); Department of Anesthesia and Pain Medicine (Riazi), Women's College Hospital, University of Toronto; Centre for Addiction & Mental Health (Lena); Department of Family and Community Medicine (Bawden, Wright, Belsito, Mukerji, Martin), Women's College Hospital; Department of Medicine (Gupta), Mount Sinai Hospital; Department of Medicine (Richardson), University Health Network; Centre for Wise Practices in Indigenous Health (Richardson, Mills), Women's College Hospital, Toronto, Ont
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14
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Pendrith C, Nayyar D, Chu C, O'Brien T, Lyons OD, Agarwal P, Martin D, Bhatia RS, Mukerji G. Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis. BMC Health Serv Res 2022; 22:198. [PMID: 35164751 PMCID: PMC8845247 DOI: 10.1186/s12913-022-07566-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/31/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic led to a dramatic shift in the delivery of outpatient medicine with reduced in-person visits and a transition to predominantly virtual visits. We sought to understand trends in visit patterns for ambulatory care sensitive conditions (ACSCs) commonly seen in internal medicine clinics. METHODS We included adult outpatients seen for an ACSC between March 15th, 2017 and March 14th, 2021 at a single-centre in Ontario, Canada. Monthly visits were assessed by visit type (new consultation, follow-up), diagnosis, and clinic. Time series analyses compared visit volumes pre- and post-pandemic. Proportion of virtual visits were compared before and during the pandemic. Patient and visit factors were compared between in-person and virtual visits. RESULTS 8274 patients with 34,021 visits were included. Monthly visits increased by 15% during the pandemic (p < 0.0001). New consultations decreased by 10% (p = 0.0053) but follow-up visits increased by 21% (p < 0.0001). Monthly heart failure visits increased by 43% (p < 0.0001) whereas atrial fibrillation visits decreased. Pre- pandemic, < 1% of visits were virtual compared to 82% during the pandemic (p < 0.0001). Less than half of heart failure visits were virtual whereas > 95% of diabetes visits were virtual. CONCLUSIONS We found a significant increase in overall visits to internal medicine clinics driven by increased volumes of follow-up visits, which more than offset decreased new consultations. There was variability in visit trends and uptake of virtual care by visit diagnosis, which may indicate challenges with delivery of virtual care for certain conditions.
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Affiliation(s)
- Ciara Pendrith
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada
| | - Dhruv Nayyar
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cherry Chu
- Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada
| | - Tara O'Brien
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Owen D Lyons
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada.,Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Martin
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Geetha Mukerji
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Women's College Hospital Institute for Health System Solutions & Virtual Care, 76 Grenville Street, Toronto, Ontario, M5S 1B3, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Women's College Hospital, Toronto, ON, Canada.
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15
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Wong BM, Rotteau L, Feldman S, Lamb M, Liang K, Moser A, Mukerji G, Pariser P, Pus L, Razak F, Shojania KG, Verma A. A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic. J Am Med Dir Assoc 2021; 23:304-307.e3. [PMID: 34922907 PMCID: PMC8610963 DOI: 10.1016/j.jamda.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 10/29/2022]
Abstract
The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.
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Affiliation(s)
- Brian M Wong
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leahora Rotteau
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada.
| | - Sid Feldman
- Baycrest Health Sciences Centre, Toronto, Ontario, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Lamb
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, North York General Hospital, North York, Ontario, Canada
| | - Kyle Liang
- Womens College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Andrea Moser
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Sienna Senior Living Canada, Markham, Ontario, Canada
| | - Geetha Mukerji
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Womens College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada; Women's College Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Pauline Pariser
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura Pus
- Womens College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Fahad Razak
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
| | - Kaveh G Shojania
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amol Verma
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General Internal Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, Ontario, Canada
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16
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Wu N, Wang S, Brazeau AS, Rahme E, Nakhla M, Chan D, Ell M, Prevost M, Lépine L, Mukerji G, Butalia S, Panagiotopoulos C, Costa DD, Henderson M, Dasgupta K. Types of Social Support Offered Through a Virtual Peer Support Network in Youth With Type 1 Diabetes. Can J Diabetes 2021. [DOI: 10.1016/j.jcjd.2021.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Budhwani S, Fujioka JK, Chu C, Baranek H, Pus L, Wasserman L, Vigod S, Martin D, Agarwal P, Mukerji G. Delivering Mental Health Care Virtually During the COVID-19 Pandemic: Qualitative Evaluation of Provider Experiences in a Scaled Context. JMIR Form Res 2021; 5:e30280. [PMID: 34406967 PMCID: PMC8457338 DOI: 10.2196/30280] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/02/2021] [Accepted: 08/03/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Virtual care delivery within mental health has increased rapidly during the COVID-19 pandemic. Understanding facilitators and challenges to adoption and perceptions of the quality of virtual care when delivered at scale can inform service planning postpandemic. OBJECTIVE We sought to understand consistent facilitators and persistent challenges to adoption of virtual care and perceived impact on quality of care in an initial pilot phase prior to the pandemic and then during scaled use during the pandemic in the mental health department of an ambulatory care hospital. METHODS This study took place at Women's College Hospital, an academic ambulatory hospital located in Toronto, Canada. We utilized a multimethods approach to collect quantitative data through aggregate utilization data of phone, video, and in-person visits prior to and during COVID-19 lockdown measures and through a provider experience survey administered to mental health providers (n=30). Qualitative data were collected through open-ended questions on provider experience surveys, focus groups (n=4) with mental health providers, and interviews with clinical administrative and implementation hospital staff (n=3). RESULTS Utilization data demonstrated slower uptake of video visits at launch and prior to COVID-19 lockdown measures in Ontario (pre-March 2020) and subsequent increased uptake of phone and video visits during COVID-19 lockdown measures (post-March 2020). Mental health providers and clinic staff highlighted barriers and facilitators to adoption of virtual care at the operational, behavioral, cultural, and system/policy levels such as required changes in workflows and scheduling, increased provider effort, provider and staff acceptance, and billing codes for physician providers. Much of the described provider experiences focused on perceived impact on quality of mental health care delivery, including perceptions on providing appropriate and patient-centered care, virtual care effectiveness, and equitable access to care for patients. CONCLUSIONS Continued efforts to enhance suggested facilitators, reduce persistent challenges, and address provider concerns about care quality based on these findings can enable a hybrid model of patient-centered and appropriate care to emerge in the future, with options for in-person, video, and phone visits being used to meet patient and clinical needs as required.
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Affiliation(s)
- Suman Budhwani
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
| | - Jamie Keiko Fujioka
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
| | - Cherry Chu
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
| | | | - Laura Pus
- Women's College Hospital, Toronto, ON, Canada
| | | | - Simone Vigod
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Institute of Health System Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Danielle Martin
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Institute of Health System Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Institute of Health System Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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18
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Laur CV, Agarwal P, Mukerji G, Goulbourne E, Baranek H, Pus L, Bhatia RS, Martin D, Bhattacharyya O. Correction: Building Health Services in a Rapidly Changing Landscape: Lessons in Adaptive Leadership and Pivots in a COVID-19 Remote Monitoring Program. J Med Internet Res 2021; 23:e31044. [PMID: 34111020 PMCID: PMC8231889 DOI: 10.2196/31044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/07/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Celia Violet Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada.,Department of Medicine, Division of Endocrinology & Metabolism, University of Toronto, Toronto, ON, Canada
| | | | - Hayley Baranek
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Laura Pus
- Women's College Hospital, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada.,University Health Network, Toronto, ON, Canada
| | - Danielle Martin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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19
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Chan AJ, Gomer S, Dimaraki EV, Lipscombe LL, Mukerji G. Improving Care Delivery for Young Adults With Type 1 Diabetes via a Multi-Faceted Quality Improvement Interdisciplinary Intervention. J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background: The transition from pediatric to adult type 1 diabetes (TID) care represents a vulnerable period for young adults (YA), and many are eventually lost to follow up. This can result in lost opportunities for patient education, worsened glycemic control and increased rates of acute diabetes complications. To address this, a multi-faceted quality improvement (QI) intervention was implemented at a YA T1D program with the goal of improving patient attendance and care delivery amongst YA with T1D.
Methods: The intervention consisted of three main components: a transitional navigator, an interdisciplinary diabetes assessment flowsheet and virtual care via phone or video conference. These components were implemented at the YA T1D program using a stepwise approach beginning in 2019. The attendance of all patients seen between January 2017 and August 2020 were tracked monthly on a run chart to identify any shifts after each component was implemented. A pre-post analysis was also performed in new patients with a minimum follow up period of 12 months to compare secondary outcomes including A1c reduction at 12 months, incidence of diabetes-related ED visits/hospitalizations, incidence of severe hypoglycemia and psychosocial counselling rates.
Results: A total of 2240 scheduled appointments was included in the primary analysis. Patient attendance improved from 59% to 79% (p<0.01) with virtual care, demonstrated by a shift in attendance sustained over 6 months after its implementation. Virtual care was utilized in 81.3% of appointments in the post-intervention period. Subgroup analysis showed the improvement in attendance was significant in follow up appointments (80% vs 59%, p<0.01), but there was no difference in attendance for initial consultations (67% vs 58%, p=0.45).
Forty-two patients were included in the pre-post analysis (n=27 in the pre-intervention and n=15 in the post-intervention period). There were with no significant difference in baseline characteristics of the two groups. Mean patient age was 20.2±2.9 years. Males comprised of 28.5% of the study population. Mean duration of diabetes was 11.1±5.3 years, and baseline average A1c was 8.6±1.7%. Preliminary analysis demonstrated there was significant improvement in preconception counselling rate (76% vs 100%, p=0.048) following the intervention. There was no significant difference in A1c reduction at 12 months, incidence of diabetes-related ED visits/hospitalizations or incidence of severe hypoglycemia.
Conclusion: Virtual care was effective in improving attendance for follow up appointments at a YA T1D clinic. Further data analysis for patients assessed in September to December 2020 is currently underway.
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Affiliation(s)
| | - Stephanie Gomer
- Division of Endocrinology and Metabolism, Women’s College Hospital, Toronto, ON, Canada
| | - Eleni V Dimaraki
- Division of Endocrinology and Metabolism, Women’s College Hospital, Toronto, ON, Canada
| | | | - Geetha Mukerji
- Division of Endocrinology and Metabolism, Women’s College Hospital, Toronto, ON, Canada
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20
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Agarwal P, Mukerji G, Laur C, Chandra S, Pimlott N, Heisey R, Stovel R, Goulbourne E, Bhatia RS, Bhattacharyya O, Martin D. Adoption, feasibility and safety of a family medicine-led remote monitoring program for patients with COVID-19: a descriptive study. CMAJ Open 2021; 9:E324-E330. [PMID: 33795222 PMCID: PMC8034257 DOI: 10.9778/cmajo.20200174] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Virtual care for patients with coronavirus disease 2019 (COVID-19) allows providers to monitor COVID-19-positive patients with variable trajectories while reducing the risk of transmission to others and ensuring health care capacity in acute care facilities. The objective of this descriptive analysis was to assess the initial adoption, feasibility and safety of a family medicine-led remote monitoring program, COVIDCare@Home, to manage the care of patients with COVID-19 in the community. METHODS COVIDCare@Home is a multifaceted, interprofessional team-based remote monitoring program developed at an ambulatory academic centre, the Women's College Hospital in Toronto. A descriptive analysis of the first cohort of patients admitted from Apr. 8 to May 11, 2020, was conducted. Lessons from the implementation of the program are described, focusing on measure of adoption (number of visits per patient total, with a physician or with a nurse; length of follow-up), feasibility (received an oximeter or thermometer; consultation with general internal medicine, social work or mental health, pharmacy or acute ambulatory care unit) and safety (hospitalizations, mortality and emergency department visits). RESULTS The COVIDCare@Home program cared for a first cohort of 97 patients (median age 41 yr, 67% female) with 415 recorded virtual visits. Patients had a median time from positive testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to first appointment of 3 (interquartile range [IQR] 2-4) days, with a median virtual follow-up time of 8 (IQR 5-10) days. A total of 4 (4%) had an emergency department visit, with no patients requiring hospitalization and no deaths; 16 (16%) of patients required support with mental and social health needs. INTERPRETATION A family medicine-led, team-based remote monitoring program can safely manage the care of outpatients diagnosed with COVID-19. Virtual care approaches, particularly those that support patients with more complex health and social needs, may be an important part of ongoing health system efforts to manage subsequent waves of COVID-19 and other diseases.
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Affiliation(s)
- Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont.
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Shivani Chandra
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Nick Pimlott
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Ruth Heisey
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Rebecca Stovel
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Elaine Goulbourne
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
| | - Danielle Martin
- Women's College Hospital Institute for Health System Solutions and Virtual Care (Agarwal, Mukerji, Laur, Chandra, Bhatia, Bhattacharyya), and Department of Family and Community Medicine (Agarwal, Bhattacharyya, Martin), and Division of Endocrinology & Metabolism (Mukerji), Department of Medicine, and Women's College Hospital Academic Family Health Team (Pimlott, Heisey), Department of Family and Community Medicine, and Division of General Internal Medicine (Stovel), Department of Medicine, University of Toronto; Division of General Internal Medicine (Stovel), Women's College Hospital; Women's College Hospital (Goulbourne, Martin); University Health Network (Bhatia); Dalla Lana School of Public Health (Martin), University of Toronto, Toronto, Ont
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21
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Laur CV, Agarwal P, Mukerji G, Goulbourne E, Baranek H, Pus L, Bhatia RS, Martin D, Bhattacharyya O. Building Health Services in a Rapidly Changing Landscape: Lessons in Adaptive Leadership and Pivots in a COVID-19 Remote Monitoring Program. J Med Internet Res 2021; 23:e25507. [PMID: 33417588 PMCID: PMC7808765 DOI: 10.2196/25507] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/18/2020] [Accepted: 12/24/2020] [Indexed: 01/19/2023] Open
Abstract
Adaptive leadership has become an essential skill for leaders in health systems to respond to the COVID-19 pandemic as new knowledge emerges and case counts rise, fall, and rise again. This leadership approach has been described as an iterative process of taking a wide view of the situation, interpreting the meaning of incoming data from multiple directions, and taking real-time action. This process is also common in start-ups, which attempt to create new products or services of uncertain value for consumer markets that may not yet exist. Start-ups manage uncertainty through "pivots," which can include changes in the target group, need, features, or intended benefit of a product or service. Pivots are large changes that account for the high likelihood of getting something wrong during development, and they are distinct from the "tweaks" or small tests of change that define quality improvement methodology. This case study describes three pivots in the launch of a remote monitoring program for COVID-19. Adaptive leadership helped inform strategic decisions, with pivots providing a framework for internal and external stakeholders to articulate options for changes to address shifting needs. There is considerable uncertainty in the appropriate design and implementation of health services, and although this case example focuses on the use of adaptive leadership and pivots during a pandemic, these strategies are relevant for health care leaders at any time.
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Affiliation(s)
- Celia Violet Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Department of Medicine, Division of Endocrinology & Metabolism, University of Toronto, Toronto, ON, Canada
| | | | - Hayley Baranek
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
| | - Laura Pus
- Women's College Hospital, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Danielle Martin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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22
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Rajeswaran V, Alexander L, Alwithenani R, Tran S, Baek J, Khan S, Jaskolka D, Usmani S, Yip P, Mukerji G. 54 - Reduction in Unnecessary Repeat HbA1c Testing in an Academic Hospital to Promote High-Value Care. Can J Diabetes 2020. [DOI: 10.1016/j.jcjd.2020.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Pritlove C, Markowitz B, Mukerji G, Advani A, Parsons JA. Experiences and perspectives of the parents of emerging adults living with type 1 diabetes. BMJ Open Diabetes Res Care 2020; 8:8/1/e001125. [PMID: 33004400 PMCID: PMC7534673 DOI: 10.1136/bmjdrc-2019-001125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Whereas it is widely recognized that emerging adulthood can be a difficult time in the life of an individual living with type 1 diabetes, relatively little is known about the experiences of their parents or guardians. These individuals once shouldered much of the burden for their child's diabetes 'self'-management, yet their contribution is often overlooked by the adult healthcare system. Here, we set out to gain an understanding of the perspectives of parents of emerging adults living with type 1 diabetes. RESEARCH DESIGN AND METHODS Semi-structured interviews were performed with a purposeful sample of parents of emerging adults with type 1 diabetes recruited from two urban young adult diabetes clinics and through a national diabetes charity. Thematic coding was derived using a constant comparative approach. RESULTS Analysis of interviews with 16 parents of emerging adults with type 1 diabetes identified three themes: parental experiences of the transition to adult care; negotiating parent-child roles, responsibilities and relationships; and new and evolving fears. Parents spoke in detail about the time surrounding their child's diagnosis of type 1 diabetes to emphasize the complexity of diabetes care and the need to establish a 'new normal' for the family. In turn, adolescence and emerging adulthood required a renegotiation of roles and responsibilities, with many parents continuing to play a role in high-level diabetes management. Several parents of emerging adults with type 1 diabetes (particularly those of young men) vocalized worries about their child's readiness to assume responsibility for their self-care, and some expressed frustration with the apparent dichotomy in the role expectations of parents between the pediatric and adult care settings. CONCLUSIONS Adult healthcare providers should recognize both the ongoing involvement of parents in the 'self'-management of emerging adults with type 1 diabetes and the unique aspects of the caregiver burden that they experience.
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Affiliation(s)
- Cheryl Pritlove
- Applied Health Research Centre, Li ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Benjamin Markowitz
- Applied Health Research Centre, Li ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada
- WCH Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Janet A Parsons
- Applied Health Research Centre, Li ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
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24
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Wu N, Brazeau AS, Nakhla M, Chan D, Da Costa D, Mukerji G, Butalia S, Pacaud D, Henderson M, Panagiotopoulos C, Rahme E, Dasgupta K. Type 1 Diabetes Mellitus Virtual Patient Network as a Peer Support Community: Protocol for Social Network Analysis and Content Analysis. JMIR Res Protoc 2020; 9:e18714. [PMID: 32865502 PMCID: PMC7490683 DOI: 10.2196/18714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/05/2020] [Accepted: 07/21/2020] [Indexed: 01/26/2023] Open
Abstract
Background Type 1 Diabetes Mellitus Virtual Patient Network (T1DM-VPN) is a private Facebook group for youths with type 1 diabetes mellitus (T1DM) in Canada intended to facilitate peer-to-peer support. It was built on the finding that stigma is prevalent among youth with T1DM and impedes self-management. Objective We aim to determine if T1DM-VPN provides support as intended and to ascertain what type of members provide support. Specifically, we will (1) identify text consistent with any one of 5 social support categories, (2) describe the network by visualizing its structure and reporting basic engagement statistics, and (3) determine whether being a designated peer leader is related to a member’s centrality (ie, importance in the network) and how frequently they offer social support. Methods We will manually extract interaction data from the Facebook group (posts, comments, likes/reactions, seen) generated from June 21, 2017 (addition of first member), to March 1, 2020. Two researchers will independently code posts and comments according to an existing framework of 5 social support categories—informational, emotional, esteem, network, and tangible—with an additional framework for nonsocial support categories. We will calculate how frequently each code is used. We will also report basic engagement statistics (eg, number of posts made per person-month) and generate a visualization of the network.
We will identify stable time intervals in the history of T1DM-VPN by modeling monthly membership growth as a Poisson process. Within each interval, each member’s centrality will be calculated and standardized to that of the most central member. We will use a centrality formula that considers both breadth and depth of connections (centrality = 0.8 × total No. of connections + 0.2 × total No. of interactions). Finally, we will construct multivariate linear regression models to assess whether peer leader status predicts member centrality and the frequency of offering social support. Other variables considered for inclusion in the models are gender and age at diagnosis. Results T1DM-VPN was launched in June 2017. As of March 1, 2020, it has 196 patient-members. This research protocol received ethics approval from the McGill University Health Centre Research Ethics Board on May 20, 2020. Baseline information about each group member was collected upon addition into the group, and collection of interaction data is ongoing as of May 2020. Conclusions This content analysis and social network analysis study of a virtual patient network applies epidemiological methods to account for dynamic growth and activity. The results will allow for an understanding of the topics of importance to youth with T1DM and how a virtual patient network evolves over time. This work is intended to serve as a foundation for future action to help youth improve their experience of living with diabetes. International Registered Report Identifier (IRRID) PRR1-10.2196/18714
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Affiliation(s)
- Nancy Wu
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Meranda Nakhla
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Deborah Chan
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Deborah Da Costa
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Geetha Mukerji
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sonia Butalia
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniele Pacaud
- Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Mélanie Henderson
- Division of Endocrinology and Diabetes, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | | | - Elham Rahme
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Kaberi Dasgupta
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada
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25
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Delos-Reyes F, Landry M, Price J, Wu W, Mukerji G, McTavish S, Harvey P, Lipscombe L. Avoiding Diabetes After Pregnancy Trial In Moms (ADAPT- M): Evaluating Fitness In Postpartum Women Who Have Had Recent Gestational Diabetes Mellitus (GDM). Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000680300.53643.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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26
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Mahmud FH, Clarke ABM, Joachim KC, Assor E, McDonald C, Saibil F, Lochnan HA, Punthakee Z, Parikh A, Advani A, Shah BR, Perkins BA, Zuijdwijk CS, Mack DR, Koltin D, De Melo EN, Hsieh E, Mukerji G, Gilbert J, Bax K, Lawson ML, Cino M, Beaton MD, Saloojee NA, Lou O, Gallego PH, Bercik P, Houlden RL, Aronson R, Kirsch SE, Paterson WG, Marcon MA. Screening and Treatment Outcomes in Adults and Children With Type 1 Diabetes and Asymptomatic Celiac Disease: The CD-DIET Study. Diabetes Care 2020; 43:1553-1556. [PMID: 32345653 DOI: 10.2337/dc19-1944] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/25/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe celiac disease (CD) screening rates and glycemic outcomes of a gluten-free diet (GFD) in patients with type 1 diabetes who are asymptomatic for CD. RESEARCH DESIGN AND METHODS Asymptomatic patients (8-45 years) were screened for CD. Biopsy-confirmed CD participants were randomized to GFD or gluten-containing diet (GCD) to assess changes in HbA1c and continuous glucose monitoring over 12 months. RESULTS Adults had higher CD-seropositivity rates than children (6.8% [95% CI 4.9-8.2%, N = 1,298] vs. 4.7% [95% CI 3.4-5.9%, N = 1,089], P = 0.035) with lower rates of prior CD screening (6.9% vs. 44.2%, P < 0.0001). Fifty-one participants were randomized to a GFD (N = 27) or GCD (N = 24). No HbA1c differences were seen between the groups (+0.14%, 1.5 mmol/mol; 95% CI -0.79 to 1.08; P = 0.76), although greater postprandial glucose increases (4-h +1.5 mmol/L; 95% CI 0.4-2.7; P = 0.014) emerged with a GFD. CONCLUSIONS CD is frequently observed in asymptomatic patients with type 1 diabetes, and clinical vigilance is warranted with initiation of a GFD.
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Affiliation(s)
- Farid H Mahmud
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Antoine B M Clarke
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kariym C Joachim
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Esther Assor
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Charlotte McDonald
- Division of Endocrinology and Metabolism, St. Joseph's Health Care, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Fred Saibil
- Division of Gastroenterology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Heather A Lochnan
- Department of Endocrinology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Zubin Punthakee
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amish Parikh
- Division of Endocrinology, Trillium Health Partners, Toronto, Ontario, Canada
| | - Andrew Advani
- Division of Endocrinology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Baiju R Shah
- Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Caroline S Zuijdwijk
- Division of Endocrinology and Metabolism, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - David R Mack
- Division of Gastroenterology, Hepatology and Nutrition, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Dror Koltin
- Division of Endocrinology, Trillium Health Partners, Toronto, Ontario, Canada
| | - Emilia N De Melo
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Eugene Hsieh
- Department of Pathology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada
| | - Jeremy Gilbert
- Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin Bax
- Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Margaret L Lawson
- Division of Endocrinology and Metabolism, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Maria Cino
- Division of Gastroenterology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Melanie D Beaton
- Division of Gastroenterology, London Health Sciences Centre, London, Ontario, Canada
| | - Navaaz A Saloojee
- Department of Gastroenterology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Patricia H Gallego
- Division of Endocrinology, Children's Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Premysl Bercik
- Department of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Robyn L Houlden
- Department of Endocrinology, Kingston General Hospital, Kingston, Ontario, Canada
| | | | - Susan E Kirsch
- Division of Endocrinology, Markham-Stouffville Hospital, Markham, Ontario, Canada
| | - William G Paterson
- Department of Gastroenterology, Kingston General Hospital, Kingston, Ontario, Canada
| | - Margaret A Marcon
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Razak F, Shin S, Pogacar F, Jung HY, Pus L, Moser A, Lapointe-Shaw L, Tang T, Kwan JL, Weinerman A, Rawal S, Kushnir V, Mak D, Martin D, Shojania KG, Bhatia S, Agarwal P, Mukerji G, Fralick M, Kapral MK, Morgan M, Wong B, Chan TCY, Verma AA. Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study. CMAJ Open 2020; 8:E514-E521. [PMID: 32819964 PMCID: PMC7850232 DOI: 10.9778/cmajo.20200098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. METHODS We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. RESULTS There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. INTERPRETATION The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.
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Affiliation(s)
- Fahad Razak
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont.
| | - Saeha Shin
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Frances Pogacar
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Hae Young Jung
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Laura Pus
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Andrea Moser
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Terence Tang
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Janice L Kwan
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Adina Weinerman
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Shail Rawal
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Vladyslav Kushnir
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Denise Mak
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Danielle Martin
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Kaveh G Shojania
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Sacha Bhatia
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Payal Agarwal
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Geetha Mukerji
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Michael Fralick
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Moira K Kapral
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Matthew Morgan
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Brian Wong
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Timothy C Y Chan
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
| | - Amol A Verma
- Division of General Internal Medicine (Razak, Verma), St. Michael's Hospital; Department of Medicine (Razak, Moser, Lapointe-Shaw, Tang, Kwan, Weinerman, Rawal, Shojania, Bhatia, Mukerji, Kapral, Morgan, Verma), University of Toronto; Li Ka Shing Knowledge Institute (Razak, Shin, Pogacar, Jung, Kushnir, Mak, Fralick, Chan, Verma), St. Michael's Hospital; Department of Mechanical and Industrial Engineering (Pogacar, Chan), University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Pus, Martin, Bhatia, Agarwal, Mukerji), Women's College Hospital; Baycrest Geriatric Health Care System (Moser); Division of General Internal Medicine (Lapointe-Shaw, Rawal, Fralick), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Kwan, Fralick, Morgan), Mount Sinai Hospital; Sunnybrook Health Sciences Centre (Weinerman, Shojania, Wong); Department of Family and Community Medicine (Martin, Agarwal), University of Toronto, Toronto, Ont
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Ibrahim S, Sidani S, Lok J, Mukerji G, Sherifali D. Recreational Cannabis Usage Among Young Adults Living with Diabetes: Protocol for a Mixed Methods Study. Diabetes Ther 2020; 11:1407-1417. [PMID: 32314248 PMCID: PMC7261302 DOI: 10.1007/s13300-020-00818-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Canada is the second country in the world to legalize recreational cannabis (marijuana). Young adults are the highest users of cannabis. Recreational cannabis use may increase anxiety, depression, breathing problems, and weight in young adults in general and further result in poor control of sugar levels, increased consumption of carbohydrates, and poor self-management in young adults living with diabetes. There is limited research on the influence of recreational cannabis usage on young adults living with diabetes. PURPOSE To explore the frequency of recreational cannabis usage, self-management behaviors and experiences of cannabis-related adverse events, to identify the factors encouraging recreational cannabis usage, and to determine the influence of recreational cannabis usage on self-reported health among young adults living with diabetes. METHODS A sequential explanatory mixed method design will be used. The first phase will be a cross-sectional online survey in which quantitative data will be collected on the demographic and health/clinical characteristics, cannabis use patterns, and diabetes self-management of young adults living with diabetes who use cannabis. The second phase will involve the collection of qualitative data through telephone, semi-structured, one-on-one interviews. Potential participants will be recruited through study flyers, posters, and clinicians from two outpatient diabetes clinics in the province of Ontario, Canada. PLANNED OUTCOMES The findings from this study may provide useful information regarding the effects of recreational cannabis consumption on young adults living with diabetes. This, in turn, may provide guidance to healthcare providers on how to counsel, assist, educate, and support diabetes-related management through strategies and interventions for this patient population, contributing to patient health and safety.
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Affiliation(s)
- Sarah Ibrahim
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada.
| | - Souraya Sidani
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON, Canada
| | - Jana Lok
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Endocrinology, Women's College Hospital, Toronto, ON, Canada
| | - Diana Sherifali
- School of Nursing, McMaster University, Hamilton, ON, Canada
- Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- McMaster Evidence Review and Synthesis Team, McMaster University, Hamilton, ON, Canada
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Marani H, Halperin IJ, Jamieson T, Mukerji G. Quality Gaps of Electronic Health Records in Diabetes Care. Can J Diabetes 2020; 44:350-355. [DOI: 10.1016/j.jcjd.2019.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 11/24/2022]
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Koshkina O, Boggild M, Tai F, Mukerji G. MON-117 Reducing Unnecessary Repeat Vitamin D Testing at a Large Ambulatory Hospital: A Quality Improvement Initiative. J Endocr Soc 2020. [PMCID: PMC7207598 DOI: 10.1210/jendso/bvaa046.1160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: With the increasing interest in the importance and potential benefits of vitamin D, there has been a significant rise in unnecessary vitamin D testing. The aim of the project was to reduce unnecessary repeat vitamin D testing at Women’s College Hospital by 50% by May 30th 2020. Methods: The Model for Improvement framework was used in the design of the quality improvement project to reduce unnecessary repeat vitamin D testing. Problem characterization was conducted to design the intervention to address root causes and iterative Plan-do-Study-Act cycles were used to develop an intervention that incorporated a best practice advisory (BPA). The primary outcome measure was unnecessary vitamin D testing. Unnecessary repeat testing was defined as: repeat 25-hydroxyvitamin D testing within 3 months or repeat 25-hydroxyvitamin D testing after a normal result (>75 mmol/L) in the preceding 12 months. Secondary outcomes which included BPAs generated, as well as the number of BPAs that resulted in no test being ordered were tracked. Paper-based orders were also tracked as a balancing measure. Results: It was identified that 12.7% of vitamin D testing (n= 289/2276) between July 2017 and July 2018 was related to unnecessary repeat testing. Following our cause and effect analysis and problem characterization, it was noted that providers ordered repeat vitamin D testing due to being unaware of prior normal results, as well as due to a knowledge gap of current testing recommendations. If the 25-hydroxyvitamin D order was identified as unnecessary at the time of order entry, a BPA was generated at the point of care. The BPA was implemented on February 4th, 2019. As of August 31st, 2019 based on the analysis of the number of BPAs generated and the number of tests not ordered as a result, there has been a 26% reduction in the number of inappropriate repeat vitamin D orders. Conclusions: Based on the preliminary data, a best practice advisory alert for vitamin D testing can be an appropriate QI intervention to reduce unnecessary vitamin D testing. Ongoing data analysis will be conducted to assess the long-term impact and sustainability of this intervention. Next steps include consideration of implementation of force function to reduce inappropriate repeat vitamin D testing.
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Affiliation(s)
- Olexandra Koshkina
- Department of Endocrinology, Women’s College Hospital, Toronto, ON, Canada
| | - Miranda Boggild
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Felicia Tai
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Department of Medicine, University of Toronto, Department of Endocrinology, Women’s College Hospital, Women’s College Institute of Health Systems Solutions and Virtual Care, Toronto, ON, Canada
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Rajeswaran V, Alexander L, Alwithenani R, Jaskolka D, Usmani S, Tran S, Khan S, Yip P, Mukerji G. MON-118 Reducing Unnecessary Repeat HbA1c Testing in a Tertiary Academic Hospital. J Endocr Soc 2020. [PMCID: PMC7209567 DOI: 10.1210/jendso/bvaa046.1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Glycated hemoglobin (HbA1c) is a surrogate marker of glycemia over the preceding three months, where the last 30 days contributes to 50% of the value (1). Therefore guidelines often recommend repeating HbA1c only after 3 months in most situations (2), but repeat testing of HbA1c is often conducted earlier when not warranted (3). We aimed to conduct a Quality Improvement (QI) initiative to reduce unnecessary repeat testing of HbA1c at a large tertiary care academic hospital in Toronto, Ontario by 50% by May 2020. Methods: The Model for Improvement Quality Improvement (QI) framework was used in the design of the QI project to reduce repeat HbA1c. Problem characterization was conducted to understand root causes and iterative Plan-Do-Study-Act cycles were used to develop a change intervention. Unnecessary HbA1c tests were the primary outcome and defined as repeat HbA1c testing within 60 days; the top three specialities that ordered unnecessary HbA1c tests were targeted for education prior to implementation of the change intervention. Results: Baseline data on all HbA1c tests in 2018 revealed repeat testing in approximately 10% of 15,290 HbA1c tests, with estimated potential savings of more than $11,000 based on the provincial reimbursement rate. The top 3 ordering specialities targeted for education included Nephrology (n=410 repeat HbA1c tests), Cardiology (n=246 repeat HbA1c tests), and Endocrinology (n=136 repeat HbA1C tests). Root cause analysis revealed that providers often ordered repeat HbA1c tests due to being unaware of prior results and a knowledge gap of testing recommendations. A laboratory forced function will be implemented on December 1, 2019 to cancel any repeat HbA1c tests within 60 days and calls to the lab to add HbA1c testing will be tracked. Conclusions: Repeat HbA1c testing is frequent in hospital settings and can be an important target for QI efforts. A forced function to cancel processing of repeat HbA1c may be an appropriate QI intervention to reduce repeat testing to promote high-value care. Ongoing data analysis will be conducted to assess the impact of this intervention. References (1) Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of Glycemia in Diabetes. Diabetes Care 2004;27(7): 1761-1773. (2) Berard LD, Siemens R, Woo V. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Monitoring Glycemic Control. Can J Diabetes 2018;42(Suppl 1):S47-S53. (3) Chami N, Simons JE, Sweetman A, Don-Wauchope AC. Rates of inappropriate laboratory test utilization in Ontario. Clinical Biochemistry 2017;50: 822-827.
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Affiliation(s)
| | | | | | | | | | - Susan Tran
- University of Toronto, Toronto, ON, Canada
| | - Sarah Khan
- University of Toronto, Toronto, ON, Canada
| | - Paul Yip
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Geetha Mukerji
- University of Toronto, Women’s College Hospital, Toronto, ON, Canada
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Abbas M, Feig D, Mukerji G. SUN-636 Gaps in Quality of Delivery of Post-Partum Care in Preconception Counselling for Pregnant Women with Pre-Existing Diabetes at a Large Academic Tertiary Centre. J Endocr Soc 2020. [PMCID: PMC7208803 DOI: 10.1210/jendso/bvaa046.1500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: Women with pre-existing diabetes are at increased risk of serious adverse pregnancy outcomes compared with the general maternity population including congenital anomaly, stillbirth and neonatal death. The 2018 Diabetes Canada Clinical Practice Guidelines (DC CPG) on Diabetes in Pregnancy recommend that women with pre-existing diabetes are provided with postpartum and preconception counseling by their diabetes healthcare team, as this is associated with improved maternal and fetal outcomes. OBJECTIVE: To evaluate the quality of physican counselling of post-partum management and pre conception advice for women with pre-existing diabetes who receive their intrapartum care at Mount Sinai Hospital Diabetes in Pregnancy Clinic in Toronto Ontario. METHODS: Eligible patients were pregnant women with pre-existing Type 1 and Type 2 diabetes who were followed in pregnancy until their 6 weeks postpartum clinic visit. Consecutive baseline chart review of patients between June 2018 - June 2019 was performed to audit documentation of physician counselling of DC CPG recommendations at the 6 week post-partum visit. Key components of the recommendations included: 1) targeting an HbA1c of <7% pre-pregnancy, 2) folic acid supplementation and neural tube defect prevention, 3) weight management and optimization of BMI, 4) contraceptive measures and family planning, 5) information regarding outcomes and risks for mother and baby 6) yearly retinal exam. RESULTS: Results of our chart review found that 42% (n=50) of women with pre-existing diabetes who received their intrapartum care at our clinic returned for their 6 week postpartum visit between June 2018-June 2019. Audit of the 6 week post-partum clinic note found that less than 20% of women had physician documentation of counselling on two or more key components of the DC CPG recommendations (1-6). CONCLUSION: There is a large gap in women attending postpartum appointments and there are significant gaps in physician documentation of counselling among women with pre-existing diabetes. Further analysis will be conducted in order to determine if there is a patient knowledge gap regarding counselling recommendations and a quality improvement project will be undertaken to close this gap.
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Affiliation(s)
- Minan Abbas
- University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - Denice Feig
- University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - Geetha Mukerji
- University of Toronto, Women’s College Hospital, Toronto, ON, Canada
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Tseng EK, Mukerji G, Weinerman A, Fuller J, McLeod A, Wong BM, Kuper A, Stroud LS. Choosing Words Wisely: Residents' Use of Rhetorical Appeals in Conversations About Unnecessary Tests. Acad Med 2020; 95:275-282. [PMID: 31517680 DOI: 10.1097/acm.0000000000002980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.
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Affiliation(s)
- Eric K Tseng
- E.K. Tseng is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada. G. Mukerji is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada. A. Weinerman is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. J. Fuller is assistant professor, Department of History and Philosophy of Science, University of Pittsburgh, Pittsburgh, Pennsylvania, and research associate, African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa. A. McLeod is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. B.M. Wong is associate professor, Department of Medicine, and associate director, Centre for Quality Improvement and Patient Safety, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. A. Kuper is associate professor, Department of Medicine, and education scientist, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. L.S. Stroud is associate professor, Department of Medicine, and centre researcher, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Shulman R, Zenlea I, Shah BR, Clarson C, Harrington J, Landry A, Punthakee Z, Palmert MR, Mukerji G, Austin PC, Parsons J, Ivers N. Testing an audit and feedback-based intervention to improve glycemic control after transfer to adult diabetes care: protocol for a quasi-experimental pre-post design with a control group. BMC Health Serv Res 2019; 19:885. [PMID: 31766999 PMCID: PMC6878686 DOI: 10.1186/s12913-019-4690-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When young adults transfer from pediatric to adult diabetes care they are at risk for deterioration of glycemic control, putting them at an increased risk of developing both acute and chronic complications. Despite increased awareness of these risks, there are gaps in care delivery during this vulnerable time and variability in the implementation of recommended transition practice. Audit and feedback (AF) interventions have a positive but variable effect on implementation of best practices. An expert group identified specific suggestions for optimizing the effectiveness of AF interventions. We aim to test an AF-based intervention incorporating these specific suggestions to improve transition practices and glycemic control in the first year after transfer from pediatric to adult diabetes care. METHODS This is a pragmatic quasi-experimental study; a series of three cohort studies (pre-implementation, early-implementation, and post-implementation) to compare the baseline adjusted hemoglobin A1c (HbA1c) in the 12 months after the final pediatric visit in five pediatric diabetes centres within the Ontario Pediatric Diabetes Network in Ontario, Canada. The intervention includes three components: 1) centre-level feedback reports compiling data from chart abstraction, linked provincial administrative datasets, and patient-reported experience measures; 2) webinars for facilitated conversations/coaching about the feedback; and 3) online repository of curated transition resources for providers. The primary outcome will be analyzed using a multivariable linear regression model. We will conduct a qualitative process evaluation to understand intervention fidelity and to provide insight into the mechanisms of action of our results. DISCUSSION There is a need to develop an innovative system-level approach to improve outcomes and the quality of care for young adults with type 1 diabetes during the vulnerable time when they transfer to adult care. Our research team, a collaboration of health services, implementation science, and quality improvement researchers, are designing, implementing, and evaluating an AF-based intervention using recommendations about how to optimize effectiveness. This knowledge will be generalizable to other care networks that aim to deliver uniformly high-quality care in diverse care settings. TRIAL REGISTRATION ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.
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Affiliation(s)
- Rayzel Shulman
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada. .,SickKids Research Institute, Toronto, Canada. .,ICES, Toronto, Canada. .,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. .,Department of Pediatrics, University of Toronto, Toronto, Canada.
| | - Ian Zenlea
- Institute for Better Health, Trillium Health Partners, Missisauga, Canada
| | - Baiju R Shah
- ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Cheril Clarson
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Jennifer Harrington
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Alanna Landry
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada.,Markham Stouffville Hospital, Markham, Canada
| | | | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada.,SickKids Research Institute, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Department of Medicine, University of Toronto, Toronto, Canada.,Women's College Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Janet Parsons
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Noah Ivers
- ICES, Toronto, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Women's College Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada.,Department of Family Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
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Allemang B, Allan K, Johnson C, Cheong M, Cheung P, Odame I, Ward R, Williams S, Mukerji G, Kuo KHM. Impact of a transition program with navigator on loss to follow-up, medication adherence, and appointment attendance in hemoglobinopathies. Pediatr Blood Cancer 2019; 66:e27781. [PMID: 31045326 DOI: 10.1002/pbc.27781] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Transition from pediatric to adult care is a period of high risk for loss to follow-up, morbidity, and mortality in adolescents and young adults (AYA) with hemoglobinopathies. The purpose of this study was to determine whether a transition program with transition navigator (TN) reduced loss to follow-up and hospitalizations and improved medication adherence and appointment attendance compared with an unstructured transfer. PROCEDURE A retrospective observational study compared all AYA with hemoglobinopathies who turned 18 one year prior to (n = 51) and one year after (n = 61) the initiation of the transition program. Data from one year prior to last pediatric appointment and one year following first adult appointment were collected from each patient. RESULTS The transition program with TN reduced loss to follow-up from 29% to 7% (P = 0.034). A greater proportion of patients in the transition cohort maintained or improved adherence to hydroxyurea or iron chelation to ≥4 days/week; exposure to the program was independently associated with such improvement (P = 0.047). A trend toward improvement or maintenance of ≥90% attendance to appointments was observed (P = 0.096). Frequency of hospitalization was not significantly different between the two cohorts (P = 0.985). CONCLUSIONS A transition program with TN significantly reduced loss to follow-up, and significantly improved and maintained fair to good medication adherence. Further analysis of economic benefit and patient satisfaction will be conducted.
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Affiliation(s)
- Brooke Allemang
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kate Allan
- Factor Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Colleen Johnson
- Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Melina Cheong
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Patrina Cheung
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isaac Odame
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Ward
- Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital, Toronto, Ontario, Canada
| | - Kevin H M Kuo
- Division of Medical Oncology and Hematology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Markowitz B, Pritlove C, Mukerji G, Lavery JV, Parsons JA, Advani A. The 3i Conceptual Framework for Recognizing Patient Perspectives of Type 1 Diabetes During Emerging Adulthood. JAMA Netw Open 2019; 2:e196944. [PMID: 31298715 PMCID: PMC6628591 DOI: 10.1001/jamanetworkopen.2019.6944] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Early emerging adulthood, the developmental life stage roughly spanning between the ages of 18 and 24 years, can be a challenging time for individuals living with type 1 diabetes, being associated with an increased risk of acute complications, loss to follow-up, and the emergence of long-term diabetes complications. Few evidence-based interventions exist, and practice guidelines instead emphasize the importance of delivering individualized, developmentally appropriate care. OBJECTIVE To inform the provision of tailored care and education by illuminating the individual lived experiences of emerging adults with type 1 diabetes. DESIGN, SETTING, AND PARTICIPANTS This qualitative study used in-depth interviews conducted with 33 emerging adults living with type 1 diabetes between October 14, 2016, and May 16, 2017. Participants were recruited from 2 urban Young Adult Diabetes Clinics in the city of Toronto, Ontario, Canada, using a convenience sampling approach. Narrative analysis of participants' accounts was conducted inductively to define story typology. MAIN OUTCOMES AND MEASURES Participant accounts of type 1 diabetes during childhood, adolescence, and emerging adulthood. RESULTS Interviews were conducted with 33 participants aged 18 to 24 years (mean [SD] age at interview, 20.6 [1.7] years); 17 (51%) were women. Duration of diabetes ranged from 3 to 20 years (mean [SD] duration, 12.0 [4.8] years). Narrative analysis identified 3 distinct story types, or lenses, termed ingrained (n = 14), intrusive (n = 12), and inconspicuous (n = 7). Ingrained narratives portrayed an active integration of diabetes self-management into daily life. Intrusive narratives were characterized by stories of struggles for acceptance and striving for control. Inconspicuous narratives were differentiated by descriptions of a willingness to ignore diabetes and its attendant daily tasks with the goals of preserving normalcy and limiting distress. Mean levels of hemoglobin A1c were higher in participants conveying an intrusive lens narrative (mean [SD], 9.3% [1.6%]) than those conveying an ingrained lens (mean [SD], 7.4% [0.7%]) (difference between intrusive and ingrained, 1.9%; 95% CI, 0.8%-2.9%; P = .007) or an inconspicuous lens (mean [SD], 8.6% [1.5%]). CONCLUSIONS AND RELEVANCE Although every person is unique, there are commonalities in how emerging adults perceive and depict their experiences living with type 1 diabetes. Among the emerging adults interviewed in the present study, the 3i conceptual framework of ingrained, intrusive, and inconspicuous lenses encapsulated these commonalities. Recognition of the different psychosocial contexts surrounding type 1 diabetes during emerging adulthood may help health care professionals individualize their care accordingly.
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Affiliation(s)
- Benjamin Markowitz
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Cheryl Pritlove
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada
- University of Toronto, Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
| | - James V. Lavery
- Hubert Department of Global Health, Rollins School of Public Health and Center for Ethics, Emory University, Atlanta, Georgia
| | - Janet A. Parsons
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Andrew Advani
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
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Hensel JM, Shaw J, Ivers NM, Desveaux L, Vigod SN, Cohen A, Onabajo N, Agarwal P, Mukerji G, Yang R, Nguyen M, Bouck Z, Wong I, Jeffs L, Jamieson T, Bhatia RS. A Web-Based Mental Health Platform for Individuals Seeking Specialized Mental Health Care Services: Multicenter Pragmatic Randomized Controlled Trial. J Med Internet Res 2019; 21:e10838. [PMID: 31165710 PMCID: PMC6684216 DOI: 10.2196/10838] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Web-based self-directed mental health applications are rapidly emerging to address health service gaps and unmet needs for information and support. OBJECTIVE The aim of this study was to determine if a multicomponent, moderated Web-based mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care. METHODS A multicenter, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, aged 16 years or older, with access to the internet and an email address, and having the ability to navigate a Web-based mental health application were eligible. A total of 812 participants were randomized 2:1 to receive immediate (immediate treatment group, ITG) or delayed (delayed treatment group, DTG) access for 3 months to the Big White Wall (BWW), a multicomponent Web-based mental health intervention based in the United Kingdom and New Zealand. The primary outcome was the total score on the Recovery Assessment Scale, revised (RAS-r) which measures mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EuroQOL 5-dimension quality of life questionnaire (EQ-5D-5L), and the Community Integration Questionnaire. An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers. RESULTS Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (-1.83 points, 95% CI -2.85 to -0.82) and GAD-7 score (-1.55 points, 95% CI -2.42 to -0.70). Follow-up was achieved for 55% (446/812) at 3 months, 48% (260/542) of ITG participants and 69% (186/270) of DTG participants. Only 58% (312/542) of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group. CONCLUSIONS The Web-based application may be beneficial; however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar Web-based interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT02896894; https://clinicaltrials.gov/ct2/show/NCT02896894 (Archived by WebCite at http://www.webcitation.org/78LIpnuRO).
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Affiliation(s)
- Jennifer M Hensel
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - James Shaw
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada
| | - Noah M Ivers
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Simone N Vigod
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ashley Cohen
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Nike Onabajo
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rebecca Yang
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Megan Nguyen
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Zachary Bouck
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Ivy Wong
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.,Women's College Research Institute, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Purno NH, Thorpe K, Mukerji G, Ray J, Lowe J, Feig DS, Lipscombe LL. Effect of postpartum glucose tolerance results on subsequent weight retention in women with recent gestational diabetes: A retrospective cohort study. Diabetes Res Clin Pract 2019; 151:169-176. [PMID: 31004671 DOI: 10.1016/j.diabres.2019.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/27/2019] [Accepted: 04/12/2019] [Indexed: 01/11/2023]
Abstract
AIMS Glucose tolerance normalizes postpartum in most women with gestational diabetes (GDM), which may provide false reassurance and decrease weight-reducing behaviours. We evaluated whether awareness of normal postpartum glucose tolerance was associated with higher weight retention than being unaware of glucose tolerance. METHODS This cohort study of women with GDM collected survey data during pregnancy and in the first and second postpartum year. We compared women who reported normal glucose tolerance ('aware, normal') in the first year to those reporting no testing or unsure of results ('unaware'). The primary outcome was self-reported weight in the second year compared between groups using multivariable linear regression. RESULTS Among 319 women, 110 (34.5%) were 'aware, normal'; 183 (57.4%) were 'unaware'; and 26 (8.2%) were 'aware, abnormal'. After adjusting for baseline weight and covariates, women with normal results had a mean 3.66 kg higher weight (CI 1.08-6.24 kg, p = 0.0056) by the second year than those unaware of results. CONCLUSIONS Women with GDM with normal postpartum glucose tolerance had significantly higher weight by the second year than those unaware of their results. Normal glucose tolerance after pregnancy may be misinterpreted as resolution of diabetes risk and decrease risk-reducing behaviours.
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Affiliation(s)
- Nabila H Purno
- Women's College Research Institute, Women's College Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation/Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Kevin Thorpe
- Institute of Health Policy, Management and Evaluation/Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Geetha Mukerji
- Women's College Research Institute, Women's College Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation/Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Sinai Health System, Toronto, Canada
| | - Joel Ray
- Institute of Health Policy, Management and Evaluation/Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Julia Lowe
- Women's College Research Institute, Women's College Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Denice S Feig
- Institute of Health Policy, Management and Evaluation/Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada; Sinai Health System, Toronto, Canada
| | - Lorraine L Lipscombe
- Women's College Research Institute, Women's College Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation/Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada.
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Jeffs L, Jamieson T, Saragosa M, Mukerji G, Jain AK, Man R, Desveaux L, Shaw J, Agarwal P, Hensel JM, Maione M, Onabajo N, Nguyen M, Bhatia R. Uptake and Scalability of a Peritoneal Dialysis Virtual Care Solution: Qualitative Study. JMIR Hum Factors 2019; 6:e9720. [PMID: 30990460 PMCID: PMC6488957 DOI: 10.2196/humanfactors.9720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 11/29/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact of these solutions. There has been less attention focused on understanding the factors influencing the uptake, usability, and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. Objective In this context, a study was undertaken to (1) assess and understand the factors influencing the uptake of a virtual care solution and (2) provide recommendations for the scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences. Methods This study used a qualitative design with semistructured interviews and a thematic analysis approach. A total of 25 stakeholders—6 patients and 3 caregivers, 6 health care providers, 2 vendors, and 8 health system decision makers—participated in this study. Results The following three primary mechanisms emerged to influence the usability of the virtual care solution: (1) receiving hands-on training and ongoing communication from a supportive team, (2) adapting to meet user needs and embedding them into workflow, and (3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: (1) co-design locally, embed into the daily workflow, and deploy over time and (2) share the benefits and build the case. Conclusions Study findings can be used by key stakeholders in their future efforts to enhance the implementation, uptake, and scalability of virtual care solutions for CKD and managing PD at home.
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Affiliation(s)
- Lianne Jeffs
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Trevor Jamieson
- St. Michael's Hospital, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Marianne Saragosa
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Geetha Mukerji
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Arsh K Jain
- London Health Sciences Centre, London, ON, Canada
| | - Rachel Man
- London Health Sciences Centre, London, ON, Canada
| | - Laura Desveaux
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - James Shaw
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Payal Agarwal
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer M Hensel
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | | | - Nike Onabajo
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Megan Nguyen
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - R Bhatia
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
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40
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Lockhart E, Hawker GA, Ivers NM, O'Brien T, Mukerji G, Pariser P, Stanaitis I, Pus L, Baker GR. Engaging primary care physicians in care coordination for patients with complex medical conditions. Can Fam Physician 2019; 65:e155-e162. [PMID: 30979773 PMCID: PMC6467654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore the dynamics of primary care physicians' (PCPs') engagement with the Seamless Care Optimizing the Patient Experience (SCOPE) project. DESIGN Qualitative study using semistructured interviews. SETTING Solo and small group primary care practices in urban Toronto, Ont. PARTICIPANTS A total of 22 of the 29 SCOPE PCPs (75.8%) were interviewed 14 to 19 months after the initiation of SCOPE. METHODS Qualitative semistructured interviews were conducted to examine influencing factors associated with PCPs' engagement in SCOPE. Transcripts were analyzed using a grounded theory-informed approach and key themes were identified. MAIN FINDINGS The SCOPE project provided practical mechanisms through which PCPs could access information and connect with resources. Contextual and historical factors including strained relationships between hospital specialists and community PCPs and PCPs' feelings of responsibility, isolation, disconnection, and burnout influenced readiness to engage. Provision of clinically useful supports in a trusting, collaborative manner encouraged PCPs' engagement in newer, more collaborative ways of working. CONCLUSION The SCOPE project provided an opportunity for PCPs to build meaningful relationships, reconnect to the broader health care system, and redefine their roles. For many PCPs, reestablishing connections reaffirmed their role in the system and enabled a more collaborative care model. Strategies for connecting community-based PCPs to the broader system need to consider contextual factors and the effects of new linkages and coordination on the identities and relationships of PCPs.
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Affiliation(s)
- Elizabeth Lockhart
- Graduate student at the Institute of Health Policy, Management and Evaluation at the University of Toronto in Ontario.
| | - Gillian A Hawker
- Professor in the Institute of Health Policy, Management and Evaluation and the Department of Medicine at the University of Toronto, and Senior Scientist at Women's College Research Institute
| | - Noah M Ivers
- Assistant Professor in the Institute of Health Policy, Management and Evaluation and the Department of Family and Community Medicine at the University of Toronto, and a family physician at Women's College Hospital
| | - Tara O'Brien
- Medical Director of the Acute Ambulatory Care Unit at Women's College Hospital and the Division of General Internal Medicine at the University of Toronto
| | - Geetha Mukerji
- Assistant Professor in the Institute of Health Policy, Management and Evaluation and the Division of Endocrinology and Metabolism at the University of Toronto, and a staff endocrinologist at Women's College Hospital
| | - Pauline Pariser
- Associate Professor in the Department of Family and Community Medicine at the University of Toronto and Associate Medical Director at University Health Network
| | - Ian Stanaitis
- Research Project Coordinator at Women's College Hospital
| | - Laura Pus
- Director, Women's Virtual at Women's College Hospital
| | - G Ross Baker
- Professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto
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Hensel JM, Shaw J, Ivers NM, Desveaux L, Vigod SN, Bouck Z, Onabajo N, Agarwal P, Mukerji G, Yang R, Nguyen M, Jeffs L, Jamieson T, Bhatia RS. Extending access to a web-based mental health intervention: who wants more, what happens to use over time, and is it helpful? Results of a concealed, randomized controlled extension study. BMC Psychiatry 2019; 19:39. [PMID: 30678676 PMCID: PMC6345062 DOI: 10.1186/s12888-019-2030-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/16/2019] [Indexed: 01/08/2023] Open
Abstract
Background Web-based mental health applications may be beneficial, but adoption is often low leaving optimal implementation and payment models unclear. This study examined which users were interested in extended access to a web-based application beyond an initial 3-month trial period and evaluated if an additional 3 months of access was beneficial. Methods This study was a concealed extension of a multi-center, pragmatic randomized controlled trial that assessed the benefit of 3 months of access to the Big White Wall (BWW), an anonymous web-based moderated, multi-component mental health application offering self-directed activities and peer support. Trial participants were 16 years of age or older, recruited from hospital-affiliated mental health programs. Participants who received access to the intervention in the main trial and completed 3-month outcome assessments were offered participation. We compared those who were and were not interested in an extension of the intervention, and re-randomized consenting participants 1:1 to receive extended access or not over the subsequent 3 months. Use of the intervention was monitored in the extension group and outcomes were measured at 3 months after re-randomization in both groups. The primary outcome was mental health recovery as assessed by total score on the Recovery Assessment Scale (RAS-r), as in the main trial. Linear mixed models were used to examine the time by group interaction to assess for differences in responses over the 3-month extension study. Results Of 233 main trial participants who responded, 119 (51.1%) indicated an interest in receiving extended BWW access. Those who were interested had significantly higher baseline anxiety symptoms compared to those who were not interested. Of the 119, 112 were re-randomized (55 to extended access, 57 to discontinuation). Only 21 of the 55 extended access participants (38.2%) used the intervention during the extension period. Change in RAS-r scores over time was not significantly different between groups (time by group, F(1,77) = 1.02; P = .31). Conclusions Only half of eligible participants were interested in extended access to the intervention with decreasing use over time, and no evidence of added benefit. These findings have implications for implementation and payment models for this type of web-based mental health intervention. Trial registration Clinicaltrials.govNCT02896894. Registered retrospectively on September 12, 2016.
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Affiliation(s)
- Jennifer M Hensel
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada. .,Department of Psychiatry, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada. .,Women's College Research Institute, Toronto, Ontario, Canada. .,Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - James Shaw
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada
| | - Noah M Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simone N Vigod
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Department of Psychiatry, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zachary Bouck
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Nike Onabajo
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Payal Agarwal
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Yang
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Megan Nguyen
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Trevor Jamieson
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Agarwal P, Mukerji G, Desveaux L, Ivers NM, Bhattacharyya O, Hensel JM, Shaw J, Bouck Z, Jamieson T, Onabajo N, Cooper M, Marani H, Jeffs L, Bhatia RS. Mobile App for Improved Self-Management of Type 2 Diabetes: Multicenter Pragmatic Randomized Controlled Trial. JMIR Mhealth Uhealth 2019; 7:e10321. [PMID: 30632972 PMCID: PMC6329896 DOI: 10.2196/10321] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 09/08/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023] Open
Abstract
Background As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A1c (HbA1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear. Objective The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA1c levels compared with controls. Methods The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app. Results The results of an analysis of covariance controlling for baseline HbA1c levels did not show evidence of intervention impact on HbA1c levels at 3 months (mean difference [ITG−WLC] −0.42, 95% CI −1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants’ 3-month HbA1c levels (95% CI −0.03 to −0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51). Conclusions The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed. Trial Registration Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)
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Affiliation(s)
- Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Geetha Mukerji
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Noah M Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Onil Bhattacharyya
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Jennifer M Hensel
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - James Shaw
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Zachary Bouck
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Trevor Jamieson
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Nike Onabajo
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Madeline Cooper
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Husayn Marani
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lianne Jeffs
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - R Sacha Bhatia
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
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O’Brien T, Ivers N, Bhattacharyya O, Calzavara A, Pus L, Mukerji G, Friedman SM, Abrams H, Stanaitis I, Hawker GA, Pariser P. A multifaceted primary care practice-based intervention to reduce ED visits and hospitalization for complex medical patients: A mixed methods study. PLoS One 2019; 14:e0209241. [PMID: 30601835 PMCID: PMC6314574 DOI: 10.1371/journal.pone.0209241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/03/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices. METHODS AND FINDINGS An interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP's experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care. CONCLUSIONS This multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.
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Affiliation(s)
- Tara O’Brien
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, Toronto, Ontario, Canada
| | - Noah Ivers
- Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Onil Bhattacharyya
- Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Calzavara
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Laura Pus
- Women’s College Hospital, Toronto, Ontario, Canada
| | - Geetha Mukerji
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, Toronto, Ontario, Canada
| | - Steven M. Friedman
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Howard Abrams
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | | | - Gillian A. Hawker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Pauline Pariser
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
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Jeffs L, Jamieson T, Saragosa M, Mukerji G, Jain AK, Man R, Desveaux L, Shaw J, Agarwal P, Hensel JM, Maione M, Nguyen M, Onabajo N, Bhatia RS. Improving safety and efficiency in care: multi-stakeholders' perceptions associated with a peritoneal dialysis virtual care solution. Patient Prefer Adherence 2018; 12:2623-2629. [PMID: 30587934 PMCID: PMC6294168 DOI: 10.2147/ppa.s181604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home. METHODS A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach. RESULTS The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies. DISCUSSION Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers. CONCLUSION The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management.
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Affiliation(s)
- Lianne Jeffs
- Sinai Health System, Toronto, ON M5G 1X5, Canada,
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON M5G 1WB, Canada,
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
| | - Trevor Jamieson
- Department of Medicine, University of Toronto, Division of General Internal Medicine, St Michael's Hospital, Women's College Hospital, Toronto, ON M5G 1WB, Canada
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Marianne Saragosa
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Geetha Mukerji
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Arsh K Jain
- London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Rachel Man
- London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - James Shaw
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Payal Agarwal
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Department of Family and Community Medicine, Women's College Hospital, University of Toronto, Toronto, ON M5S 1B2, Canada
| | - Jennifer M Hensel
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- Department of Psychiatry, University of Toronto, Women's College Hospital, Women's College Research Institute, Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Maria Maione
- St Michael's Hospital, Toronto, ON M5G 1WB, Canada
| | - Megan Nguyen
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Nike Onabajo
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - R Sacha Bhatia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada,
- Institute for Health System Solutions and Virtual Care (WIHV), Women's College Hospital, Toronto, ON M5S 1B2, Canada
- University Health Network, Toronto, ON M5S 1B2, Canada
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45
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Puri N, Assal A, Mukerji G. Improving Diabetic Ketoacidosis Management at a Tertiary Care Hospital. Can J Diabetes 2018. [DOI: 10.1016/j.jcjd.2018.08.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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46
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Alhashemi N, Singh N, Mukerji G, Saeed O, Pisani S. Gaps in Influenza and Pneumococcal Vaccination Counselling and Status Documentation Among Patients with Diabetes. Can J Diabetes 2018. [DOI: 10.1016/j.jcjd.2018.08.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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47
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Mukerji G, Halperin I, Hunter K, Segal P, Wolfs M, Bevan L, Jeffs L, Goguen J. Developing a set of indicators to monitor quality in ambulatory diabetes care using a modified Delphi panel process. Int J Qual Health Care 2018; 30:65-74. [PMID: 29340632 DOI: 10.1093/intqhc/mzx167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 11/24/2017] [Indexed: 12/31/2022] Open
Abstract
Objective There is a large evidence to practice gap in diabetes care with limited performance assessments that capture the full spectrum of care delivery. Our study aimed to develop a set of ambulatory diabetes quality indicators across six domains (effectiveness, safety, patient-centered, timely, equitable and efficient) to provide a broad view of quality. Design A modified Delphi panel process was conducted. Phase I involved compiling a list of indicators through literature review and generation of patient and healthcare provider-derived indicators through interviews and surveys, respectively. Phase II involved panelists rating indicators using the Agency for Healthcare Research and Quality measure attributes on 9-point Likert scale, attending a face-to-face meeting followed by re-rating, and final ranking. Setting This study was conducted across five adult academic medical centers affiliated with the University of Toronto. Participants A multi-disciplinary Delphi panel (n = 16) including patients was assembled. Main Outcome measure For indicator advancement for ranking, ≥75% of panelists' responses in the top tertile (between 7 and 9) with a median composite score of ≥7 was required. Results There were 202 indicators included in the Delphi panel process including 171 from a comprehensive literature review, 14 from patient interviews, and 17 from healthcare provider surveys. Following the first round, 40 indicators proceeded directly to ranking, while 162 indicators were re-rated and distilled down to 12 for ranking. In the final ranking round, the 52 indicators were reduced to 35 including 13 effective, 10 safe, 6 patient-centered, 1 equitable, 3 efficient and 2 timely indicators. Conclusion Thirty-five selected indicators developed with broad stakeholder engagement can be used to monitor quality in diabetes care.
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Affiliation(s)
- Geetha Mukerji
- Women's College Hospital, 76 Grenville St, Toronto, Ontario M5S 1B2, Canada.,Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada
| | - Ilana Halperin
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
| | - Katie Hunter
- Centre for Effective Practice, 400 University Ave Suite 2100, Toronto, Ontario M5G 1S5, Canada
| | - Phillip Segal
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,University Health Network, 101 College St, Toronto, Ontario M5G 1L7, Canada
| | - Maria Wolfs
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| | - Lindsay Bevan
- Centre for Effective Practice, 400 University Ave Suite 2100, Toronto, Ontario M5G 1S5, Canada
| | - Lianne Jeffs
- St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
| | - Jeannette Goguen
- Department of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada.,St. Michael's Hospital, 30 Bond St, Toronto, Ontario M5B 1W8, Canada
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Clement M, Filteau P, Harvey B, Jin S, Laubscher T, Mukerji G, Sherifali D. Organization of Diabetes Care. Can J Diabetes 2018; 42 Suppl 1:S27-S35. [DOI: 10.1016/j.jcjd.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 02/06/2023]
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49
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Halperin IJ, Mukerji G, Maione M, Segal P, Wolfs M, Goguen J, Jeffs L. Adult Patient Perspectives on Care for Type 1 and Type 2 Diabetes Across the Institute of Medicine's 6 Domains of Quality. Can J Diabetes 2018; 42:36-43. [DOI: 10.1016/j.jcjd.2017.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/16/2017] [Accepted: 03/16/2017] [Indexed: 11/30/2022]
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50
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Mukerji G, Weinerman A, Schwartz S, Atkinson A, Stroud L, Wong BM. Communicating wisely: teaching residents to communicate effectively with patients and caregivers about unnecessary tests. BMC Med Educ 2017; 17:248. [PMID: 29228940 PMCID: PMC5725805 DOI: 10.1186/s12909-017-1086-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/27/2017] [Indexed: 05/20/2023]
Abstract
BACKGROUND With rising healthcare costs and a focus on quality, there is a growing need to promote resource stewardship in medical education. Physicians need to be able to communicate effectively with patients/caregivers seeking tests and treatments that are unnecessary. This study aimed to evaluate the impact of an interactive workshop on residents' knowledge of resource stewardship and communication skills when counseling patients/caregivers about requests for unnecessary testing. METHODS Participants were 83 Internal Medicine and Pediatrics residents at the University of Toronto in 2014-15. The evaluation compared resource stewardship knowledge and communication skills of 57 (69%) residents that attended the resource stewardship workshop to 26 residents (31%) who did not. Knowledge and communication skills assessment consisted of a written test and a structured assessment using standardized patient raters, respectively. A linear regression was applied to determine predictors of overall communication skills performance. RESULTS Workshop attendance resulted in better performance on the knowledge test (4.3 ± 1.9 vs. 3.1 ± 1.7 out of 8, p = 0.01), but not better performance on the communication skills assessment (4.1 ± 0.8 vs. 4.0 ± 0.9 out of 5, p = 0.56). Higher training level (p = 0.01) and knowledge test scores (p = 0.046) were independent predictors of better overall communication skills, after adjusting for gender, training level, workshop attendance, knowledge and self-reported prior feedback on communication skills. CONCLUSIONS An interactive workshop can improve knowledge of resource stewardship, but improving communication skills with patients/caregivers about unnecessary testing may require additional training or reinforcement in the clinical learning environment. These teaching and assessment approaches can support the integration of education on resource stewardship into medical education.
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Affiliation(s)
- Geetha Mukerji
- Department of Medicine, University of Toronto and Women’s College Hospital Institute of Health Systems Solutions and Virtual Care, 76 Grenville Street, Room 3414, Toronto, ON M5S 1B2 Canada
| | - Adina Weinerman
- Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Sarah Schwartz
- Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON Canada
| | - Adelle Atkinson
- Department of Pediatrics, University of Toronto and Hospital for Sick Children, Toronto, ON Canada
| | - Lynfa Stroud
- Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Brian M. Wong
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON Canada
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