Energizing scholarly activity in a regional medical campus.

Medical education is increasingly delivered at distributed sites away from Academic Health Sciences Centres. The Council of Ontario Faculties of Medicine recommends schools develop resources and metrics to foster regional campus scholarly activity. Opportunities for distributed program trainees must support learning core skills in research and critical appraisal to comply with medical school accreditation standards and to develop their interests and skills in scholarly work for their future medical careers. We describe a scholarly activity program that is a template for distributed campuses or regional teaching sites seeking to increase learner and faculty engagement and research productivity.

La formation médicale décentralisée se déroule de plus en plus souvent loin des centres universitaires de sciences de la santé. Le Conseil des facultés de médecine de l'Ontario recommande aux facultés de se doter de ressources et de indicateurs pour encourager les activités d'érudition sur les campus régionaux. Les possibilités offertes aux stagiaires des programmes décentralisés doivent favoriser l'apprentissage des habiletés de base en recherche et en lecture critique pour se conformer aux normes d'agrément des facultés de médecine et développer des intérêts et des habiletés en érudition qui leur seront utiles dans leur carrière médicale. Nous décrivons un programme d'activités d'érudition qui peut servir de modèle pour les milieux de formation décentralisés ou les sites d'enseignement régionaux souhaitant stimuler la productivité scientifique et l'implication des apprenants et du corps professoral dans la recherche.

Scholarly activity as a selection criterion in the Canadian Residency Matching Service (CaRMS): A review of published criteria by internal medicine, family medicine, and pediatrics programs.

BACKGROUND: Undergraduate medical students seek as much information as possible as to how residency programs select candidates. The Canadian Residency Matching Service (CaRMS) website is one of their primary sources of information. Students may be more competitive in the match if they know whether scholarly activity is used in the selection process by their preferred programs, as described on the CaRMS website. METHODS: For all 17 Canadian faculties of medicine, 2019 R1 entry internal medicine, family medicine and pediatrics program descriptions were reviewed on the CaRMS website looking for keywords related to scholarly activity. RESULTS: Forty-one percent of family medicine, 65% of internal medicine and 71% of pediatric programs explicitly stated having interest in applicants with scholarly experience. In Western Canada, 80% of internal medicine and 60% of pediatrics programs included scholarly activity in their CaRMS description of criteria considered in ranking applications. Similarly, in Ontario, 66% of internal medicine and 83% of pediatrics programs mentioned scholarly activity as a valuable quality. In Quebec 100% of family medicine and 50% of pediatrics programs include scholarly activity in their descriptions. Pediatrics and family medicine programs (100%) in Atlantic Canada mentioned scholarly activities but neither of the two Atlantic Canada internal medicine programs mentioned scholarly activities. CONCLUSION: Undergraduate medical students can use this project to prioritize extracurricular activities and scholarly work to be competitive for application to family medicine, internal medicine and pediatrics residency programs.

CONTEXTE: Les étudiants de premier cycle en médecine cherchent autant de renseignements que possible sur la manière dont les programmes de résidence sélectionnent les candidats. Le site Web du Service canadien de jumelage des résidents (CaRMS) représente l'une de leur principale source de renseignements. Les étudiants peuvent être plus compétitifs dans le jumelage s'ils savent comment les activités d'érudition sont utilisées dans le processus de sélection par leurs programmes préférés, comme il est décrit sur le site Web de CaRMS. MÉTHODES: Pour l'ensemble des 17 facultés de médecine canadiennes, les descriptions des programmes d'entrée R1 de 2019 en médecine interne, en médecine familiale et en pédiatrie ont été examinées sur le site Web du CaRMS pour la recherche de mots clés liés aux activités d'érudition. RÉSULTATS: 41 % des programmes de médecine familiale, 65 % de ceux en médecine interne et 71 % de ceux en pédiatrie énonçaient explicitement avoir un intérêt pour les candidats avec une expérience en érudition. Dans l'Ouest canadien, 80 % des programmes en médecine interne et 60 % de ceux en pédiatrie comportaient une activité d'érudition dans leur description CaRMS des critères dont ils tenaient compte dans le classement des demandes. De même, en Ontario, 66 % des programmes en médecine interne et 83 % de ceux en pédiatrie mentionnaient que les activités d'érudition représentaient une qualité importante. Au Québec, 100 % des programmes en médecine familiale et 50 % de ceux en pédiatrie présentent une activité d'érudition dans leur description. Les programmes de pédiatrie et de médecine familiale (100 %) dans le Canada atlantique mentionnent les activités scientifiques, mais aucun des deux programmes de médecine interne du Canada atlantique ne mentionnait des activités scientifiques. CONCLUSION: Les étudiants de premier cycle en médecine peuvent utiliser le présent projet pour prioriser leurs activités extracurriculaires et le travail d'érudition pour être compétitifs lors de leurs applications dans des programmes de médecine familiale, de médecine interne et de pédiatrie.

Long term outcomes of cluster randomized trial to improve cardiovascular health at population level: The Cardiovascular Health Awareness Program (CHAP).

STUDY QUESTION: The Cardiovascular Health Awareness Program (CHAP) cardiovascular risk reduction program consisted of sessions run by local volunteers in local pharmacies during which cardiovascular risk was assessed, healthy lifestyle and preventive care was promoted, and the participants were oriented to local resources to support changes in modifiable risk factors. A clustered randomized trial implemented in September 2006 across 39 communities targeting community-dwelling individuals 65 years and older showed a significant reduction in hospitalization one year after its implementation (rate ratio of 91 [95% confidence interval (CI): 86%-97%]). This study explores the impact of CHAP in the first five years. METHODS: Using health administrative data housed at the Institute for Clinical Evaluative Sciences, we established a closed cohort consisting of all individuals eligible in these communities at the study onset whom we followed over time. We assessed hospitalizations and survival using a negative binomial model for count data and Cox regression to assess time to first event, accounting for the clustered design. The primary outcome was the rate of cardiovascular-related hospitalizations defined as congestive heart failure, stroke or acute myocardial infarction. RESULTS: Most estimates pointed to an advantage for the intervention arm, but only all-cause mortality reached statistical significance (hazard ratio [95% CI] = 0.955 [0.914-0.999]). The hospitalization cardiovascular-related hospitalization rate ratio was (0.958, 95% CI: 0.898-1.022) in favour of the intervention communities, translating to an estimated 408 averted hospitalizations over the five-year period. There was no evidence of the effect of time from start of intervention. CONCLUSIONS: The consistent direction of the outcomes in favour of the intervention arms suggests that CHAP likely had a meaningful impact on reducing cardiovascular-related morbidity and mortality. Given the low cost of the intervention, further development of CHAP should be pursued.

Patient and Public Involvement in Identifying Dementia Research Priorities.

OBJECTIVES: To engage persons with dementia, friends, family, caregivers, and health and social care providers to identify and prioritize their questions for research related to living with dementia and prevention, diagnosis, and treatment of dementia. DESIGN: The Canadian Dementia Priority Setting Partnership (PSP) followed James Lind Alliance PSP methods. Results were compared with the World Health Organization research prioritization exercise and the United Kingdom Dementia PSP. SETTING: Canada. PARTICIPANTS: In the first survey, 1,217 individuals and groups from across Canada submitted their questions about dementia. 249 participated in the interim prioritization. For the final prioritization workshop, the 28 participants included persons with dementia, friends, family, caregivers, health and social care providers, Alzheimer Society representatives, and members of an organization representing long-term care home residents. RESULTS: The Canadian Dementia PSP top 10 priorities relate to health, quality of life, societal issues, and dementia care. Five priorities overlap with one or both of the other two prioritization initiatives. CONCLUSION: These results provide researchers and research funding agencies with topics that individuals with personal or professional experience of dementia prioritize, but they are not intended to preclude research into other aspects of dementia.

Is Dementia Screening of Apparently Healthy Individuals Justified?

Despite efforts to raise awareness and develop guidelines for care of individuals with dementia, reports of poor detection and inadequate management persist. This has led to a call for more identification of people with dementia, that is, screening individuals who may or may not complain of symptoms of dementia in both acute settings and primary care. The following should be considered before recommending screening for dementia among individuals in the general population. Dementia Tests. Low prevalence reduces positive predictive value of tests and screening tests will miss people who have dementia and identify people who do not have dementia in substantial numbers. Clinical Issues. The clinical course of dementia has not yet been shown to be amenable to intervention. Misdiagnosis and overdiagnosis can have significant long-term effects including stigmatization, loss of employment, and autonomy. Economic Issues. Health systems do not have the capacity to respond to increased demand resulting from screening. In conclusion, at present attention to life-course risk reduction and support in the community for frail and cognitively impaired older adults is a better use of limited healthcare resources than introduction of unevaluated dementia screening programs.

Guide to enable health charities to increase recruitment to clinical trials on dementia.

INTRODUCTION: The Alzheimer Society embarked on a project to improve ways that the 60 provincial and local Societies in Canada can work with local researchers to support recruitment of volunteers to clinical trials and studies. A Guide to assist these offices was produced to design ethical recruitment of research volunteers within their client populations. METHODS: Consultations with individuals from provincial and local Societies, as well as researchers and leaders from health-related organizations, were conducted to identify in what ways these organizations are involved in study volunteer recruitment, what is and is not working, and what would be helpful to support future efforts. The Guide prototype used scenarios to illustrate study volunteer recruitment practices as they have been or could be applied in Societies. An implementable version of the Guide was produced with input from multiple internal and external reviewers including subject-matter experts and target users from Societies. RESULTS: Society staff reported that benefits of using the Guide were that it served as a catalyst for conversation and reflection and identified the need for a policy. Also, it enabled Society readiness to respond to requests by persons with dementia and their caregivers wishing to participate in research. A majority (94%) of participating Society staff across Canada agreed that they would increase their capacity to support research recruitment. DISCUSSION: Charitable organizations that raise funds for research have a role in promoting the recruitment of persons with dementia and their caregivers into clinical trials and studies. The Guide was produced to facilitate organizational change to both create a positive culture regarding research as well as practical solutions that can help organizations achieve this goal.

Alzheimer's and other dementias in Canada, 2011 to 2031: a microsimulation Population Health Modeling (POHEM) study of projected prevalence, health burden, health services, and caregiving use.

BACKGROUND: Worldwide, there is concern that increases in the prevalence of dementia will result in large demands for caregivers and supportive services that will be challenging to address. Previous dementia projections have either been simple extrapolations of prevalence or macrosimulations based on dementia incidence. METHODS: A population-based microsimulation model of Alzheimer's and related dementias (POHEM:Neurological) was created using Canadian demographic data, estimates of dementia incidence, health status (health-related quality of life and mortality risk), health care costs and informal caregiving use. Dementia prevalence and 12 other measures were projected to 2031. RESULTS: Between 2011 and 2031, there was a projected two-fold increase in the number of people living with dementia in Canada (1.6-fold increase in prevalence rate). By 2031, the projected informal (unpaid) caregiving for dementia in Canada was two billion hours per year, or 100 h per year per Canadian of working age. CONCLUSIONS: The projected increase in dementia prevalence was largely related to the expected increase in older Canadians, with projections sensitive to changes in the age of dementia onset.

Reducing the confusion and controversies around pragmatic trials: using the Cardiovascular Health Awareness Program (CHAP) trial as an illustrative example.

UNLABELLED: Knowledge translation (KT) involves implementation of evidence-based strategies and guidelines into practice to improve the process of care and health outcomes for patients. Findings from pragmatic trials may be used in KT to provide patients, healthcare providers and policymakers with information to optimize healthcare decisions based on how a given strategy or intervention performs under the real world conditions. However, pragmatic trials have been criticized for having the following problems: i) high rates of loss to follow-up; ii) nonadherence to study intervention; iii) unblinded treatment and patient self-assessment, which can potentially create bias; iv) being less perfect experiments than efficacy trials; v) sacrificing internal validity to achieve generalizability; and vi) often requiring large sample sizes to detect small treatment effects in heterogeneous populations. In this paper, we discuss whether these criticisms hold merit, or if they are simply driven by confusion about the purpose of pragmatic trials. We use the Cardiovascular Health Awareness Program (CHAP) trial--a community randomized pragmatic trial designed to assess whether offering a highly organized, community-based CHAP intervention compared to usual care can reduce cardiovascular disease-related outcomes--to address these specific criticisms and illustrate how to reduce this confusion. TRIAL REGISTRATION: Current controlled trials ISRCTN50550004 (9 May 2007).

A new approach to improving healthcare personnel influenza immunization programs: a randomized controlled trial.

BACKGROUND: Healthcare personnel influenza immunization rates remain sub-optimal. Following multiple studies and expert consultations, the "Successful Influenza Immunization Programs for Healthcare Personnel: A Guide for Program Planners" was produced. This trial assessed the impact of the Guide with facilitation in improving healthcare personnel influenza immunization rates in Canadian healthcare organizations. METHODS: A sample of 26 healthcare organizations across six Canadian provinces (ON, MB, NS, BC, SK, NL) was randomized to Intervention (n=13) or Control groups (n=13). Baseline influenza immunization rates were obtained for 2008-2009; the study groups were followed over two subsequent influenza seasons. The Intervention group received the Guide, facilitation support through workshops for managers and ongoing support. The Control groups conducted programs as usual. The Groups were compared using their reported influenza healthcare personnel influenza immunization rates and scores from a program assessment questionnaire. FINDINGS: Twenty-six organizations agreed to participate. 35% (9/26) of sites were acute care hospitals, 19% (5/26) continuing care, long-term care organizations or nursing homes, and 46% (12/26) were mixed acute care hospitals and long-term care or regional health authorities. The median rate of influenza immunization among healthcare personnel for the Intervention group was 43%, 44%, and 51% at three points in time respectively, and in the CONTROL GROUP: 62%, 57%, and 55% respectively. No significant differences were observed between the groups at the three points in time. However, there was a 7% increase in the median rates between the Baseline Year and Year Two in the Intervention group, and a 6% decrease in the CONTROL GROUP over the same time period, which was statistically significant (0.071 versus -0.058, p < 0.001). INTERPRETATION: This pragmatic randomized trial of the Guide with facilitation of its implementation improved healthcare personnel immunization rates, but these rates continued to be sub-optimal and below rates achievable in programs requiring personnel to be immunized. TRIAL REGISTRATION: ClinicalTrials.gov NCT01207518.

The impact of a cardiovascular health awareness program (CHAP) on reducing blood pressure: a prospective cohort study.

BACKGROUND: Hypertension is an important and modifiable cardiovascular risk factor that remains under-detected and under-treated, especially in the older individuals. Community-led interventions that integrate primary health care and local resources are promising approaches to improve awareness and management of hypertension and other cardiovascular risk factors. We aimed to evaluate the effect of a community-based Cardiovascular Health Awareness Program (CHAP) on participants' blood pressure. METHODS: This study followed a cohort of community residents that participated in CHAP across 22 mid-sized Ontario communities over an 18-month period. The participants' baseline risk factors, including blood pressure, and subsequent measures of blood pressure were recorded. We employed a bivariate linear mixed-effect model to estimate the change of systolic and diastolic blood pressure over time among the participants who attended more than two CHAP sessions. RESULTS: Of 13,596 participants, 2498 attended more than two CHAP sessions. For those repeated participants (attending more than two sessions) initially identified with high blood pressure, the average reduction of systolic blood pressure was from 142 to 123 mmHg over an 18-month period, a monthly rate ratio of 0.992 (95% CI: 0.991,0.994; p < 0.01). Similarly, the average reduction of diastolic blood pressure was from 78 to 69 mmHg, a monthly rate ratio of 0.993 (95% CI: 0.991,0.994; p < 0.01). The average blood pressure of the participants with normal baseline blood pressure remained controlled and unchanged. We also found that older adult participants who lived alone, were diagnosed with hypertension, reported healthier eating habits, and presented with a higher baseline systolic blood pressure had significantly greater odds of attending more than one session. CONCLUSIONS: CHAP was associated with a reduction in systolic and diastolic blood pressure for those participants who attended more than one session. The magnitude of blood pressure reductions was significant clinically and statistically.

A method for identifying research priorities for health systems research on health and aging.

A rapid and feasible priority-setting method conducted within a limited budget was used to identify research topics that would have an influence on health services for older adults. Health and aging researchers, policy makers, and caregivers were recruited to complete Delphi surveys that generated and ranked topics and identified other potential researchers. An interdisciplinary team of researchers was selected to produce and submit a proposal to a peer-review-granting agency. This method can be adapted by organizations to determine the focus of their research agenda and to engage individuals for collaboration on future research projects.

Community mobilization, participation, and blood pressure status in a Cardiovascular Health Awareness Program in Ontario.

PURPOSE: To determine the feasibility of a community-wide approach integrated with primary care (Cardiovascular Health Awareness Program [CHAP]) to promote monitoring of blood pressure (BP) and awareness of cardiovascular disease risk. DESIGN: Demonstration project. SETTING: Two midsized Ontario communities. PARTICIPANTS: Community-dwelling seniors. INTERVENTION: CHAP sessions were offered in pharmacies and promoted to seniors using advertising and personalized letters from physicians. Trained volunteers measured BP, completed risk profiles, and provided risk-specific education materials. METHOD: We examined the distribution of risk factors among participants and predictors of multiple visits and elevated BP. RESULTS: Opinion leaders aided recruitment of family physicians (n  =  56/63) and pharmacists (n  =  18/19). Over 90 volunteers were recruited. Invitations were mailed to 4394 seniors. Over 10 weeks, there were 4165 assessments of 2350 unique participants (approximately 30% of senior residents). 37.5% of attendees had untreated (16%; 360/2247) or uncontrolled (21.5%; 482/2247) high BP. Participants who received a letter (odds ratio [OR] 2.5, 95% confidence interval [CI] 2.1-3.0), had an initial elevated BP (OR 1.2, 95% CI 1.0-1.5), or reported current antihypertensive medication (OR 1.4, 95% CI 1.1-1.6) were more likely to attend multiple sessions (p ≤ .05 for all). Older age (≥ 70 years; OR 1.5, 95% CI 1.3-1.8), BMI ≥ 30 (OR 1.7, 95% CI 1.4-2.2), current antihypertensive medication (OR 1.6, 95% CI 1.3-1.9), and diabetes (OR 2.4, 95% CI 1.9-3.2) predicted elevated BP (p < .001 for all). CONCLUSION: The program yielded learning about community mobilization and identified a substantial number of seniors with undiagnosed/uncontrolled high BP.

Economic appraisal of a community-wide cardiovascular health awareness program.

BACKGROUND: Cardiovascular disease (CVD) is a leading cause of hospitalizations, death, and health care costs. Although studies have shown that modifying CVD risk factors at the patient level improves patient prognosis, the effect of community-wide interventions at the population level has been uncertain. OBJECTIVE: To evaluate the resource use and cost consequences of a community-wide Cardiovascular Health Awareness Program (CHAP). METHODS: Thirty-nine medium-sized communities in Ontario, Canada, participated in a community cluster randomized controlled trial stratified by population size and geographic location. All community-dwelling elderly residents (>65 years) in each community were included. Family physicians, pharmacists, community nurses, local organizations, and volunteers in the intervention communities implemented the program. Rates and costs of CVD hospitalizations, all hospitalizations, emergency department visits, physician visits, and prescription medication use in the year before and after the intervention were compared for the 19 control and 20 CHAP communities by using province-wide linked administrative databases. The cost of implementing and administrating CHAP in each community was combined with total community health care cost to determine the net cost effect. RESULTS: CHAP was associated with a reduction in CVD hospitalization costs. There were no differences in utilization rates or costs for overall hospitalizations, in visits to emergency rooms, physicians, or specialists, or in the use of prescription medications. Results were robust over a range of cost assumptions. CONCLUSIONS: A community-wide CVD awareness program can be implemented and can reduce CVD-related hospitalization costs at the level of the community without a corresponding increase in overall health care costs.

Measuring influenza immunization coverage among health care workers in acute care hospitals and continuing care organizations in Canada.

BACKGROUND: Immunizing health care workers against influenza is important for preventing and reducing disease transmission in health care environments. We describe the ability of Canadian health care organizations to measure influenza immunization coverage among health care workers and identify factors associated with comprehensive influenza immunization measurement. METHODS: A Web-based survey was distributed to influenza immunization campaign planners responsible for delivering the 2010-2011 influenza vaccine to health care workers working in acute care hospitals or long-term continuing care organizations. The primary outcome was the ability to comprehensively measure influenza immunization coverage. RESULTS: Of the 1,127 health care organizations approached, 721 (64%) responded. Ninety-one percent had incomplete immunization coverage measurement; 7% could not measure coverage among any personnel. After multivariable adjustment, organizations with a written influenza immunization implementation plan (odds ratio, 2.0; 95% confidence interval, 1.1-3.5) or a policy or procedure describing how to calculate or report immunization rates (odds ratio, 2.1; 95% confidence interval, 1.2-3.9) were more likely to have comprehensive measurement of influenza immunization coverage than organizations without these practices. CONCLUSION: Most organizations demonstrated incomplete measurement of influenza immunization among health care workers. Given the use of influenza immunization coverage as a measure of quality of care, further work is needed to develop a standardized approach to improve its measurement.

Comparison of blood pressure measurements using an automated blood pressure device in community pharmacies and family physicians' offices: a randomized controlled trial.

BACKGROUND: Accurate measurement of blood pressure is the foundation of appropriate diagnosis, treatment and ongoing management of hypertension. The use of automated blood pressure devices in community settings such as pharmacies provide opportunities for additional blood pressure measurement; however, it is important to ensure that these measurements are comparable to those taken in physicians' offices using the same devices. We conducted a randomized controlled trial to assess whether blood pressure readings assessed by use of an automated device differed according to the setting, specifically in community pharmacies and family physicians' offices. METHODS: We included adults aged 65 years and older who did not live in long-term care facilities or in hospital. The trial was administered by volunteer peer health educators, family physicians and pharmacists in 2 midsized communities in Ontario from April to September 2010. The 5 participating family physicians mailed invitations to their eligible patients. Those who gave informed consent were randomly allocated to 1 of 2 assessment sequences: group A had their blood pressure measured at their physician's office, then at a pharmacy, then again at their physician's office; those in group B had their blood pressure measured at a pharmacy, then at their physician's office, then again at a pharmacy. An automated blood pressure device (BpTRU) was used in both settings. We calculated the differences in mean systolic and diastolic blood pressure, and we compared the readings at both settings and by sequence of assessment. RESULTS: In total, 275 adults completed the trial (mean age 75.9 yr, 49.5% male, 46.9% with a self-reported diagnosis of hypertension). There were no statistically significant differences in systolic or diastolic blood pressure measurements associated with the sequence of assessment or the setting. There was a significant difference in the overall mean systolic blood pressure between the 2 assessment sequences (group A 122.0 v. group B 127.8 mm Hg, p < 0.001). INTERPRETATION: Automated devices used in pharmacies to measure blood pressure provide accurate and valid information that can be used in the diagnosis and management of hypertension among older adults in the community. TRIAL REGISTRATION: www.controlled-trials.com, no. ISRCTN91799042.

Comparison of visual estimation methods for regular and modified textures: real-time vs digital imaging.

A variety of methods are available for assessing diet; however, many are impractical for large research studies in an institutional environment. Technology, specifically digital imaging, can make diet estimations more feasible for research. Our goal was to compare a digital imaging method of estimating regular and modified-texture main plate food waste with traditional on-site visual estimations, in a continuing and long-term care setting using a meal-tray delivery service. Food waste was estimated for participants on regular (n=36) and modified-texture (n=42) diets. A tracking system to ensure collection and digital imaging of all main meal plates was developed. Four observers used a modified Comstock method to assess food waste for vegetables, starches, and main courses on 551 main meal plates. Intermodal, inter-rater, and intra-rater reliability were calculated using intraclass correlation for absolute agreement. Intermodal reliability was based on one rater's assessments. The digital imaging method results were in high agreement with the real-time visual method for both regular and modified-texture food (intraclass correlation=0.90 and 0.88, respectively). Agreements between observers for regular diets were higher than those for modified-texture food (range=0.91 to 0.94; 0.82 to 0.91, respectively). Intra-rater agreements were very high for both regular and modified-texture food (range=0.93 to 0.99; 0.91 to 0.98). The digital imaging method is a reliable alternative to estimating regular and modified-texture food waste for main meal plates when compared with real-time visual estimation. Color, shape, reheating, mixing, and use of sauces made modified-texture food waste slightly more difficult to estimate, regardless of estimation method.