A mixed-method study evaluating an innovative care model for rural patients undergoing outpatient breast surgery.

BACKGROUND: The Delta Oasis program was launched in New Brunswick in 2006 to offer patients from rural areas who were undergoing breast cancer surgery and their families 1 night of free accommodations and a postoperative consultation with an extramural nurse. We sought to investigate patient experiences with this program. METHODS: This mixed-method retrospective study took place from 2020 to 2022 and compared the preoperative anxiety and quality of recovery of program participants and control patients who were discharged home over 100 km from hospital. We conducted 2 × 2 analysis of variance to evaluate the effects of intervention group and surgery type. We conducted semistructured interviews with intervention participants, which we then thematically analyzed. Two patient partners were engaged during data synthesis to support the interpretation of results. RESULTS: We included 34 patients who participated in the program and 18 control patients. No statistically significant differences were found between treatment groups in preoperative anxiety and quality of recovery, regardless of surgery type. Thematic analysis of interviews with 17 intervention participants revealed that they were highly satisfied with the program and that the experience helped reduce stress and discomfort related to their surgery. INTERPRETATION: The Delta Oasis program is a cost-effective alternative to inpatient care after breast cancer surgery and is highly regarded by rural patients; expansion to other regions with the inclusion of additional low-risk surgeries could help address hospital capacity issues. This study contributes to our understanding of the patient experience with the Delta Oasis program and informs the development of similar programs elsewhere.

"It's a lonely battle": A qualitative study of older adult Canadians' experiences with chronic obstructive pulmonary disease medication adherence and support.

Background: Medication adherence is critical for optimal management of chronic obstructive pulmonary disease (COPD) and is influenced by patient, treatment and societal factors. Currently, little is known about the patient perspectives of older adult Canadians with COPD regarding medication adherence. Therefore, the purpose of this study was to explore the lived experiences of older Canadian adults with COPD regarding medication adherence and management. Methods: Semi-structured interviews were conducted with 20 community-dwelling older adults with COPD, and iterative thematic analysis was performed. Results: Six themes emerged from these data: (1) continuity of care, (2) importance of pharmacy for information and care, (3) medication self-management, (4) "there needs to be more information," (5) drug costs a concern and (6) "it's a lonely battle." Conclusion: Findings suggested a need for improved continuity of care, disease-related information provision and means of addressing psychosocial needs. Holistic approaches to patient education and self-management, with consideration for varying health literacy, are needed.

Exploring the psychosocial impact of simple robotic assistive technology on adolescents with neuromuscular disease.

Introduction: Adolescents with neuromuscular disease face significant challenges accessing social leisure activities. Assistive technology has provided new opportunities for those with neuromuscular disease to augment their social lives and leisure pursuits. However, there is limited research evaluating the impact of these technologies. Methods: This study employed mixed methods to evaluate the potential impact of simple robotics on psychosocial factors and quality of life for those adolescents living with neuromuscular diseases. Semi-structured qualitative interviews were performed, as well as the adult Psychosocial Impact of Assistive Technology Device (PIADS) with 9 adolescents, ranging in age from 13 to 19 years old. Results: Thematic analysis of the qualitative data resulted in five major themes: everyday lives and seasonality; socialization; leisure activities; robotics as a leisure activity; and ease of use of robotics. The PIADS found the individual scores demonstrated a range from very little yet positive perceived impact to maximum positive impact in each subscale (competence, adaptability, and self-esteem). Conclusions: Simple mainstream robotics, paired with personalized access methods to control them, offer potential leisure and social integration opportunities to adolescents with neuromuscular diseases in a variety of settings, indoors and outdoors. The findings of this study suggest there are opportunities for this type of mainstream technology to be applied not just to adolescents, but potentially children of all ages with neuromuscular disease, across a variety of environments.

A dynamic version of the FRAM for capturing variability in complex operations.

Functional Resonance Analysis Method (FRAM) is a function-based approach to model complex socio-technical systems and to manage variability. The current FRAM related tools are unable to capture qualitative and quantitative characteristics of variability as well as temporal variations. This study presents in detail a dynamic FRAM-based tool, which is called DynaFRAM. It is introduced to address the variability-related deficiencies of the FRAM related tools. It aims to capture variability in complex operations. It is a dynamic tool developed to capture time related variations in complex operations. This increases the attractiveness of the DynaFRAM for complex operations where specialists and practitioners make decisions in complicated situations. The ability of the DynaFRAM is demonstrated by examining a healthcare related case study. Although the ability of the DynaFRAM is assessed through capturing variations in healthcare operations, it can be applied to other domains in a similar manner.•The DynaFRAM is a dynamic FRAM-based tool.•It is able to captures different characteristics of variability.•It facilitates understanding and analysis of variability in complex operations.

Treatment of Mild Hyperkalemia in Hospitalized Patients: An Unnecessary Practice?

BACKGROUND: Sodium polystyrene sulfonate (SPS) is one of the most commonly used treatments for mild hyperkalemia. Other treatments include insulin, sodium bicarbonate, and salbutamol, which may be given alone or in combination. The results of research examining treatment effectiveness for mild hyperkalemia (e.g., the ability of SPS to achieve normokalemia) thus far have been inconsistent. Given that the effectiveness of treatment for mild hyperkalemia is debatable, new research is needed. OBJECTIVE: To determine whether treatment of hospitalized patients with mild hyperkalemia (using SPS or another approach, relative to no treatment) was associated with achievement of normokalemia (serum potassium < 5.1 mmol/L). METHODS: For this retrospective, quasi-experimental study, hospitalized patients with index serum potassium level between 5.1 and 6.4 mmol/L were identified. Post-index serum potassium level within 24 hours was dichotomized (< 5.1 or ≥ 5.1 mmol/L). Pre-index serum creatinine and serum potassium levels were recorded as the average of the first 5 values immediately before the index potassium value. For each patient, treatment was categorized as no treatment, SPS treatment, or other treatment strategy. RESULTS: Among the 1944 patients included in the analysis, the average age was 66.8 (standard deviation 13.5) years; 605 (31.1%) of the patients were women and 1339 (68.9%) were men. Logistic regression results indicated that patients who were female and/or had higher pre-index serum potassium were less likely to return to normokalemia within 24 hours after the time of the index serum potassium value. Treatment category was not a statistically significant predictor of the achievement of normokalemia. Most patients with mild hyperkalemia (> 74.5% in each treatment category) achieved normokalemia, whether or not they received treatment. CONCLUSIONS: The findings of this study suggest that although follow-up is required for mild hyperkalemia in hospitalized patients, active treatment may be unnecessary.

CONTEXTE: Le sulfonate de polystyrène de sodium (SPS) est l'un des traitements les plus communément utilisés pour l'hyperkaliémie légère. D'autres traitements comprennent l'insuline, le bicarbonate de sodium et le salbutamol, qui peuvent être administrés seuls ou ensemble. Les résultats des recherches se penchant sur l'efficacité des traitements de l'hyperkaliémie légère (p. ex., la capacité du SPS à rétablir la normokaliémie) sont contradictoires jusqu'à présent. Étant donné que l'efficacité du traitement de l'hyperkaliémie légère est discutable, de nouvelles recherches sont nécessaires. OBJECTIF: Déterminer si le traitement des patients hospitalisés, présentant une hyperkaliémie légère, (à l'aide de SPS ou d'une autre approche, comparativement à l'absence de traitement) était associé à l'atteinte de la normokaliémie (potassium sérique < 5,1 mmol/L). MÉTHODES: Des patients hospitalisés, dont l'indice de concentration sérique de potassium se situait entre 5,1 et 6,4 mmol/L, ont été identifiés pour participer à cette étude rétrospective quasi expérimentale. La concentration sérique de potassium mesurée dans les 24 heures après le diagnostic d'hyperkaliémie légère a été dichotomisée (< 5,1 ou ≥ 5,1 mmol/L). Les indices de concentrations sériques de créatinine et de potassium avant le diagnostic d'hyperkaliémie légère ont été obtenus par la moyenne des cinq premières valeurs situées immédiatement avant celle de la concentration de potassium. Le classement du traitement de chaque patient était le suivant: Aucun traitement, Traitement par SPS ou Autre stratégie de traitement. RÉSULTATS: L'âge moyen des 1944 patients inclus dans l'analyse était de 66,8 ans (écart type 13,5); 605 (31,1 %) d'entre eux étaient des femmes et 1339 (68,9 %) des hommes. Les résultats de la régression logistique indiquaient que les patientes, donc les femmes, qui avaient un indice sérique de potassium plus élevé au moment du diagnostic, avaient moins de chances de retourner à la normokaliémie dans les 24 heures après l'instant de la mesure de la valeur de l'indice sérique de potassium. La catégorie de traitement n'était pas une variable prédictive statistiquement significative de l'atteinte de la normokaliémie. La plupart des patients présentant une hyperkaliémie légère (> 74,5 % dans chaque catégorie de traitement) atteignaient la normokaliémie, qu'ils aient reçu ou non un traitement. CONCLUSIONS: Les résultats de cette étude laissent entendre que, malgré la nécessité d'un suivi des patients hospitalisés en cas d'hyperkaliémie légère, un traitement actif pourrait s'avérer inutile.

Medical and Undergraduate Student Perceptions on Scribing in an Emergency Department.

Background  A shift towards electronic medical records (EMR) has increased physician burnout and decreased physician satisfaction and productivity. One solution to alleviate EMR stressors is the implementation of medical scribes. Scribes have been shown to increase physician productivity and satisfaction. The study objective was to elucidate medical and undergraduate student scribing experience to determine if that experience can incentivize scribes to work in the emergency department. Methods  Ten students scribed and shadowed at a tertiary ED between July 4, 2019, and August 10, 2019. Medical students participated in two scribing and two non-scribing (shadowing) sessions, each lasting four hours. Undergraduate students only had a scribing condition. To facilitate scribing, a laptop with a wireless keyboard was provided, as well as a stand-up laptop tray.  An exit survey and semi-structured interviews were conducted after the scribing experience. The majority of insights were extracted from interviews. Transcripts were coded into thematic coding trees and analyzed using thematic analysis.  Results  All undergraduate students preferred volunteering in the ED over other volunteer experiences. All undergraduates cited direct access to the medical field, resume building, and perceived value added to the health care team as motivators to continue scribing. Most students credited demystification of the medical profession as a motivator. Most medical students felt scribing should be integrated into their curriculum. Based on survey results, five undergraduate students would volunteer 40 hours/week. Conclusion Our study showed that a volunteer model of scribing is feasible. Importantly, scribing may be an invaluable experience for directing career goals and ensuring that students intrinsically interested in medicine pursue the profession. Although a volunteer model may not provide the desired benefit in terms of ED efficiency, it may be an integral part of training the next wave of physicians.

Modeling and analyzing hospital to home transition processes of frail older adults using the functional resonance analysis method (FRAM).

The main purpose of this study was to model and analyze hospital to home transition processes of frail older adults in order to identify the challenges within this process. A multi-phase, multi-sited and mixed methods design was utilized, in which, Phase 1 included collecting semi-structured interviews and focus group data, and Phase 2 consisted of six patient/caregiver dyad prospective case studies. This study was conducted in three hospitals in three cities in a single province in Canada. The Functional Resonance Analysis Method (FRAM) was employed to model daily operations of the transition process. The perspectives of both healthcare providers and patients/caregivers were used to build the FRAM model. The transition model was then tested using a customized version of the FRAM. The six patient/caregiver cases were used in the process of testing the FRAM model. The results of building the FRAM model showed that five categories of functions contributed to the transition model, including admission, assessment, synthesis, decision-making, and readmission. The outcomes of using the customized version of the FRAM revealed challenges affecting the transition process including waitlists for geriatric units, team-based care, lack of a discharge planner, financial concerns, and follow-up plans. The findings of this study could assist managers and other decision makers to improve the transition processes of frail older adults by addressing these challenges. The FRAM method employed in this study can be applied widely to identify work practices that are more or less successful, so that procedures and practices can be adapted to nudge healthcare processes towards paths that will yield better outcomes.

The evolution of the cancer formulary review in Canada: Can centralization improve the use of economic evaluation?

Public reimbursement of drugs is a costly proposition for health care systems. Decisions to add drugs to the public formulary are often guided by review processes and committees. The evolution of the formulary review process in Canada's publicly funded health system is characterized by increased centralization and systematization. In the past, the review of evidence and recommendation was conducted at the regional level, but was replaced with the pan-Canadian Oncology Drug Review in 2011. We assess the extent to which centralization and systematization of the review process have responded to past challenges, focusing on the use of economic evaluation in the process. Past challenges with economic evaluation experienced by regionalized review committees were identified from literature and qualitative data collected in the province of Nova Scotia. We categorize these using a typology with a macro-, meso, and micro-level hierarchy, which provides a useful framework for understanding at which level change is required, and who has the authority to influence change. Using grounded theory methods, we identify approaches used by Nova Scotia past committee members to compensate for perceived shortcomings of the process. These include an undue reliance on other committee members, on the multidisciplinarity of the committee, and on past decisions. Using a policy analysis approach, we argue that centralization and systematization of the review process only partially address the shortcomings of the previous regionalized process. Lessons from Canada can inform policy discussions across all health systems, where similar challenges with the formulary review process have been identified. © 2016 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.