Capacity development in patient-oriented research: programme evaluation and impact analysis.

BACKGROUND: National and provincial funding was invested to increase the quantity and quality of patient-oriented research (POR) across Canada. Capacity development became a priority to ensure all stakeholders were prepared to engage in POR. In part, this need was met through an annual Studentship competition in the province of Alberta, providing funding to students whose research incorporated principles of POR. However, despite efforts to build capacity in the health research trainee population, little is known about the outcomes of these programmes. This evaluation study examined the outcomes of a POR capacity development programme for health research trainees. METHODS: Final impact narrative reports were submitted by the 21 Studentship programme awardees for 2015 and 2016 who represent a variety of health disciplines across three major research universities. The reports describe the programme outcomes as well as the overall impact on individual, project and professional development as POR trainees. A synthesis of structured and categorised report data was conducted, along with additional qualitative analyses as new themes emerged that were not apparent in the competency framework utilised in the programme design. RESULTS: Awardee reports detailed the impact of the Studentship programme on the key themes of increased knowledge and skill, relationship building, confidence and leadership, as well as project and career impact. The impacts felt most profoundly by the awardees were not reflective of the competencies that guided programme design. The outcomes were then re-examined using a health research capacity development framework to gain a more comprehensive view of programme impact. CONCLUSION: The Studentship programme narratives provided insight into the rarely tracked capacity development outcomes of POR research trainees. Awardee narratives indicated significant development beyond the intended competencies and suggested a need to revisit the competency framework for POR in Alberta. While competencies were useful in guiding the design of the initial programme, a more comprehensive capacity development framework was required to capture the broader impacts on trainee development. Future capacity development programmes may benefit from these early programme insights, specifically the need for more robust competencies for POR. Further exploration of evaluation methods for short-term awards and sustainability of capacity development programmes is warranted.

Understanding the Experiences of East African Immigrant Women With Gestational Diabetes Mellitus.

OBJECTIVES: East African (EA) women are a subpopulation who are at very high risk for gestational diabetes (GDM) and poor obstetric outcomes, but little is known about the care experiences of this understudied group. The objective of this study was to document the impact of a diagnosis of GDM and the perceptions of diabetes care among EA immigrant women. METHODS: Semistructured in-depth interviews were conducted with 10 EA immigrant women diagnosed with GDM in Calgary; they were recruited from community and tertiary care settings. Interviews were transcribed verbatim and analyzed using inductive thematic content analysis to explore participants' experiences when accessing and receiving care. RESULTS: EA immigrant women had varied experiences related to GDM. Thematic analysis revealed the negative impact of GDM diagnoses on women, including the burdens of self-care, fear, community influences and cultural and financial barriers. The positive impacts of the experience of diagnosis noted were primarily in the empowerment to make healthful behaviour changes. CONCLUSIONS: Study findings point to the need for more context-specific and culturally appropriate support and care. Diagnoses of GDM extended beyond the individuals affected and impacted their families culturally, psychologically and financially. Addressing the emergent themes during pregnancy is imperative to improving care providers' engagement with EA immigrant women in postpartum diabetes screening activities and beyond. The findings of this study contain elements transferable to other immigrant groups in similar socioecologic contexts.

A Survey of Rounding Practices in Canadian Adult Intensive Care Units.

OBJECTIVE: To describe rounding practices in Canadian adult Intensive Care Units (ICU) and identify opportunities for improvement. DESIGN: Mixed methods design. Cross sectional survey of Canadian Adult ICUs (n = 180) with purposefully sampled follow-up interviews (n = 7). MEASUREMENTS AND MAIN RESULTS: Medical directors representing 111 ICUs (62%) participated in the survey. Rounding practices varied across ICUs with the majority reporting the use of interprofessional rounds (81%) that employed an open (94%) and collaborative (86%) approach, occurred at the patient's bedside (82%), and started at a standard time (79%) and standard location (56%). Most participants reported that patients (83%) and family members (67%) were welcome to attend rounds. Approximately half of ICUs (48%) used tools to facilitate rounds. Interruptions during rounds were reported to be common (i.e., ≥ 1 interruption for ≥ 50% of patients) in 46% of ICUs. Four themes were identified from qualitative analysis of participant responses to open-ended survey questions and interviews: multidisciplinarity, patient and family involvement, factors influencing productivity, and teaching and learning. CONCLUSIONS: There is considerable variation in current rounding practices in Canadian medical/surgical ICUs. Opportunities exist to improve ICU rounds including ensuring the engagement of essential participants, clearly defining participant roles, establishing a standardized approach to the rounding process, minimizing interruptions, modifying the role of teaching, utilizing a structured rounding tool, and developing a metric for measuring rounding quality.

Perceived Barriers to and Facilitators of Patient-to-Provider E-Mail in the Management of Diabetes Care.

OBJECTIVES: 1) to describe current utilization of e-mail in the clinical care of patients with diabetes; and 2) to identify barriers to and facilitators of the adoption of e-mail in diabetes care. METHODS: Participants included diabetes care providers, including 9 physicians and 7 allied health professionals (AHPs). Participation involved, first, completing a self-administered survey to evaluate the use of e-mail within diabetes-related clinical practice. Second, focus group discussions were conducted with diabetes care providers using semistructured interviews to collect data about their perceptions of using e-mail to exchange information with patients diagnosed with diabetes. Patients' perspectives on the use of e-communication with their care providers was also proposed on the basis of the discussions. RESULTS: Significant differences were found between physicians and AHPs concerning questions that were related to the use of e-mail and the amount of time spent using e-mail to communicate to patients. There was perceived function and value to the use of e-mail among AHPs, while few physicians used e-mail routinely and were uncertain about its potential in improving care. Five themes, including barriers, benefits, risks, safeguards and compensation, were developed from the focus group interviews. CONCLUSIONS: Currently, most of the physicians surveyed do not e-mail patients directly; however, AHPs frequently use e-mail in diabetes care and find this tool valuable. Variation in practices regarding clinical e-mail across care disciplines suggest that appropriate policy with guidelines for e-mail and e-communication within the health care system may improve uptake of clinical e-mail and perhaps, by extension, improve efficiency and access in diabetes care.

A "Realist Review" approach to e-health: the case of type 2 diabetes in youth.

As e-health technology becomes more ubiquitous in our health and health care environments, a flexible, robust understanding of what works and under what circumstances is needed. Traditional meta-analyses tell us how frequently a technology has worked for previous populations, but not why. Realist Reviews can contribute to understanding why interventions work and by extension how results of past studies can be applied to emerging health challenges. The utility of such a method is considered in e-health interventions to address the serious growing challenge of Type 2 diabetes and metabolic syndrome in young people.

Tele-ICU - a Canadian review.

Based on the learnings and experiences from implementations in the United States, telemedicine may offer certain advantages to help address some of the challenges faced by the Canadian critical care community resulting from staff shortages and increasing demands for quality care. The initial and operating costs of the technology and its impact on direct bedside care are perceived to be significant drivers of resistance to its wide spread implementation. This qualitative review of the available literature summarizes the opportunities and challenges with the potential use of telemedicine to enhance the delivery of critical care services in Canada.

Telemedicine in the intensive care unit environment--a survey of the attitudes and perspectives of critical care clinicians.

PURPOSE: This study was conducted to assess the preimplementation knowledge and perceptions of intensive care unit (ICU) clinicians regarding the ability of telemedicine in the ICU environment (Tele-ICU) to address challenges resulting from the shortages of experienced critical care human resources and the drive to improve quality of care. METHODS: An online survey was administered to clinicians from a Canadian multisite critical care department. Qualitative and quantitative analyses were undertaken to identify key positive and negative themes. RESULTS: The overall self-rated knowledge about Tele-ICU was low, with significant uncertainty particularly related to the novelty of the technology, lack of widespread existing implementations, and insufficient education. A significant degree of skepticism was expressed regarding the ability of Tele-ICU to address the challenges of staff shortages and quality of care. CONCLUSIONS: Significant uncertainty and skepticism were expressed by critical care clinicians regarding the ability of Tele-ICU to address the challenges of human resource limitation and the delivery of quality care. This suggests the need for further research and education of system impact beyond patient outcomes related to this new technology.

Analysis of the suitability of 'video-visits' for palliative home care: implications for practice.

We conducted a retrospective chart review to estimate the extent to which palliative home care visits could be carried out using videophones and to explore factors that might inform the eligibility criteria for video-visits. Four hundred palliative home care health records of deceased clients from 2002 were randomly selected from the Health Records Office in one Canadian health region. One visit was randomly selected from each of these health records. Three hundred and fifty-four visits were coded, and based on professional nursing judgment, the coder estimated whether video-visits could have been carried out. Approximately 43% of the visits were considered appropriate for video-visits. The results suggest that four factors may inform eligibility and decisions about a client's suitability for video-visits: diagnosis (cancer versus non-cancer), low Edmonton Symptom Assessment System (ESAS) score, no care-giver present, number and types of interventions required. Patients with a cancer diagnosis were more likely to be suitable for video-visits, which suggests that disease trajectory, rather than diagnosis of 'palliative', may be more influential in determining the care required and appropriateness of videophone use.

Moving research into practice: A decision framework for integrating home telehealth into chronic illness care.

Home telehealth is an effective alternative for some aspects of traditional care in chronic illnesses such as diabetes, congestive heart failure and asthma. However, in spite of evidence to support use of home telehealth technologies, they have not been adopted as predicted. A significant challenge for decision-makers is applying results from multiple small studies to the care of large numbers of clients in a health region. Aside from the technology, this complex decision must also include expected client outcomes, variations in nursing resources and their deployment in service delivery. This paper presents research evidence supporting the effectiveness of home telehealth for diabetes care, with attention to the range of technologies and outcome measures reported. It also discusses implications of a recently released national study on "Homecare Indicators" that reported resource allocation and outcomes in home care. The burden of illness, evidence of technology effectiveness and proposed home care outcome indicators are considered together in a decision framework to demonstrate an approach for decision-makers and practitioners to transfer home telehealth research into practice. The resulting decision framework is applied to diabetes care within one large health region in Canada to illustrate its utility as a research transfer strategy.

Telehomecare for vulnerable populations: The evaluation of new models of care.

The use of telehomecare has the potential to facilitate access to healthcare services for vulnerable populations. However, evidence on the implications of telehomecare on various aspects related to patients, healthcare professionals, organizations, and healthcare systems is still limited. Assessing the various effects of telehomecare for these different groups of stakeholders is thus an essential step to ensure future integration of this technology into mainstream healthcare services. A synthesis of lessons learned from the evaluation of three telehomecare experimentations targeting specific vulnerable groups is proposed. This paper presents the various models that were implemented to assess telehomecare services for vulnerable populations, explores issues related to conducing telehomecare evaluations, and provides a reflection on key factors that might influence the success of telehomecare projects. Lessons learned from these three experimentations provide valuable insights to orient the development of telehomecare services for various vulnerable groups in the population.

Stakeholder readiness for telehomecare: implications for implementation.

Numerous pilot studies have demonstrated that telehomecare technology may improve client outcomes through timely intervention and health crises prevention, thereby reducing return visits to hospitals and physician offices. Although the potential of telehomecare to increase access to services and improve quality of care and health outcomes is recognized, expectations for its widespread adoption have not been realized. Factors affecting diffusion of innovations include, among other things, perceptions of the technology, organizational characteristics, and communication. These require further exploration for telehealth applications because evidence alone will not automatically produce large-scale conversions in practice. This 12-month study was designed to assess the readiness of clients, health care professionals, and organizations to adopt telehomecare services for adult diabetic clients within the Calgary Health Region. A qualitative approach was used to collect data through focus groups with clients and home care nurses along with interviews with family physicians and key informants responsible for planning and resource allocation in diabetic homecare and telehealth programs. The transcripts of these interviews were analyzed for themes, which were categorized with respect to their effect on quality of care (including structure, process or outcome of care), including those related to the individual client, the health care provider, and the organization as a whole. The study findings identified differences in stakeholder conceptions of the technology, including common themes among clients, providers, and organizations. Implications of study results for developing a strategy to incorporate telehomecare into routine community care are discussed.

Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study.

PURPOSE: To evaluate the use of remote reading of digital retinal photographs in the diagnosis of severe (referral-warranted) retinopathy of prematurity (ROP) during longitudinal screening for ROP. STUDY DESIGN: Prospective, longitudinal cohort study. SUBJECTS: Forty-four consecutive premature infants at risk for ROP. METHODS: All infants were examined longitudinally, over a series of examinations, by indirect ophthalmoscopy (gold standard) and digital photography using the RetCam-120 Digital Retinal Camera (Massie Research Laboratories Inc., Dublin, CA) equipped with an ROP lens. Images were stored and read remotely by a masked reader. Referral-warranted ROP was defined as ROP in zone 1, the presence of plus disease or the presence of any stage 3 ROP. We determined whether and when referral-warranted ROP was diagnosed for each eye, of each infant, on each examination, during the course of each of the infant's screening. RESULTS: Severe (referral-warranted) ROP was diagnosed in 23 eyes by indirect ophthalmoscopy during their series of examinations. Digital photography had a sensitivity of 100% and a specificity of 96% in detecting referral-warranted ROP. The positive predictive value of digital photography was 92%, and the negative predictive value was 100%. In 87% of eyes, referral-warranted ROP was diagnosed by digital photography before or at the same time as indirect ophthalmoscopy. CONCLUSIONS: Longitudinal remote reading of digital photographs using the RetCam-120 system has excellent specificity and sensitivity in detecting referral-warranted ROP. This pilot study has shown that remote reading of digital photographs has promise for telemedicine strategies in ROP screening.