Management of sleep disorder by preceptors in a family medicine residency program in Calgary, Alberta: a mixed-methods study.

BACKGROUND: Most prescriptions for sedative-hypnotics are written by family physicians. Given the influence of preceptors on residents' prescribing, this study explored how family physician preceptors manage sleeping problems. METHODS: Family physician preceptors affiliated with a postgraduate training program in Alberta were invited to participate in this mixed-methods study, conducted from January to October 2021. It included a quantitative survey of preceptors' attitudes to treatment options for sleep disorder, perceptions of patient expectations and self-efficacy beliefs. Participants indicated their responses on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Respondents were then asked whether they were interested in participating in a semistructured qualitative interview that elicited preceptors' management of sleep disorder in response to a series of vignettes. We analyzed the quantitative data using descriptive statistics and the qualitative interviews using thematic analysis. RESULTS: Of the 76 preceptors invited to participate, 47 (62%) completed the survey, and 10 were interviewed. Thirty-two survey respondents (68%) were in academic teaching clinics, and 15 (32%) were from community clinics. The majority of participants (34 [72%]) agreed they had sufficient expertise to use nondrug treatment. Most (43 [91%]) had made efforts to reduce prescribing, and 45 (96%) felt able to support patients empathically when not using sleeping medication. The qualitative data showed that management of sleeping disorder was emotionally challenging. Participants hesitated to prescribe sedatives and reported "exceptions" to prescribing, many of which included indications within guideline recommendations. Participants were reluctant to change a colleague's management. INTERPRETATION: Preceptors were confident using nonpharmacologic management to treat sleep disorder and hesitant to use sedative-hypnotics, presenting legitimate use of sedatives as exceptional behaviour. Acknowledging social norms and affective aspects involved in prescribing may support balanced prescribing of sedative-hypnotics for sleep disorder and reduce physician anxiety.

A comparison of machine learning algorithms and traditional regression-based statistical modeling for predicting hypertension incidence in a Canadian population.

Risk prediction models are frequently used to identify individuals at risk of developing hypertension. This study evaluates different machine learning algorithms and compares their predictive performance with the conventional Cox proportional hazards (PH) model to predict hypertension incidence using survival data. This study analyzed 18,322 participants on 24 candidate features from the large Alberta's Tomorrow Project (ATP) to develop different prediction models. To select the top features, we applied five feature selection methods, including two filter-based: a univariate Cox p-value and C-index; two embedded-based: random survival forest and least absolute shrinkage and selection operator (Lasso); and one constraint-based: the statistically equivalent signature (SES). Five machine learning algorithms were developed to predict hypertension incidence: penalized regression Ridge, Lasso, Elastic Net (EN), random survival forest (RSF), and gradient boosting (GB), along with the conventional Cox PH model. The predictive performance of the models was assessed using C-index. The performance of machine learning algorithms was observed, similar to the conventional Cox PH model. Average C-indexes were 0.78, 0.78, 0.78, 0.76, 0.76, and 0.77 for Ridge, Lasso, EN, RSF, GB and Cox PH, respectively. Important features associated with each model were also presented. Our study findings demonstrate little predictive performance difference between machine learning algorithms and the conventional Cox PH regression model in predicting hypertension incidence. In a moderate dataset with a reasonable number of features, conventional regression-based models perform similar to machine learning algorithms with good predictive accuracy.

Co-designing person-centred quality indicator implementation for primary care in Alberta: a consensus study.

BACKGROUND: We aimed to contribute to developing practical guidance for implementing person-centred quality indicators (PC-QIs) for primary care in Alberta, Canada. As a first step in this process, we conducted stakeholder-guided prioritization of PC-QIs and implementation strategies. Stakeholder engagement is necessary to ensure PC-QI implementation is adapted to the context and local needs. METHODS: We used an adapted nominal group technique (NGT) consensus process. Panelists were presented with 26 PC-QIs, and implementation strategies. Both PC-QIs and strategies were identified from our extensive previous engagement of patients, caregivers, healthcare providers, and quality improvement leaders. The NGT objectives were to: 1. Prioritize PC-QIs and implementation strategies; and 2. Facilitate the participation of diverse primary care stakeholders in Alberta, including patients, healthcare providers, and quality improvement staff. Panelists participated in three rounds of activities. In the first, panelists individually ranked and commented on the PC-QIs and strategies. The summarized results were discussed in the second-round face-to-face group meeting. For the last round, panelists provided their final individual rankings, informed by the group discussion. Finally, we conducted an evaluation of the consensus process from the panelists' perspectives. RESULTS: Eleven primary care providers, patient partners, and quality improvement staff from across Alberta participated. The panelists prioritized the following PC-QIs: 'Patient and caregiver involvement in decisions about their care and treatment'; 'Trusting relationship with healthcare provider'; 'Health information technology to support person-centred care'; 'Co-designing care in partnership with communities'; and 'Overall experience'. Implementation strategies prioritized included: 'Develop partnerships'; 'Obtain quality improvement resources'; 'Needs assessment (stakeholders are engaged about their needs/priorities for person-centred measurement)'; 'Align measurement efforts'; and 'Engage champions'. Our evaluation suggests that panelists felt that the process was valuable for planning the implementation and obtaining feedback, that their input was valued, and that most would continue to collaborate with other stakeholders to implement the PC-QIs. CONCLUSIONS: Our study demonstrates the value of co-design and participatory approaches for engaging stakeholders in adapting PC-QI implementation for the primary care context in Alberta, Canada. Collaboration with stakeholders can promote buy-in for ongoing engagement and ensure implementation will lead to meaningful improvements that matter to patients and providers.

Person-centred care (PCC) is a model of care where patient needs and preferences are included in decisions about care and treatment. To improve PCC in primary care in Alberta, Canada, we plan to use person-centred quality indicators (PC-QIs). Using PC-QIs involves surveying patients about their care experiences and using this information to make improvements. For example, if 20% of patients do not feel they are getting enough information, the clinic may create a checklist for the providers so information is not missed. We engaged a panel of 11 people, including patients, family doctors, and staff who support quality improvement in clinics across the province to decide together which PC-QIs primary care clinics in Alberta should use. We also asked the panel to decide the most important strategies that would make using the PC-QIs more successful. The panel chose PC-QIs related to: patient and caregiver involvement in decisions about care and treatment, a trusting relationship with the healthcare provider, having health information technology to support PCC, partnering with communities in healthcare, and the patient's overall experience. The most important strategies were: developing partnerships among people working in primary care in Alberta, discussing their needs and common efforts for improving PCC, engaging "champions," and securing funding that would be needed. Finally, we asked the panelists to share their experiences with participating in this process. Panelists found the process useful and that their input was valued. Most panelists would also like to continue to work together to put the PC-QIs into practice.

Leaving the Walkman and ICD-9 Behind: Modernizing the Disease Classification System Used by Canadian Physicians.

The International Classification of Diseases, Ninth Revision (ICD-9) was released in the 1970s and adopted in Canada for physician billing claims in 1979 (CIHI n.d.b.; WHO & International Conference for the Ninth Revision of the International Classification of Diseases 1977). ICD-9 is no longer adequate for representing our modern healthcare environment and patient needs. We summarize the findings from a small survey of ICD-9 users across Canada - such as family physicians, researchers and decision makers - who describe the limitations of ICD-9 and the features that they would desire in a new or updated classification system.

Informing the implementation and use of person-centred quality indicators: a mixed methods study on the readiness, barriers and facilitators to implementation in Canada.

OBJECTIVES: To ensure optimal implementation of person-centred quality indicators (PC-QIs), we assessed the readiness of Canadian healthcare organisations and explored their perceived barriers and facilitators to implementing and using PC-QIs. DESIGN: Mixed methods. SETTING AND PARTICIPANTS: Representatives of Canadian healthcare delivery and coordinating organisations that guide the development and/or implementation of person-centred care (PCC) measurement. Representatives from primary care clinics and organisations from the province of Alberta, Canada also participated. METHODS: We conducted a survey with representatives of Canadian healthcare organisations. The survey comprised two sections that: (1) assessed readiness for using PC-QIs, and (2) were based on the Organizational Readiness for Change Assessment tool. We summarised the survey results using descriptive statistics. We then conducted follow-up interviews with organisations representing system and clinical-level perspectives to further explore barriers and facilitators to implementing PC-QIs. The interviews were informed by and analysed using the Consolidated Framework for Implementation Research. RESULTS: Thirty-three Canadian regional healthcare organisations across all 13 provinces/territories participated in the survey. Only 5 of 26 PC-QIs were considered highly feasible to implement for 75% of organisations and included: coordination of care, communication, structures to report performance, engaging patients and caregivers and overall experience. A representative sample of 10 system-level organisations and 11 primary care organisations/clinics participated in the interviews. Key barriers identified were: resources and staff capacity for quality improvement, a shift in focus to COVID-19 and health provider motivation. Facilitators included: prioritisation of PCC measurement, leadership and champion engagement, alignment with ongoing provincial strategic direction and measurement efforts, and the use of technology for data collection, management and reporting. CONCLUSIONS: Despite high interest and policy alignment to use PC-QI 'readiness' to implement them effectively remains a challenge. Organisations need to be supported to collect, use and report PCC data to make the needed improvements that matter to patients.

Development and validation of a hypertension risk prediction model and construction of a risk score in a Canadian population.

Identifying high-risk individuals for targeted intervention may prevent or delay hypertension onset. We developed a hypertension risk prediction model and subsequent risk sore among the Canadian population using measures readily available in a primary care setting. A Canadian cohort of 18,322 participants aged 35-69 years without hypertension at baseline was followed for hypertension incidence, and 625 new hypertension cases were reported. At a 2:1 ratio, the sample was randomly divided into derivation and validation sets. In the derivation sample, a Cox proportional hazard model was used to develop the model, and the model's performance was evaluated in the validation sample. Finally, a risk score table was created incorporating regression coefficients from the model. The multivariable Cox model identified age, body mass index, systolic blood pressure, diabetes, total physical activity time, and cardiovascular disease as significant risk factors (p < 0.05) of hypertension incidence. The variable sex was forced to enter the final model. Some interaction terms were identified as significant but were excluded due to their lack of incremental predictive capacity. Our model showed good discrimination (Harrel's C-statistic 0.77) and calibration (Grønnesby and Borgan test, [Formula: see text] statistic = 8.75, p = 0.07; calibration slope 1.006). A point-based score for the risks of developing hypertension was presented after 2-, 3-, 5-, and 6 years of observation. This simple, practical prediction score can reliably identify Canadian adults at high risk of developing incident hypertension in the primary care setting and facilitate discussions on modifying this risk most effectively.

Prediction of hypertension using traditional regression and machine learning models: A systematic review and meta-analysis.

OBJECTIVE: We aimed to identify existing hypertension risk prediction models developed using traditional regression-based or machine learning approaches and compare their predictive performance. METHODS: We systematically searched MEDLINE, EMBASE, Web of Science, Scopus, and the grey literature for studies predicting the risk of hypertension among the general adult population. Summary statistics from the individual studies were the C-statistic, and a random-effects meta-analysis was used to obtain pooled estimates. The predictive performance of pooled estimates was compared between traditional regression-based models and machine learning-based models. The potential sources of heterogeneity were assessed using meta-regression, and study quality was assessed using the PROBAST (Prediction model Risk Of Bias ASsessment Tool) checklist. RESULTS: Of 14,778 articles, 52 articles were selected for systematic review and 32 for meta-analysis. The overall pooled C-statistics was 0.75 [0.73-0.77] for the traditional regression-based models and 0.76 [0.72-0.79] for the machine learning-based models. High heterogeneity in C-statistic was observed. The age (p = 0.011), and sex (p = 0.044) of the participants and the number of risk factors considered in the model (p = 0.001) were identified as a source of heterogeneity in traditional regression-based models. CONCLUSION: We attempted to provide a comprehensive evaluation of hypertension risk prediction models. Many models with acceptable-to-good predictive performance were identified. Only a few models were externally validated, and the risk of bias and applicability was a concern in many studies. Overall discrimination was similar between models derived from traditional regression analysis and machine learning methods. More external validation and impact studies to implement the hypertension risk prediction model in clinical practice are required.

The effectiveness of person-centred quality improvement strategies on the management and control of hypertension in primary care: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of person-centred quality improvement strategies on the management and control of adults with hypertension in primary care. METHODS: A systematic review and meta-analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person-centred quality improvement strategies for the management and control of essential hypertension among adults ( ≥ 18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes. RESULTS: Eight studies were included (total of 5654 patients). Findings favour use of person-centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self-management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration. CONCLUSION: Person-centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person-centred quality improvement intervention most effective in improving hypertension outcomes.

Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process.

OBJECTIVE: The purpose of this project was to develop a best-practices document on chiropractic care for pregnant and postpartum patients with low back pain (LBP), pelvic girdle pain (PGP), or a combination. METHODS: A modified Delphi consensus process was conducted. A multidisciplinary steering committee of 11 health care professionals developed 71 seed statements based on their clinical experience and relevant literature. A total of 78 panelists from 7 countries were asked to rate the recommendations (70 chiropractors and representatives from 4 other health professions). Consensus was reached when at least 80% of the panelists deemed the statement to be appropriate along with a median response of at least 7 on a 9-point scale. RESULTS: Consensus was reached on 71 statements after 3 rounds of distribution. Statements included informed consent and risks, multidisciplinary care, key components regarding LBP during pregnancy, PGP during pregnancy and combined pain during pregnancy, as well as key components regarding postpartum LBP, PGP, and combined pain. Examination, diagnostic imaging, interventions, and lifestyle factors statements are included. CONCLUSION: An expert panel convened to develop the first best-practice consensus document on chiropractic care for pregnant and postpartum patients with LBP or PGP. The document consists of 71 statements on chiropractic care for pregnant and postpartum patients with LBP and PGP.

"Doing our best for patient safety": An international and interprofessional qualitative study with spinal manipulative therapy providers in community-based settings.

BACKGROUND: Patient safety research is expanding from hospitals to community-based healthcare settings. Knowledge gaps persist among manual therapy professions that may impede patient safety initiatives within musculoskeletal care settings. OBJECTIVES: To describe perceptions of patient safety among chiropractors and physiotherapists who provide spinal manipulation therapy (SMT). DESIGN: Qualitative descriptive study. METHOD: Cross-sectional data were collected using the SafetyNET Survey to Support Quality Improvement. SMT providers (n = 705) in 3 countries completed surveys, with 84 providing written responses to an open-ended question about patient safety. Qualitative thematic analysis described providers' perceptions about patient safety within their practice. RESULTS: SMT providers' perceptions were influenced by professional, patient, and practice setting factors. Five themes and 10 supporting categories were developed. Doing Our Best for Patient Safety concerned Avoiding Mistakes and Prioritizing Safety.Putting Patients First focused on Developing Relationships and Individualizing Care.Working and Learning Together advocated for Interprofessional Communication and Collaborative Learning. Organizing Practice Processes emphasized Standardizing Procedures and Benchmarking Progress.Considering Practitioner Identity highlighted how Recognizing Difference among SMT providers and Challenging Fears of other healthcare professionals and patients about SMT were important for enhancing patient safety. CONCLUSION: Findings align with World Health Organization guiding principles that the nature of healthcare settings influence patient safety strategies. Most responses focused on individual strategies to prevent adverse events. However, this approach may overlook the benefits of identifying and documenting adverse events, setting time to discuss adverse events with clinic members, standardizing clinical practices, and building transparent patient safety cultures across healthcare professions and settings.

Summarising and synthesising regression coefficients through systematic review and meta-analysis for improving hypertension prediction using metamodelling: protocol.

INTRODUCTION: Hypertension is one of the most common medical conditions and represents a major risk factor for heart attack, stroke, kidney disease and mortality. The risk of progression to hypertension depends on several factors, and combining these risk factors into a multivariable model for risk stratification would help to identify high-risk individuals who should be targeted for healthy behavioural changes and/or medical treatment to prevent the development of hypertension. The risk prediction models can be further improved in terms of accuracy by using a metamodel updating technique where existing hypertension prediction models can be updated by combining information available in existing models with new data. A systematic review and meta-analysis will be performed of hypertension prediction models in order to identify known risk factors for high blood pressure and to summarise the magnitude of their association with hypertension. METHODS AND ANALYSIS: MEDLINE, Embase, Web of Science, Scopus and grey literature will be systematically searched for studies predicting the risk of hypertension among the general population. The search will be based on two key concepts: hypertension and risk prediction. The summary statistics from the individual studies will be the regression coefficients of the hypertension risk prediction models, and random-effect meta-analysis will be used to obtain pooled estimates. Heterogeneity and publication bias will be assessed, along with study quality, which will be assessed using the Prediction Model Risk of Bias Assessment Tool checklist. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review and meta-analysis. We plan to disseminate the results of our review through journal publications and presentations at applicable platforms.

Pregnancy anxiety and preterm birth: The moderating role of sleep.

OBJECTIVE: Preterm birth (PTB) is a prevalent public health concern. Pregnancy anxiety, poor sleep quality, and short sleep duration have been associated with an increased risk of PTB. Theoretically, sleep variables could moderate the strength of the relationship between pregnancy anxiety and PTB; investigating this question was the primary aim of this study. METHOD: The sample consisted of 290 pregnant women who were assessed at 2 time points in pregnancy: Time 1 (< 22 weeks gestational age [GA]; MGA = 15.04, SD = 3.55) and Time 2 (32 weeks GA; MGA = 32.44, SD = 0.99). Pregnancy anxiety was assessed with the Pregnancy-Related Anxiety Scale, sleep quality was assessed by the Pittsburgh Sleep Quality Index, and sleep duration was assessed via actigraphy. Data on gestational age at birth were obtained from the electronic medical record. RESULTS: After adjustment for relevant covariates, higher levels of pregnancy anxiety were associated with shorter gestational length and an increased risk of PTB. There were no direct associations between sleep quality or sleep duration and gestational length or PTB. Pregnancy anxiety interacted with sleep duration such that pregnancy anxiety was significantly associated with shorter gestational length and PTB only when women had relatively shorter sleep duration (approximately < 8.3 hr). CONCLUSIONS: This study reveals new evidence of an interaction between pregnancy anxiety and sleep duration in the prediction of the timing of delivery. The findings point to avenues to better understand and potentially ameliorate risk for PTB. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

SafetyNET Community-based patient safety initiatives: development and application of a Patient Safety and Quality Improvement Survey.

OBJECTIVES: To: 1) develop/adapt and validate an instrument to measure patient safety attitudes and opinions of community-based spinal manipulative therapy (SMT) providers; 2) implement the instrument; and 3) compare results among healthcare professions. METHODS: A review of the literature and content validation were used for the survey development. Community-based chiropractors and physiotherapists in 4 Canadian provinces were invited. RESULTS: The Agency for Healthcare Research and Quality's (AHRQ) Medical Office Survey on Patient Safety Culture was the preferred instrument. The survey was modified and validated, measuring 14 patient safety dimensions. 276 SMT providers volunteered to respond to the survey. Generally, SMT providers had similar or better patient safety dimension scores compared to the AHRQ 2016 medical offices database. DISCUSSION: We developed the first instrument measuring patient safety attitudes and opinions of community-based SMT providers. This instrument provides understanding of SMT providers' opinions and attitudes on patient safety and identifies potential areas for improvement.

OBJECTIFS: 1) Élaborer/adapter et valider un instrument servant à évaluer les attitudes à l'égard de la sécurité du patient et les opinions des praticiens effectuant des manipulations vertébrales (MV); 2) adopter cet instrument; et 3) comparer les résultats obtenus entre les professionnels de la santé. MÉTHODOLOGIE: Pour élaborer le sondage, on a revu la littérature, on a validé le contenu et on a invité des chiropraticiens et des physiothérapeutes de quatre provinces canadiennes à participer. RÉSULTATS: Le Medical Office Survey on Patient Safety Culture de l'Agency for Healthcare Research and Quality's (AHRQ) était l'instrument préféré. Le sondage a été modifié et validé et a servi à mesurer 14 aspects de la sécurité du patient. 276 professionnels effectuant des MV ont accepté de répondre au sondage. En règle générale, les cotes obtenues chez les professionnels effectuant des MV pour ce qui des aspects de la sécurité étaient comparables ou meilleurs que celles des professionnels de la santé enregistrés dans la base de données de 2016 de l'AHRQ. DISCUSSION: On a élaboré le premier instrument servant à évaluer les attitudes à l'égard de la sécurité et les opinions des praticiens effectuant des MV dans une collectivité. Cet instrument permet de comprendre les opinions et les attitudes à l'égard de la sécurité du patient des professionnels effectuant des MV et de cerner les aspects qui pourraient être améliorés.

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission.

OBJECTIVE: To assess the efficacy of an electronic discharge communication tool (e-DCT) for preventing death or hospital readmission, as well as reducing patient-reported adverse events after hospital discharge. The e-DCT assessed has already been shown to yield high-quality discharge summaries with high levels of patient and physician satisfaction. METHODS: This two-arm randomised controlled trial was conducted in a Canadian tertiary care centre's internal medicine medical teaching units. Out of the 1953 patients approached and screened for inclusion, 1399 were randomised and available for data linkage for determination of the primary outcome. Participants were randomly assigned to e-DCT versus usual care (traditional discharge communication generated by dictation). The primary outcome was a composite of death or readmission within 90 days. The secondary outcome included any patient-reported adverse events within 30 days of discharge. RESULTS: Among 1399 randomised participants, 230 of 701 participants (32.8%) in the e-DCT group experienced the primary composite outcome of death or readmission within 90 days vs 205 of 698 participants (29.4%) in the usual care group (p=0.166). The incidence at 30 days of patient-reported adverse outcomes (35% for e-DCT vs 34% for usual care) and adverse events (2.1% for e-DCT vs 1.8% for usual care) also did not differ significantly between groups. CONCLUSIONS: The e-DCT tested did not reduce the composite endpoint of death or readmission at 90 days, nor the incidence of patient-reported adverse events at 30 days. This neutral finding for hard clinical endpoints needs to be considered in the context of high patient and physician satisfaction, and high quality of discharge summaries.

The High Prevalence of Vitamin D Insufficiency in Cord Blood in Calgary, Alberta (APrON-D Study).

OBJECTIVE: Vitamin D is important in promoting healthy pregnancy and fetal development. We undertook this study to measure 25-hydroxyvitamin D in maternal and cord blood and to identify maternal factors related to vitamin D status in Calgary. METHODS: Blood samples collected at the time of delivery from the Alberta Pregnancy Outcomes and Nutrition study cohort (ApronStudy.ca) participants were processed for plasma and assayed using liquid chromatography mass spectrometry methodology for 25(OH)D3. RESULTS: Ninety-two pairs of maternal and cord blood samples were obtained. The prevalence of 25(OH)D3 insufficiency-25(OH)D3 <75 nmol/L-was 38% and 80% in women and neonates, respectively. Vitamin D supplementation was the only clinical factor associated with 25(OH)D3 sufficiency, and the odds of sufficiency were 3.75 (95% CI 1.00 to 14.07) higher for women and 5.27 (95% CI 1.37 to 20.27) when over 2000 IU/day were used. CONCLUSION: Using liquid chromatography mass spectrometry, we demonstrated a very high prevalence of vitamin D insufficiency in cord blood and that the use of high dose vitamin D was associated with greater odds of sufficiency in pregnant women and cord blood in Alberta.

Pregnancy loss in women with von Willebrand disease: a single-center pilot study.

: The risk of pregnancy loss in von Willebrand disease (VWD) has been inconsistently reported. Von Willebrand factor (VWF) is a known regulator of angiogenesis, so has the potential to affect placental function. We sought to determine the risk of pregnancy loss and placenta-mediated pregnancy complications in women with VWD, compared with women without VWD. Women with VWD followed in the Southern Alberta Rare Blood and Bleeding Disorders Clinic were invited to participate in a questionnaire (February-June 2014). The same questionnaire was sent to women without VWD identified in a low-risk obstetrical clinic in Calgary, Alberta, Canada. The primary outcome was the proportion of pregnancies that ended in pregnancy loss. Secondary outcomes were preeclampsia, fetal growth restriction, placental abruption, and preterm labor less than 37 weeks gestation. Of the 30 (31.6%) VWD participants that responded, 26 (86.7%) were diagnosed with Type 1 VWD, of which 11 (42.3%) had VWF antigen or activity levels less than 30%. In women with VWD, there were 20 pregnancy losses out of 80 pregnancies [25.0%, 95% confidence interval (CI), 16.81-35.48], compared with eight losses out of 50 pregnancies in the control group (16.0%, 95% CI, 8.34-28.51; P = 0.28). There was no difference in the risk of preeclampsia (1.7 versus 0%, P = 1.00) or preterm labor (16.7 versus 7.1%, P = 0.23) among VWD and control groups. There were no other placenta-mediated pregnancy complications reported. There is no significant difference in pregnancy loss between women with and without VWD; however, a large multicenter study is needed to clarify the risk of pregnancy loss in women with VWD.

Patient safety principles in family medicine residency accreditation standards and curriculum objectives: Implications for primary care.

OBJECTIVE: To conduct a thematic analysis of the College of Family Physicians of Canada's (CFPC's) Red Book accreditation standards and the Triple C Competency-based Curriculum objectives with respect to patient safety principles. DESIGN: Thematic content analysis of the CFPC's Red Book accreditation standards and the Triple C curriculum. SETTING: Canada. MAIN OUTCOME MEASURES: Coding frequency of the patient safety principles (ie, patient engagement; respectful, transparent relationships; complex systems; a just and trusting culture; responsibility and accountability for actions; and continuous learning and improvement) found in the analyzed CFPC documents. RESULTS: Within the analyzed CFPC documents, the most commonly found patient safety principle was patient engagement (n = 51 coding references); the least commonly found patient safety principles were a just and trusting culture (n = 5 coding references) and complex systems (n = 5 coding references). Other patient safety principles that were uncommon included responsibility and accountability for actions (n = 7 coding references) and continuous learning and improvement (n = 12 coding references). CONCLUSION: Explicit inclusion of patient safety content such as the use of patient safety principles is needed for residency training programs across Canada to ensure the full spectrum of care is addressed, from community-based care to acute hospital-based care. This will ensure a patient safety culture can be cultivated from residency and sustained into primary care practice.

A framework to assess patient-reported adverse outcomes arising during hospitalization.

BACKGROUND: The assessment of adverse events from a patient-centered view includes patient-reported adverse outcomes. An adverse outcome refers to any suboptimal outcome experienced by the patient; when adverse outcomes are identified through a patient interview these are called patient-reported adverse outcomes. An adverse event is an adverse outcome that is more likely due to the processes of medical care rather than to the mere progression of disease. In the context of a large-scale study assessing post-hospitalization adverse events, we developed a conceptual framework to assess patient-reported adverse outcomes (PRAOs). This methodological manuscript describes this conceptual framework. METHODS: The PRAO framework builds on a validated adverse event ascertainment method including three phases: Phase 1 involves an inquiry to ascertain the occurrence of any patient-reported adverse outcome. It is completed by a structured telephone interview to obtain details - from a patient perspective - on symptoms that developed and/or worsened after hospitalization. Phase 2 involves the classification of PRAOs by physicians not involved in the patient care. Physician-reviewers then rate the PRAOs using well-adopted scales to determine whether the occurrence was the natural progression of the underlying illness or due to medical care. When the PRAO is rated as "due to medical care", it is then classified as an "adverse event". Phase 3 involves the classification of adverse events as preventable or ameliorable. RESULTS: Out of the 1347 patients contacted at 1-month post-discharge, 469 reported AOs and after reviewing 369 cases, 29 were classified as AEs. Observed agreement levels between raters were 87.3, 85.5, and 85.2 % respectively displaying a good agreement (k > 0.60). CONCLUSION: The framework incorporates PRAOs as a way to identify cases that need to be evaluated for adverse events. Further validation of this framework is warrant with the final aim of implementation at larger scale. The implementation of this framework will enable clinicians, researchers and healthcare institutions to compare outcome rates across providers and over time.

The Current Recommended Vitamin D Intake Guideline for Diet and Supplements During Pregnancy Is Not Adequate to Achieve Vitamin D Sufficiency for Most Pregnant Women.

BACKGROUND: The aims of this study were to determine if pregnant women consumed the recommended vitamin D through diet alone or through diet and supplements, and if they achieved the current reference range vitamin D status when their reported dietary intake met the current recommendations. METHODS: Data and banked blood samples collected in second trimester from a subset of 537 women in the APrON (Alberta Pregnant Outcomes and Nutrition) study cohort were examined. Frozen collected plasma were assayed using LC-MS/MS (liquid chromatography-tandem mass spectrometry) to determine 25(OH)D2, 25(OH)D3, 3-epi-25(OH)D3 concentrations. Dietary data were obtained from questionnaires including a Supplement Intake Questionnaire and a 24-hour recall of the previous day's diet. RESULTS: Participants were 87% Caucasian; mean (SD) age of 31.3 (4.3); BMI 25.8 (4.7); 58% were primiparous; 90% had education beyond high school; 80% had a family income higher than CAN $70,000/year. 25(OH)D2, 25(OH)D3, and 3-epi-25(OH)D3) were identified in all of the 537 plasma samples;3-epi-25(OH)D3 contributed 5% of the total vitamin D. The median (IQR) total 25(OH)D (D2+D3) was 92.7 (30.4) nmol/L and 20% of women had 25(OH)D concentration < 75 nmol/L. The median (IQR) reported vitamin D intake from diet and supplements was 600 (472) IU/day. There was a significant relationship between maternal reported dietary vitamin D intake (diet and supplement) and 25(OH)D and 3-epi-25(OH)D3 concentrations in an adjusted linear regression model. CONCLUSIONS: We demonstrated the current RDA (600 IU/ day) may not be adequate to achieve vitamin D status >75 nmol/L in some pregnant women who are residing in higher latitudes (Calgary, 51°N) in Alberta, Canada and the current vitamin D recommendations for Canadian pregnant women need to be re-evaluated.

The role of maternal cardiac vagal control in the association between depressive symptoms and gestational hypertension.

Reduced cardiac vagal control, indexed by relatively lower high-frequency heart rate variability (HF-HRV), is implicated in depressed mood and hypertensive disorders among non-pregnant adults whereas research in pregnancy is limited. This study examined whether maternal HF-HRV during pregnancy mediates the association between depressed mood and gestational hypertension. Depressive symptoms (Edinburgh Depression Scale) and HF-HRV were measured during early (M=14.9 weeks) and late (M=32.4 weeks) pregnancy in 287 women. Gestational hypertension was determined by chart review. Depressive symptoms were associated with less HF-HRV (b=-0.02, p=.001). There was an indirect effect of depressed mood on gestational hypertension through late pregnancy HF-HRV (b=0.04, 95% CI 0.0038, 0.1028) after accounting for heart rate. These findings suggest cardiac vagal control is a possible pathway through which prenatal depressed mood is associated with gestational hypertension, though causal ordering remains uncertain.