Perspectives on Quality of Care in Kidney Transplantation: A Semistructured Interview Study.

BACKGROUND: There is currently no agreement as to what constitutes quality transplant care, and there is a lack of consistency in the approach to assessing transplantation quality. We aimed to ascertain the views of patients, clinicians, and program administrators about quality care for kidney transplant patients. METHODS: Semistructured qualitative interviews were conducted with 20 patients, 17 physicians, and 11 program administrators. Transcripts were analyzed using inductive thematic analysis. RESULTS: We identified 8 themes: access to treatment (standardized transplant referral, lengthy transplant evaluation process, lengthy living donor evaluation); accessibility of services (alternative access options, flexible appointment availability, appropriate amount of follow-up, barriers for accessing care); program resources (comprehensive multidisciplinary care, knowledgeable staff, peer support groups, educational resources, patient navigators/ advocates); communication of information (taking time to answer questions, clear communication about treatment, communication tailored to patients, health promotion and illness prevention); attitude of care providers (positive and supportive attitude, patient centered care); health outcomes (freedom from dialysis, Long-term health, short-term health, fear of infections); patient satisfaction (returning to normal life, patient satisfaction with care); and safety (reducing infection risk, quick response to complications, patient health status on the waitlist). CONCLUSIONS: There is a need to move beyond basic clinical outcomes and focus on increasing ease of access, the patient-provider relationship, and outcomes that are most important to the patients.

Quality Metrics in Solid Organ Transplantation: A Systematic Review.

BACKGROUND: The best approach for determining whether a transplant program is delivering high-quality care is unknown. This review aims to identify and characterize quality metrics in solid organ transplantation. METHODS: Medline, Embase, and Cochrane Central Register of Controlled Trials were searched from inception until February 1, 2017. Relevant full text reports and conference abstracts that examined quality metrics in organ transplantation were included. Two reviewers independently extracted study characteristics and quality metrics from 52 full text reports and 24 abstracts. PROSPERO registration: CRD42016035353. RESULTS: Three hundred seventeen quality metrics were identified and condensed into 114 unique indicators with sufficient detail to be measured in practice; however, many lacked details on development and selection, were poorly defined, or had inconsistent definitions. The process for selecting quality indicators was described in only 5 publications and patient involvement was noted in only 1. Twenty-four reports used the indicators in clinical care, including 12 quality improvement studies. Only 14 quality metrics were assessed against patient and graft survivals. CONCLUSIONS: More than 300 quality metrics have been reported in transplantation but many lacked details on development and selection, were poorly defined, or had inconsistent definitions. Measures have focused on safety and effectiveness with very few addressing other quality domains, such as equity and patient-centeredness. Future research will need to focus on transparent and objective metric development with proper testing, evaluation, and implementation in practice. Patients will need to be involved to ensure that transplantation quality metrics measure what is important to them.

Physical frailty and functional status in patients with advanced kidney disease: a protocol for a systematic review.

BACKGROUND: Predicting outcomes in those with chronic kidney disease or following transplantation is challenging, and current models lack detailed patient-level information. Frailty and poor functional status are risk factors for adverse patient outcomes that may be useful additions to prognostic tools in patients with chronic kidney disease. The purpose of this systematic review is to examine whether frailty or functional status are associated with increased risk of mortality or adverse clinical outcomes in patients with advanced kidney disease. METHODS/DESIGN: We will conduct a systematic review to identify and evaluate studies linking frailty and functional status with patient outcomes in populations with advanced kidney disease. We will search MEDLINE, Embase, and the Cochrane Central Register for Controlled Trials. Two reviewers will conduct all screening and data extraction independently. A modified version of the Quality In Prognosis Studies tool will be used to evaluate the quality of the studies. If meta-analysis of outcome data is possible, a random effects model will be used. DISCUSSION: The results of this review will inform the development, selection, and validation of appropriate metrics needed to improve prognostication in patients with chronic kidney disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016045251.

Quality metrics in solid organ transplantation: protocol for a systematic scoping review.

BACKGROUND: Transplantation is often the best, if not the only treatment for end-stage organ failure; however, the quality metrics for determining whether a transplant program is delivering safe, high quality care remains unknown. The purpose of this study is to identify and describe quality indicators or metrics in patients who have received a solid organ transplant. METHODS/DESIGN: We will conduct a systematic scoping review to evaluate and describe quality indicators or metrics in patients who have received a solid organ transplant. We will search MEDLINE, Embase, and the Cochrane Central Register for Controlled Trials. Two reviewers will conduct all screening and data extraction independently. The articles will be categorized according to the six domains of quality, and the metrics will be appraised using criteria for a good quality measure. DISCUSSION: The results of this review will guide the development, selection, and validation of appropriate quality metrics necessary to drive quality improvement in transplantation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016035353 .

Self-report Pregnancy Physical Activity Questionnaire overestimates physical activity.

OBJECTIVES: Physical activity (PA) research during pregnancy relies heavily on indirect/subjective measures of PA, which may be less accurate than directly measured PA. We tested whether the Pregnancy Physical Activity Questionnaire (PPAQ) could accurately estimate PA by comparing PPAQ results to directly measured PA. METHODS: In a sample of 29 women who completed the PPAQ, PA was directly measured in the second trimester of pregnancy using Actical® accelerometers (valid day = 10+ hours; 4-7 valid days). Activity variables from the PPAQ were calculated using all questions, and also by only considering the leisure time section. Women were classified as 'active' or 'non-active' using Canadian PA guidelines for adults (150 minutes moderate to vigorous PA (MVPA)/ week, bouts of 10+ minutes). Bonferroni corrections were used to adjust for multiple comparisons. Data presented as mean ± standard deviation or median (interquartile range). RESULTS: The PPAQ overestimated MVPA by 12.12 (14.34) hours/week in the combined sample, and the difference remained substantial when investigating the non-active [overestimate = 11.54 (10.10) hrs/wk] and the active women [overestimate = 16 ± 11 hrs/wk] separately. PPAQ-measured PA variables did not correlate with any of their respective Actical®-measured variables (p > 0.008). The leisure time PPAQ questions overestimated MVPA by 1 ± 3 hrs/wk, with a positive correlation between PPAQ-leisure time MVPA and Actical®-measured MVPA (r = 0.565, p = 0.001). CONCLUSION: The PPAQ significantly overestimates MVPA and does not provide an accurate estimate of PA in pregnancy. While PPAQ leisure time questions may help distinguish trends in PA, data from subjective questionnaires may result in misinterpretation of relationships between prenatal PA and health outcomes.

Parental perceptions and childhood dietary quality.

The early years represent a critical period of growth and development of health behaviours. While optimal child growth is associated with a complex set of factors, the importance of diet quality is undeniable. The objective of this narrative review is to examine contributors to child diet quality and parental perception and how such perceptions might affect child diet quality. An extensive literature search was conducted, generating a variety of sources including research trials (randomized and non-randomized), lab-based studies, cohort studies, topical reviews, government or NGO reports and grey literature. In addition, reflection and opinion, accrued through regular interaction with families, regarding some of the potential links has also been included. Parental perception of diet quality is influenced by many different social, biological economical and psychological factors. Research suggests that diet quality of today's children is sub-optimal and a parent's perception of their child's diet may not accurately reflect this reality. Various parental attitudes and perceptions/misperceptions are important to address as knowledge awareness and beliefs can impact diet quality as can parental practices, and family structure. Issues related to socioeconomics and convenience, and a child's preferences and their peer and/or social environment are also potential factors impacting child diet quality. Knowing that parents play such an integral role in the development and maintenance of their child's health behaviours, addressing misconceptions and unhealthy parental beliefs about diet quality may be an important area for early intervention and prevention work in childhood obesity.

Young children and parental physical activity levels: findings from the Canadian health measures survey.

BACKGROUND: Physical inactivity is a global public health concern. The relationship between dependent children in the home and parental physical activity has not been quantified using objective measures, nor has the relative association of the physical activity levels of mothers and fathers been examined. PURPOSE: To investigate the association of children of different ages in the home on two measures of parental physical activity: daily moderate-to-vigorous physical activity (MVPA) and likelihood of meeting the guideline of 150 minutes of MVPA per week accumulated in 10-minute bouts. METHODS: Data were from the 2007-2009 Canadian Health Measures Survey (n=2315), and analyses were conducted between February and December 2011. MVPA was measured directly using accelerometry. Linear (minutes of MVPA) and logistic (meeting physical activity guidelines) regression models were performed to determine if the presence, number of children, or the age of the youngest child at home was associated with parental physical activity. All models were adjusted for parental age, marital status, household income, employment, and BMI. RESULTS: Mothers whose youngest child was aged <6 years and fathers whose youngest was aged 6-11 years engaged in fewer minutes of daily MVPA than those without dependent children. Linear regression results identified that in comparison to those without children, women whose youngest child in the home was aged <6 years participated in 7.7 minutes less activity per day (p=0.007) whereas men engaged in 5.7 fewer minutes per day, or 54 and 40 minutes per week less, respectively. Similarly, logistic regression analyses indicated that both women and men were less likely to meet guidelines if their youngest child in the home was aged <6 years (OR=0.31, 95% CI=0.11, 0.87; OR=0.34, 95% CI=0.13, 0.93). CONCLUSIONS: The physical activity level of parents with young children present in the home was lower than that of those without children. Given the many physiologic, psychological, and social benefits of healthy active living, research efforts should continue to focus on strategies to encourage parents with young children to establish or re-engage in a physically active lifestyle, not only for their own health but to model healthy behavior for the next generation.

Can we modify the intrauterine environment to halt the intergenerational cycle of obesity?

Child obesity is a global epidemic whose development is rooted in complex and multi-factorial interactions. Once established, obesity is difficult to reverse and epidemiological, animal model, and experimental studies have provided strong evidence implicating the intrauterine environment in downstream obesity. This review focuses on the interplay between maternal obesity, gestational weight gain and lifestyle behaviours, which may act independently or in combination, to perpetuate the intergenerational cycle of obesity. The gestational period, is a crucial time of growth, development and physiological change in mother and child. This provides a window of opportunity for intervention via maternal nutrition and/or physical activity that may induce beneficial physiological alternations in the fetus that are mediated through favourable adaptations to in utero environmental stimuli. Evidence in the emerging field of epigenetics suggests that chronic, sub-clinical perturbations during pregnancy may affect fetal phenotype and long-term human data from ongoing randomized controlled trials will further aid in establishing the science behind ones predisposition to positive energy balance.