Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study.

This population-based study analyzes hip fracture and osteoporosis treatment rates among older adults, stratified by place of residence prior to fracture. Hip fracture rates were higher among older adults living in the community and discharged to long-term care (LTC) after fracture, compared to LTC residents and older adults living in the community. Only 23% of LTC residents at high fracture risk received osteoporosis treatment. PURPOSE: This population-based study examines hip fracture rate and osteoporosis management among long-term care (LTC) residents > 65 years of age compared to community-dwelling older adults at the time of fracture and admitted to LTC after fracture, in Ontario, Canada. METHODS: Healthcare utilization and administrative databases were linked using unique, encoded identifiers from the ICES Data Repository to estimate hip fractures (identified using the Public Health Agency of Canada algorithm and International Classification of Diseases (ICD)-10 codes) and osteoporosis management (pharmacotherapy) among adults > 66 years from April 1, 2014 to March 31, 2018. Sex-specific and age-standardized rates were compared by pre-fracture residency and discharge location (i.e., LTC to LTC, community to LTC, or community to community). Fracture risk was determined using the Fracture Risk Scale (FRS). RESULTS: At baseline (2014/15), the overall age-standardized hip fracture rate among LTC residents was 223 per 10,000 person-years (173 per 10,000 females and 157 per 10,000 males), 509 per 10,000 person-years (468 per 10,000 females and 320 per 10,000 males) among the community to LTC cohort, and 31.5 per 10,000 person-years (43.1 per 10,000 females and 25.6 per 10,000 males). During the 5-year observation period, the overall annual average percent change (APC) for hip fracture increased significantly in LTC (AAPC = + 8.6 (95% CI 5.0 to 12.3; p = 0.004) compared to the community to LTC group (AAPC = + 2.5 (95% CI - 3.0 to 8.2; p = 0.248)) and the community-to-community cohort (AAPC - 3.8 (95% CI - 6.7 to - 0.7; p = 030)). However, hip fracture rate remained higher in the community to LTC group over the study period. There were 33,594 LTC residents identified as high risk of fracture (FRS score 4 +), of which 7777 were on treatment (23.3%). CONCLUSION: Overall, hip fracture rates have increased in LTC and among community-dwelling adults admitted to LTC after fracture. However, hip fracture rates among community-dwelling adults have decreased over time. A non-significant increase in osteoporosis treatment rates was observed among LTC residents at high risk of fracture (FRS4 +). Residents in LTC are at very high risk for fracture and require individualized based on goals of care and life expectancy.

A "Patient Preference" Model of Recruitment for Research from Primary-Care-Based Memory Clinics: A Promising New Approach.

Recruiting persons with dementia for clinical trials can be challenging. Building on a guide initially developed to assist primary-care-based memory clinics in their efforts to support research, a key stakeholder working group meeting was held to develop a standardized research recruitment process, with input from patients, care partners, researchers, and clinicians. Discussions in this half-day facilitated meeting focused on the wishes and needs of patients and care partners, policy and procedures for researchers, information provided to patients, and considerations for memory clinics. Patients and care partners valued the opportunity to contribute to science and provided important insights on how to best facilitate recruitment. Discussions regarding proposed processes and procedures for research recruitment highlighted the need for a new, patient-driven approach. Accordingly, a key stakeholder co-designed "Memory Clinic Research Match" program was developed that has the potential to overcome existing barriers and to increase recruitment for dementia-related research.

Cost-utility analysis of a multispecialty interprofessional team dementia care model in Ontario, Canada.

OBJECTIVES: To examine the cost-effectiveness of Multi-specialty INterprofessional Team (MINT) Memory Clinic care in comparison to the provision of usual care. DESIGN: Using a Markov-based state transition model, we performed a cost-utility (costs and quality-adjusted life years, QALY) analysis of MINT Memory Clinic care and usual care not involving MINT Memory Clinics. SETTING: A primary care-based Memory Clinic in Ontario, Canada. PARTICIPANTS: The analysis included data from a sample of 229 patients assessed in the MINT Memory Clinic between January 2019 and January 2021. PRIMARY OUTCOME MEASURES: Effectiveness as measured in QALY, costs (in Canadian dollars) and the incremental cost-effectiveness ratio calculated as the incremental cost per QALY gained between MINT Memory Clinics versus usual care. RESULTS: MINT Memory Clinics were found to be less expensive ($C51 496 (95% Crl $C4806 to $C119 367) while slightly improving quality of life (+0.43 (95 Crl 0.01 to 1.24) QALY) compared with usual care. The probabilistic analysis showed that MINT Memory Clinics were the superior treatment compared with usual care 98% of the time. Variation in age was found to have the greatest impact on cost-effectiveness as patients may benefit from the MINT Memory Clinics more if they receive care beginning at a younger age. CONCLUSION: Multispecialty interprofessional memory clinic care is less costly and more effective compared with usual care and early access to care significantly reduces care costs over time. The results of this economic evaluation can inform decision-making and improvements to health system design, resource allocation and care experience for persons living with dementia. Specifically, widespread scaling of MINT Memory Clinics into existing primary care systems may assist with improving quality and access to memory care services while decreasing the growing economic and social burden of dementia.

Frailty prevalence and efficient screening in primary care-based memory clinics.

BACKGROUND: Little is known about the prevalence of frailty among patients with memory concerns attending a primary care-based memory clinic. OBJECTIVE: This study aims to describe the prevalence of frailty among patients attending a primary care-based memory clinic and to determine if prevalence rates differ based on the screening tool that is used. METHODS: We conducted a retrospective medical record review for all consecutive patients assessed in a primary care-based memory clinic over 8 months. Frailty was measured in 258 patients using the Fried frailty criteria, which relies on physical measures, and the Clinical Frailty Scale (CFS), which relies on functional status. Weighted kappa statistics were calculated to compare the Fried frailty and the CFS. RESULTS: The prevalence of frailty was 16% by Fried criteria and 48% by the CFS. Agreement between Fried frailty and CFS was fair for CFS 5+ (kappa = 0.22; 95% confidence interval: 0.13, 0.32) and moderate for CFS 6+ (kappa = 0.47; 0.34, 0.61). Dual-trait measures of hand grip strength with gait speed were found to be a valid proxy for Fried frailty phenotype. CONCLUSIONS: Among primary care patients with memory concerns, frailty prevalence rates differed based on the measure used. Screening for frailty in this population using measures relying on physical performance may be a more efficient approach for persons already at risk of further health instability from cognitive impairment. Our findings demonstrate how measure selection should be based on the objectives and context in which frailty screening occurs.

There is some evidence that frailty and dementia are inter-related. This study aimed to describe the prevalence of frailty among patients attending a primary care-based memory clinic using 2 commonly used frailty measures: the Fried frailty phenotype criteria and the Clinical Frailty Scale (CFS). Frailty prevalence in patients with memory concerns is at least double that of regular primary care practice; prevalence is 16% when the Fried frailty phenotype is used, which incorporates physical frailty measures, as compared with prevalence of 48% when the more function-based measure of CFS is used. Screening tools should be selected considering the objectives and context in which they are used. Within primary care-based memory clinics, physical frailty measures may be most optimal. Using hand grip and gait speed screening as a valid proxy for Fried frailty phenotype offers a feasible and practical way of identifying frailty relating more to physical underlying conditions. Based on our study findings, frailty screening within primary care-based memory clinics is justified for patients 65 years+; early identification and intervention may prevent further decline and adverse outcomes. Further research in this area will increase our understanding of frailty and dementia in this context and how to best plan care.

An innovative approach to recruiting participants for dementia research: primary care and researcher perspectives.

Aim: To describe clinician and researcher perceptions of a new, patient preference focused approach to recruiting patients for research from primary care-based memory clinics. Methods: Memory clinic clinicians completed a survey and key informants completed an individual interview to gather their perceptions of this new program. Results: The majority of clinicians were 'satisfied' or 'very satisfied' with this recruitment approach and indicated that this approach would have minimal negative impact on patient care or create conflict of interest. Key informants valued the program for its patient-centred approach, the integration of research into care and potential for increased recruitment. Discussion: These findings are suggestive of support for this recruitment approach. Pilot testing will inform feasibility, effectiveness and process improvements.

Recruitment of participants for dementia research: interprofessional perspectives from primary care-based memory clinics.

Aim: To understand clinician attitudes and the barriers that impede research recruitment from specialized primary care-based memory clinics. Materials & methods: Clinicians completed a survey on attitudes and barriers to research recruitment from memory clinics. Results: Comfort and willingness to recruit for research were low to moderate and were lower for drug trials than for observational and non-drug trials. Respondents believed that it is important to have a standardized recruitment process. Identified barriers provide some insights into the factors that contribute to discomfort and lack of willingness to recruit research participants. Discussion: Findings can inform future efforts to develop a recruitment process that addresses identified barriers, while also providing an opportunity to increase participant recruitment in dementia research.

Recruitment of persons living with dementia from primary care for research is challenging and can be a barrier to study completion. Multispecialty Interprofessional Team (MINT) Memory Clinics may provide a unique opportunity for recruiting patients for research studies. In this study, clinicians completed a survey on attitudes and barriers to research recruitment from memory clinics in primary care. Clinician comfort and willingness to recruit for research were low to moderate. A number of barriers to recruiting patients for research from MINT Clinics were identified and included limited time, workload issues, limited information to share with patients, and their lack of knowledge about and experience with research. These study findings can help to develop a recruitment process that addresses identified barriers and helps to increase participant recruitment in dementia research.

Frailty screening in older adults: is annual screening necessary in primary care?

BACKGROUND: The Case-finding for Complex Chronic Conditions in Adults 75+ (C5-75) involves annual frailty screening in primary care using dual-trait screening measures of handgrip strength and gait speed, with additional screening for co-existing conditions in those deemed frail. OBJECTIVE: To identify low-risk individuals who could be screened for frailty every 2 years, rather than annually. METHODS: This study examined a prospective cohort of patients who completed at least two annual C5-75 screenings between April 2014 and December 2018. Handgrip strength and gait speed on initial assessment were categorized based on proximity to frailty thresholds and were used to predict frailty risk on the second assessment. We used Fisher's exact test to assess differences in risk. Logistic regression models tested associations between independent variables of age, patient activity level, falls history, grip strength and gait speed on first assessment and dependent variable of frailty on subsequent assessment. RESULTS: Analyses included 571 patients with two annual assessments. Frailty risk on the second assessment was significantly higher for patients who had gait speed or grip strength within 20% of the frailty threshold (5.7%), compared with the other categories (0.7%, 0.9%, 0%; P = 0.002); 60% of patients fell within these lower risk categories. Controlling for grip strength and gait speed, no other measures had significant associations with frailty risk. CONCLUSIONS: Our results demonstrate that 60% patients are at low risk (<1%) of transitioning to frailty by the next annual assessment. Reducing screening frequency from annually to every 2 years may be appropriate for these patients.

Frail older adults are at greater risk for illness, functional decline, increased health service use and institutionalization. Adults 75 years of age and older should be screened regularly for frailty to provide early treatment for co-occurring conditions that may impact frailty but that may also be affected by frailty. Walking (gait) speed and handgrip strength are feasible measures of frailty to use on an annual basis in primary care. This study assesses the transition to frailty over a 1-year time period for the purpose of streamlining frailty screening in primary care for those patients who do not require annual screening. We found that when patients' grip strength and gait speed scores were 20% higher than the point at which people are identified as frail, they are at low risk for becoming frail by their next annual assessment. Frailty screening every 2 years may be appropriate for these patients. This streamlined screening process may make it more feasible for busy family practices to implement this type of frailty screening.

Comparing Virtual to In-Person Delivery of Continuing Medical Education in Dementia Care: Which Is Preferred?

OBJECTIVES: There is limited understanding of learners' perceptions of virtual learning during the COVID-19 pandemic, as well as the use of virtual modalities for interprofessional education (IPE) in primary care. Four of 7 in-person annual "Booster Day" IPE sessions for health professionals working in primary care-based memory clinics in Ontario, Canada, were canceled when the pandemic was declared; these sessions were replaced with 2 sessions delivered via live-streamed videoconferencing. This study compares Booster Day session participants' perceptions of the in-person and virtual sessions and assesses their preferences for in-person or virtual sessions in the future. DESIGN: Survey methodology. SETTING AND PARTICIPANTS: Interprofessional primary care-based memory clinic team members attending 1 of 5 annual IPE events, 3 delivered in-person immediately prior to the COVID-19 pandemic and 2 subsequently delivered virtually via videoconferencing. METHODS: Chi-squared test and analysis of variance was used to identify significant differences in reaction, attitude, and preference ratings between delivery modalities. RESULTS: There were no significant differences in satisfaction, relevance, knowledge acquisition, and intentions to apply new knowledge between delivery modalities. Although attendance via videoconferencing was perceived as useful, enjoyable, engaging, and as more feasible to attend, it was rated as less enjoyable and perceived as having fewer opportunities for networking than in-person sessions. Most participants preferred in-person sessions. CONCLUSIONS AND IMPLICATIONS: Quality engagement and networking, as afforded by in-person IPE, are highly valued by health professionals attending dementia-related education. IPE on complex health issues of the older people requiring interprofessional perspectives may be best suited to in-person formats.

Multispecialty Interprofessional Team Memory Clinics: Enhancing Collaborative Practice and Health Care Providers' Experience of Dementia Care.

This study explored whether working within Multispecialty INterprofessional Team (MINT) memory clinics has an impact on health care professionals' perceptions of the challenges, attitudes, and level of collaboration associated with providing dementia care. Surveys were completed by MINT memory clinic members pre- and 6-months post-clinic launch. A total of 228 pre-and-post-training surveys were matched for analysis. After working in the MINT memory clinics for 6 months, there were significant reductions in mean ratings of the level of challenge associated with various aspects of dementia care, and significant increases in the frequency with which respondents experienced enthusiasm, inspiration, and pride in their work in dementia care and in ratings of the extent of collaboration for dementia care. This study provides some insights into the effect of collaborative, interprofessional approaches on health care professionals' perceptions of the challenges and attitudes associated with providing dementia care and level of collaboration with other health professionals.

A Non-Pharmacologic Approach to Manage Behaviours in Confused Medically Ill Older Adults in Acute Care.

BACKGROUND: Non-pharmacological interventions are recommended to manage challenging behaviours among cognitively impaired older adults, however few studies have enrolled patients in acute care. This study aimed to determine the feasibility of implementing non-pharmacological interventions to manage behaviours in hospitalized older adults. METHOD: A self-identity approach was used to identify potentially engaging activities for 13 older medically ill adults admitted to acute hospital; these activities were trialed for a two-week period. Data were collected on frequency of intervention administration and assistance required, as well as frequency of behaviours and neuroleptic use in the seven days prior to and following the trial of activities. RESULTS: Per participant, 5-11 interventions were prescribed. Most frequently interventions were tried two or more times (46%); 9% were not tried at all. Staff or family assistance was not required for 27% of activities. The mean number of documented behaviours across participants was 4.8 ± 2.3 in the pre-intervention period and 2.1 ± 1.9 in the post-intervention period. Overall the interventions were feasible and did not result in increasing neuroleptic use. CONCLUSION: Non-pharmacologic interventions may be feasible to implement in acute care. More research in this area is justified.

The geriatric certificate program: collaborative partnerships for building capacity for a competent workforce.

Many practicing health care providers find themselves ill-prepared to meet the complex care needs of older adults. The Geriatric Certificate Program (GCP) represents a collaborative partnership leveraging existing educational courses, with new courses developed to fill existing education gaps, aimed at improving quality of care for older adults. This paper describes the GCP and examines its impact on knowledge, skills, clinical practice, as well as confidence, comfort, and competence in providing geriatric care. Upon program completion, all graduates (N = 146; 100%) completed an online evaluation survey. The majority of graduates reported (5-point scale: 1 = much less now; 5 = much more now) being more confident (88%), comfortable (83%), and competent (89%) to provide optimal geriatric care than prior to the program. The GCP provides a significant opportunity for health care providers to build their capacity for the care of older adults. Key lessons learned in implementing the GCP and suggestions for further development are discussed.

Factors That Predict 1-Year Incident Hip and Non-Hip Fractures for Home Care Recipients: A Linked-Data Retrospective Cohort Study.

OBJECTIVES: The purpose of our study was to identify factors that predict 1-year incident hip and major osteoporotic non-hip fractures (ie, wrist, spine, pelvis, humerus) for home care recipients while accounting for the competing risk of death. DESIGN: We conducted a retrospective cohort study with linked population data. SETTING AND PARTICIPANTS: All home care recipients in Ontario, Canada, receiving services for more than 6 months with an admission assessment between April 1, 2011, and March 31, 2015, were included. METHODS: Clinical data from the Resident Assessment Instrument Home Care were linked to fracture data from the Discharge Abstract Database and the National Acute Care Reporting System. Competing risk proportional hazard regressions using the Fine and Grey method were performed to model the association between potential risk factors and fracture. RESULTS: Previous fall, previous fracture, cognitive impairment, unsteady gait, alcohol use, tobacco use, and Parkinson disease were consistently associated with all fracture types. Cognitive impairment (hazard ratio 2.09; 95% confidence interval 1.86-2.36) and wandering [1.66 (1.06-1.27)] were most predictive of hip fractures and being female [1.86 (1.76-1.98)] and experiencing a previous fracture [1.86 (1.76-1.98)] were most predictive of non-hip fractures. Risk factors unique to non-hip fractures as compared with hip fractures were locomotion ability outdoors and psychotropic medication use. CONCLUSIONS AND IMPLICATIONS: Our results indicate that, in addition to typical fracture risk factors, home care recipients have unique characteristics that increase their risk. Fracture risk assessment tools and subsequent prevention strategies should be modified to accurately identify home care recipients at risk for imminent 1-year fracture.

Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process.

OBJECTIVES: To develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool. DESIGN: A modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels. SETTING AND PARTICIPANTS: A national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members. METHODS: Round 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17). RESULTS: In round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions. CONCLUSIONS AND IMPLICATIONS: An evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.

The C5-75 Program: Meeting the Need for Efficient, Pragmatic Frailty Screening and Management in Primary Care.

Case-Finding for Complex Chronic Conditions in Seniors 75+ (C5-75) is a systematic approach to identify frailty using gait speed and hand-grip strength and to screen for co-morbid conditions. We identified the C5-75 features offering the highest yield for identifying frailty and to streamline the screening program. Analyses included 1,948 C5-75 assessments completed from 2013 to 2018. Age 85 or older, less than regular physical activity, and more than two falls in the previous six months had the strongest associations with frailty. Exempting patients under 85 who reported regular physical activity and less than two falls excluded 39.1 per cent of the cohort while maintaining a sensitivity of 95.2 per cent and a negative predictive value of 99.4 per cent for frailty. These findings provide insight into optimizing screening for frailty, making it more feasible to implement and to identify co-existing conditions that may contribute to or be affected by frailty.

Enabling Advance Care Planning in Dementia Care: A Primary Care Approach.

BACKGROUND: Lack of tools to support advance care planning (ACP) has been identified as a significant barrier to implementing these discussions. AIM: We pilot tested an ACP framework tool for use with persons living with dementia (PLWD) in primary care-based memory clinics and an Adult Day Program; this study describes user and recipient experiences with this framework. METHODS: We used a mixed methods approach. Health professionals completed an online survey following pilot testing and PLWD and substitute decision makers (SDM) completed survey immediately following the ACP discussion assessing their satisfaction (5-point scale) with the framework and exploring potential outcomes. Interviews with health professionals, PLWD, and SDM were conducted to gather more in-depth information on their perceptions of the ACP framework/ discussion. RESULTS: Surveys were completed by 12 health professionals, 13 PLWD, and 16 SDM. While PLWD and SDM were satisfied with the ACP discussion (M = 4.0/5), health professionals were minimally satisfied with the ease of use of the framework (M = 2.0/5), acceptability for patients (M = 2.4/5) and feasibility in practice (M = 1.9/5). Sixteen interviews were completed with 8 health professionals, 1 PLWD, and 7 SDM. While health professionals valued ACP, lack of time and training were identified barriers to framework use. SDM felt better prepared for future decisions and PLWD were put at ease, knowing that their wishes for care were understood. CONCLUSION: PLWD and SDM value the opportunity for ACP, and although health professionals identified some concerns with framework administration, they acknowledge the value and importance of ACP. Continuing efforts to refine ACP processes are justified.

Preventing Fractures in Long-Term Care: Translating Recommendations to Clinical Practice.

The Ontario Osteoporosis Strategy for long-term care (LTC) aims to support fracture risk-reduction. LTC specific recommendations for fracture prevention were developed in 2015. This article describes the use of the Knowledge-to Action framework to guide the development and application of research evidence on fracture prevention in older adults. Knowledge translation activities highlighted fractures as a significant source of morbidity in LTC, significant gaps in fracture risk assessment and treatment, and barriers and facilitators to guideline implementation. Multifaceted knowledge translation strategies, targeting staff in LTC homes in Ontario, Canada to support fracture guideline implementation have included education, audit and feedback, team-based action planning, and engagement of LTC residents, their families, and health professionals. Provincial administrative databases were accessed to monitor fracture rates between 2005 and 2015. Our research has identified enablers and barriers to knowledge use such as limited knowledge of osteoporosis, fracture risk, and prevention. Province-wide over a 10-year period, hip fracture rates in LTC decreased from 2.3% to 1.9%, and any fracture rates decreased from 4% to 3.6%. This body of work suggests that multifaceted knowledge translation initiatives are feasible to implement in LTC and can improve the uptake of clinical recommendations for fracture prevention. A key aspect of our fracture prevention knowledge translation activities has been the full engagement of key stakeholders to assist in the co-development and design of knowledge translation products.

A Decade of Dementia Care Training: Learning Needs of Primary Care Clinicians.

INTRODUCTION: Limited knowledge of dementia among health professionals is a well-documented barrier to optimal care. This study examined the self-perceived challenges with dementia care and learning needs among primary care clinicians and assessed whether these were associated with years of practice and perceived preparedness for dementia care. METHODS: Participants were multi-disciplinary clinicians attending a 5-day team-based dementia education program and physicians attending a similar condensed continuing medical education workshop. Pre-education, they completed an online survey in which they rated (5-point scales): interest in learning about various dementia-related topics, perceived challenges with various dementia-related practice activities and preparedness for dementia care, provided additional dementia-related topics of interest, number of years in clinical practice, and discipline. RESULTS: Thirteen hundred surveys were completed across both education programs. Mean ratings of preparedness for dementia care across all respondents reflected that they felt somewhat prepared for dementia care. Challenge ratings varied from low to very challenging and mean ratings reflected a high level of interest in learning more about all of the dementia-related topics; significant differences between disciplines in these ratings were identified. In most cases, perceived challenges and learning needs were not correlated with number of years in clinical practice, but in some cases lower ratings of preparedness for dementia care were associated with higher ratings of the challenges of dementia care. DISCUSSION: Clinicians perceived that their formal education had not prepared them well for managing dementia and desired more knowledge in all topic areas, regardless of years in practice. Implications for education are discussed.

The Value in Mental Health Screening for Individuals With Spinal Cord Injury: What Patients Tell Us.

OBJECTIVE: To gather consumer perspectives of a mental health screening protocol and to identify the incidence of previously unrecognized mental health concerns (case finding). DESIGN: Pilot study using mixed methods: quantitative (survey) and qualitative (interviews). SETTING: Primary care health team in Kitchener, Ontario, Canada. PARTICIPANTS: Patients (N=15) with spinal cord injury living in the community. Participants ranged in age from 21 to 81 years of age (mean=46); 12 were men, 8 had tetraplegia and 5 paraplegia. The number of years since injury ranged from 1 to 32 (mean=13). INTERVENTION: Implementation of a mental health screening protocol consisting of standardized screening tools for depression, anxiety, substance abuse, social isolation, somatoform disorder, functional status, chronic pain, and cognitive impairment. MAIN OUTCOME MEASURES: Positive results on screening tool, acceptability of the screening process, perceptions of the value of screening, and intentions to follow resulting treatment recommendations. RESULTS: Screening identified 11 of 15 individuals with a chronic pain condition; 1 individual screened positive for depression, 1 for anxiety, 3 for potential substance abuse, and 1 for social isolation. Most of the participants (12/13) rated the screening protocol as very acceptable. All but 1 individual intended to follow resulting treatment recommendations. Interview analyses generated themes related to disclosure of experiences that were incomplete that concealed important information and perceptions that the screening protocol failed to assess resiliency. Although perceived as valuable, participants felt screening tools alone did not capture information important to them. CONCLUSIONS: Screening tools alone may not identify mental health issues. Interviews in addition to screening tools are needed to accurately identify mental health issues in this population. Identification of mental health issues is critical to ensuring access to effective interventions and improving health outcomes and quality of life for individuals with SCI.

Improving primary care for persons with spinal cord injury: Development of a toolkit to guide care.

OBJECTIVE: To identify a set of essential components for primary care for patients with spinal cord injury (SCI) for inclusion in a point-of-practice toolkit for primary care practitioners (PCP) and identification of the essential elements of SCI care that are required in primary care and those that should be the focus of specialist care. DESIGN: Modified Delphi consensus process; survey methodology. SETTING: Primary care. PARTICIPANTS: Three family physicians, six specialist physicians, and five inter-disciplinary health professionals completed surveys. OUTCOME MEASURES: Importance of care elements for inclusion in the toolkit (9-point scale: 1 = lowest level of importance, 9 = greatest level of importance) and identification of most responsible physician (family physician, specialist) for completing key categories of care. Open-ended comments were solicited. RESULTS: There was consensus between the respondent groups on the level of importance of various care elements. Mean importance scores were highest for autonomic dysreflexia, pain, and skin care and lowest for preventive care, social issues, and vital signs. Although, there was agreement across all respondents that family physicians should assume responsibility for assessing mental health, there was variability in who should be responsible for other care categories. Comments were related to the need for shared care approaches and capacity building and lack of knowledge and specialized equipment as barriers to optimal care. CONCLUSION: This study identified important components of SCI care to be included in a point-of-practice toolkit to facilitate primary care for persons with SCI.