Designing an App for Immunosuppression Adherence and Communication: A Qualitative Approach.

BACKGROUND: Immunosuppression nonadherence may be the most important factor limiting long-term allograft survival. OBJECTIVE: Following user-centered design, we explored the essential priorities and preferences of kidney transplant recipients and healthcare providers (HCP) to inform development of a smartphone app to improve immunosuppression adherence and communication. DESIGN: A qualitative descriptive research design was used. SETTING: The University of Alberta Hospital adult kidney transplant program in Edmonton, Canada. PARTICIPANTS: Participants were recruited by convenience sampling and included 32 kidney transplant recipients and 11 HCPs. METHODS: Seven focus groups (5 with recipients and 2 with HCPs) were conducted to inform app development. Sessions were recorded, and transcripts were coded to elucidate themes. RESULTS: App development to improve adherence was not a priority for HCP. Recipients prioritized choice: that all features be optional. Recipients preferred support while traveling; access to laboratory results; and use by younger or newly transplanted recipients. Both recipients and HCP preferred linkage to pharmacy; and self-management and accountability.For the app to improve communication, HCPs believed the priorities to be addressed included: clarity on scope of app; legal, ethical, and professional obligations; and charting. Both recipients and HCP prioritized HCP workload, and broader medication and health concerns. Healthcare providers preferred tech support; both recipients and HCPs preferred app access for nontransplant HCP. LIMITATIONS: Limitations include underrepresentation of physicians, recipients with racial/ethnic diversity, and potential selection bias of transplant recipients who perceived themselves to be adhering to immunosuppression medications. CONCLUSION: Future research is needed for the app to become a comprehensive, secure platform for broader communication between recipients and HCP, pharmacies, and nontransplant clinicians while streamlining HCP workload.

CONTEXTE: La non-observance du traitement immunosuppresseur pourrait s'avérer le facteur limitant ayant la plus grande incidence sur la survie à long terme de l'allogreffe. OBJECTIFS: Suivant une conception centrée sur l'utilisateur, nous avons exploré les préférences et les priorités essentielles des receveurs d'une greffe rénale et des fournisseurs de soins de santé (FSS) afin d'orienter le développement d'une application pour téléphones intelligents visant à améliorer les communications et l'observance du traitement immunosuppresseur. TYPE D'ÉTUDE: Un plan de recherche qualitatif et descriptif a été utilisé. CADRE: Le program de transplantation rénale pour adultes du University of Alberta Hospital à Edmonton (Canada). PARTICIPANTS: Les participants ont été recrutés par échantillonnage de commodité. L'étude a inclus 32 receveurs d'une greffe rénale et 11 FSS. MÉTHODOLOGIE: Sept groupes de discussion (5 avec les receveurs, 2 avec les FSS) ont été organisés pour guider le développement de l'application. Les séances ont été enregistrées et les transcriptions ont été codées afin de préciser les thèmes. RÉSULTATS: Le développement d'une application pour améliorer l'observance au traitement n'était pas une priorité pour les FSS. Les receveurs d'une greffe priorisaient d'avoir le choix : ils souhaitaient que toutes les fonctionnalités soient facultatives. Les receveurs d'une greffe avaient une préférence pour une application qui offrirait du soutien lors de leurs déplacements, qui permettrait un accès aux résultats de laboratoire et qui soit utilisée par les nouveaux greffés et les receveurs plus jeunes. Tous les participants préféraient que l'application propose un lien vers la pharmacie et qu'elle favorise l'autogestion et la responsabilisation.Pour que l'application améliore la communication, les FSS étaient d'avis qu'il fallait s'attarder aux priorités suivantes : la clarté de la portée de l'application; les obligations juridiques, éthiques et professionnelles; et la tenue des dossiers. Tant les receveurs d'une greffe que les FSS accordaient une priorité à la charge de travail des professionnels de la santé et aux préoccupations plus générales en matière de santé et de médicaments. Les FSS préféraient une assistance technique; et tous les participants avaient une préférence pour que l'application soit accessible aux FSS ne travaillant pas en transplantation. LIMITES: Parmi les limites figurent la sous-représentation des médecins, l'absence de receveurs issus de la diversité raciale/ethnique et un possible biais de sélection des receveurs d'une greffe qui se perçoivent comme adhérant à leur traitement immunosuppresseur. CONCLUSION: D'autres recherches sont nécessaires pour que l'application devienne une plateforme complète et sécurisée qui facilite la communication entre les patients, les professionnels de la santé, les pharmacies et les cliniciens ne travaillant pas en transplantation, tout en allégeant la charge de travail des fournisseurs de soins.

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada.

Importance: Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. Objective: To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. Design, Setting, and Participants: This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Interventions: Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Main Outcomes and Measures: Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. Results: A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). Conclusions and Relevance: The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.

Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives.

BACKGROUND: Knowledge Translation evidence from health care practitioners and administrators implementing Enhanced Recovery After Surgery (ERAS) care has allowed for the spread and scale of the health care innovation. There is a need to identify at a health system level, what it takes from a leadership perspective to move from implementation to sustainability over time. The purpose of this research was to systematically synthesize feedback from health care leaders to inform further spread, scale and sustainability of ERAS care across a health system. METHODS: Alberta Health Services (AHS) is the largest Canadian health system with approximately 280,000 surgeries annually at more than 50 surgical sites. In 2013 to 2014, AHS used a structured approach to successfully implement ERAS colorectal guidelines at six sites. Between 2016 and 2018, three of the six sites expanded ERAS to other surgical areas (gynecologic oncology, hepatectomy, pancreatectomy/Whipple's, and cystectomy). This research was designed to explore and learn from the experiences of health care leaders involved in the AHS ERAS implementation expansion (eg. surgical care unit, hospital site or provincial program) and build on the model for knowledge mobilization develop during implementation. Following informed consent, leaders were interviewed using a structured interview guide. Data were recorded, coded and analyzed qualitatively through a combination of theory-driven immersion and crystallization, and template coding using NVivo 12. RESULTS: Forty-four individuals (13 physician leaders, 19 leading clinicians and hospital administrators, and 11 provincial leaders) were interviewed. Themes were identified related to Supportive Environments including resources, data, leadership; Champion and Nurse coordinator role; and Capacity Building through change management, education, and teams. The perception and role of leaders changed through initiation and implementation, spread, and sustainability. Barriers and enablers were thematically aligned relative to outcome assessment, consistency of implementation, ERAS care compliance, and the implementation of multiple guidelines. CONCLUSIONS: Health care leaders have unique perspectives and approaches to support spread, scale and sustainability of ERAS that are different from site based ERAS teams. These findings inform us what leaders need to do or need to do differently to support implementation and to foster spread, scale and sustainability of ERAS.

Researcher-decision-maker partnerships in health services research: practical challenges, guiding principles.

BACKGROUND: In health services research, there is a growing view that partnerships between researchers and decision-makers (i.e., collaborative research teams) will enhance the effective translation and use of research results into policy and practice. For this reason, there is an increasing expectation by health research funding agencies that health system managers, policy-makers, practitioners and clinicians will be members of funded research teams. While this view has merit to improve the uptake of research findings, the practical challenges of building and sustaining collaborative research teams with members from both inside and outside the research setting requires consideration. A small body of literature has discussed issues that may arise when conducting research in one's own setting; however, there is a lack of clear guidance to deal with practical challenges that may arise in research teams that include team members who have links with the organization/community being studied (i.e., are "insiders"). DISCUSSION: In this article, we discuss a researcher-decision-maker partnership that investigated practice in primary care networks in Alberta. Specifically, we report on processes to guide the role clarification of insider team members where research activities may pose potential risk to participants or the team members (e.g., access to raw data). SUMMARY: These guiding principles could provide a useful discussion point for researchers and decision-makers engaged in health services research.

Prevalence of violence against women reported in a rural health region.

INTRODUCTION: Violence against women in Canada is an important public health problem. Published research that reports prevalence of violence against women by province or region is limited, and estimates of the rates of violence experienced by rural women are sparse. METHODS: This study reports the results of a secondary analysis of data to examine the prevalence of physical and sexual assault reported by women in a rural health region in Alberta, Canada. The report of assault was then examined to determine its relationship to self-reported health conditions, behaviours and health service use. RESULTS: In this study, 5% of women reported experiencing physical assault in the last 12 months and 23% reported experiencing sexual assault in their lifetime. Younger women reported more assault than older women. Women who reported sexual assault were more likely to report having used illicit drugs. Women who reported physical assault within the last 12 months were significantly more likely to also report having accessed mental health services and emergency services within the past year. Most women had seen a general practitioner or family doctor within the last 12 months. CONCLUSION: We argue that an integrated community-based model of service that includes the health sector is necessary to address violence against women in rural areas.

A case study of volunteers providing labour and childbirth support in hospitals in Canada.

OBJECTIVE: to document the process and outcome of an attempt to combine and institutionalise two grassroots health programmes that provided trained volunteers to support women through labour and childbirth in hospital. DESIGN: a qualitative, descriptive, comparative case study of programmes, with data collected through in-depth individual interviews with key informants and document review. SETTING: a Regional Health Authority in Canada. PARTICIPANTS: 16 women, from various stakeholder groups, with knowledge about the programmes. FINDINGS: despite considerable effort expended, the unified regional programme was not realised. This research highlights contextual factors that were salient for the programme's implementation. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: complex individual, interpersonal and institutional factors needed to be acknowledged but were not addressed in programme planning. This research may be relevant to policy and decision makers considering expansion of grassroots or community programmes to regional levels of service.

Women's perceptions of future risk after low-energy fractures at midlife.

PURPOSE: Low-energy fractures experienced by women at midlife and beyond place them at increased risk of future fractures and may be early indicators of low bone density. We report here on women's postfracture narratives to provide insight into how family physicians might tailor their messages to patients in communicating risk. METHODS: An interview guide was used in face-to-face interviews with women aged 40 years and older. Patients were asked to describe their fracture experience and recovery during the subsequent year. Interviews were audiorecorded and transcribed verbatim. Analysis was done initially using an immersion-crystallization approach. RESULTS: Twenty-two women participated in this research. The analysis showed women's reactions to information about their risk fell into 3 groups. The first took a laissez faire approach, preferring to wait and see what the future held. The second group recognized some of the things they should be doing but were inconsistent in maintaining changes or seeking relevant information. The third group saw information about future risk as salient and important to their daily lives. They actively sought out information, including discussions with their family physicians. CONCLUSIONS: Discovering whether patients have had an injury and, if so, how they perceive future risk is important because the invisibility of this health hazard calls for vigilance early on in women's lives. Family physicians can help patients move from perceiving the fractures as isolated accidents to understanding them as indicators of future risk by discussing the importance of bone health in the short and long term.

After the fall: women's views of fractures in relation to bone health at midlife.

Past research has established the link between low energy fractures and the risk for future fractures. These fractures are potential markers for investigation of bone health, and may be precursors for osteoporosis. In spite of its significant public health burden, including burden of illness and economic costs, many individuals are not aware of the risk factors for and consequences of osteoporosis. This is a study of women aged 40 and older who experienced low energy fractures (e.g., from non-trauma sources and falls from no higher than standing height). We gathered data, using focus group interviews, about their experiences and understanding of the fractures in relation to bone health. Women often attributed the fractures to particular situations and external events (e.g., slipping on ice, tripping on uneven ground), and viewed the fractures as accidents. Women often felt that others are at risk for poor bone health, but believed that they themselves are different from those really at risk. Although the fractures are potential triggers for preventive efforts, few women connected their fracture to future risk. What is perceived by women (and others) as random and an accident is often a predictable event if underlying risk factors are identified. Only when there is more awareness of poor bone health as a disease process and fractures as markers for bone fragility will women, men and health care providers take action to prevent future fractures and established bone disease.