Collaborative implementation science: a Can-SOLVE CKD case example.

ABSTRACT: Research is critical for uncovering new and effective therapies for better health outcomes, yet there remains a significant lag between identifying evidence-based interventions and implementing them into practice. Research teams can often be experienced in evidence generation, but less so in evidence implementation, underscoring the need for more customized tools to support them in this latter step. The implementation stage can be especially challenging given how strategies must be tailored to the unique end users and contexts of a given intervention. Therefore, our patient-oriented kidney research network sought to create an "Implementation Toolkit" and "Pathway to Implementation" guide to help research teams and their operational and clinical partners in implementing their interventions. Importantly, the tools were created using input and feedback from diverse groups, including patient partners, implementation science experts, researchers, operational leaders, and policymakers, all of whom play role in supporting the implementation of health interventions. Our tools are widely applicable to diverse teams, regardless of the intervention or innovation being implemented. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A214.

The impact of the Starting dialysis on Time, At home on the Right Therapy (START) project on the use of peritoneal dialysis.

BACKGROUND: Peritoneal dialysis (PD) is actively promoted, but increasing PD utilisation is difficult. The objective of this study was to determine if the Starting dialysis on Time, At Home, on the Right Therapy (START) project was associated with an increase in the proportion of dialysis patients receiving PD within 6 months of starting therapy. METHODS: Consecutive patients over age 18, with end-stage kidney failure, who started dialysis between 1 April 2015 and 31 March 2018 in the province of Alberta, Canada. Programmes were provided with high-quality data about the individual steps in the process of care that drive PD utilisation that were used to identify problem areas, design and implement interventions to address them, and then evaluate whether those interventions had impact. The primary outcome was the proportion of patients receiving PD within 6 months of starting dialysis. Secondary outcomes included hospitalisation, death or probability of transfer to haemodialysis (HD). Interrupted time series methodology was used to evaluate the impact of the quality improvement initiative on the primary and secondary outcomes. RESULTS: A total of 1962 patients started dialysis during the study period. Twenty-seven per cent of incident patients received PD at baseline, and there was a 5.4% (95% confidence interval: 1.5-9.2) increase in the use of PD in the province immediately after implementation. There were no changes in the rates of hospitalisation, death or probability of transfer to HD after the introduction of START. CONCLUSIONS: The approach used in the START project was associated with an increase in the use of PD in a setting with high baseline utilisation.

A study protocol for improving the delivery of acute kidney replacement therapy (KRT) to critically ill patients in Alberta - DIALYZING WISELY.

BACKGROUND: Acute kidney replacement therapy (KRT) is delivered to acutely ill patients to support organ function and life in the Intensive Care Unit (ICU). Implementing standardized acute KRT pathways can ensure its safe and effective management. At present, there is no standardized approach to the management of acute KRT in Alberta ICUs. METHODS: Dialyzing Wisely is a registry embedded, stepped-wedge, interrupted time-series evaluation of the implementation of a standardized, stakeholder-informed, and evidence-based acute KRT pathway into Alberta ICUs. The acute KRT pathway will consist of two distinct phases. First, we will implement routine monitoring of evidence-informed key performance indicators (KPIs) of acute KRT. Second, we will provide prescriber and program reports for acute KRT initiation patterns. After the implementation of both phases of the pathway, we will evaluate acute KRT performance quarterly and implement a customized suite of interventions aimed at improving performance. We will compare this with baseline and evaluate iterative post implementation effects of the care pathway. DISCUSSION: Dialyzing Wisely will implement, monitor, and report a suite of KPIs of acute KRT, coupled with a care pathway that will transform the quality of acute KRT across ICUs in Alberta. This program will provide a framework for scaling evidence-informed approaches to monitoring and management of acute KRT in other jurisdictions. We anticipate improvements in acute KRT performance, decreased healthcare system costs and improved patient quality of life by decreasing patient dependence on maintenance dialysis. TRIAL REGISTRATION: Clinicaltrials.gov , NCT05186636. Registered 11, January, 2022.

Laboratory reporting of framingham risk score increases statin prescriptions in at-risk patients.

BACKGROUND: The under-utilization of cardiovascular preventative therapy with statins warrants novel interventions to optimize prescriptions in at-risk patients. We investigated the role of a laboratory generated Framingham Risk Score (FRS) provided to primary care clinicians in changing statin use in a primary care setting. METHODS: Data was acquired from the electronic medical records of 1573 anonymized patients undergoing routine lipid testing. Follow-up statin use and low-density lipoprotein cholesterol levels were obtained for 2 years post intervention. FRS parameters were entered into a laboratory information system, and provided to ordering physicians along with the cholesterol profile and the appropriate current Canadian Dyslipidemia treatment recommendation in a single report. Statin prescription rates following the intervention were compared with historical use 6 months prior to the study. RESULTS: A total of 1283 participants (mean age of 60 ± 11 years) had an FRS report and were considered for analysis. Two hundred individuals filled a statin prescription in the 6 months prior to their index lipid test, and an additional 84 filled a statin prescription following the intervention (42% increase). The relative and absolute increase in statin prescription was 47.3% and 13.6% in the high-risk group p < 0.001, 53.3% and 8.1% in the intermediate-risk group p < 0.001, and 17.0% and 1.42% in the low-risk group p = 0.008, respectively. CONCLUSION: The use of the laboratory reported FRS was associated with a significant increase in the rate of statin prescription across all risk groups. The expansion of FRS reporting across other health regions would improve cardiovascular risk prevention.

Starting Dialysis on Time, At Home on the Right Therapy (START): Description of an Intervention to Increase the Safe and Effective Use of Peritoneal Dialysis.

BACKGROUND: Most of the patients with end-stage kidney failure are treated with dialysis. Jurisdictions around the world are actively promoting peritoneal dialysis (PD) because it is equivalent to hemodialysis in terms of clinical outcomes, but is less costly. Unfortunately, PD penetration remains low. OBJECTIVES: The Starting dialysis on Time, At Home, on the Right Therapy (START) Project had 2 overarching goals: (1) to provide information that would help programs increase the safe and effective use of PD, and (2) to reduce inappropriate, early initiation of dialysis in patients with kidney failure. In this article, we focus on the first objective and describe the rationale for START and the methods employed. DESIGN: The START Project was a comprehensive, province-wide quality improvement intervention. SETTING: The START project was implemented in both Alberta Kidney Care (AKC)-South and AKC-North, including all 7 renal programs in the province. PATIENTS: The project included all patients who commenced maintenance dialysis between October 1, 2015, and March 31, 2018, in Alberta, Canada who met our inclusion criteria. MEASUREMENTS: We reported baseline characteristics of incident dialysis patients overall, and by site. Our key performance indicator was the proportion of patients who received PD for any period of time within 180 days of the first dialysis treatment. Reports also included detailed metrics pertaining to the 6 steps in the process of modality selection and we had the capacity to provide more granular data on an as-needed basis. To understand loss of PD patients, we reported the numbers of incident patients who recovered kidney function, experienced technique failure, received a transplant, were lost to follow-up, transferred to another program, or died. METHODS: START provided dialysis programs with a conceptual framework for understanding the drivers of PD utilization. High-quality, detailed data were collected using a tool that was custom-built for this purpose, and were mapped to steps in the process of care that drove the outcomes of interest. This allowed sites to identify gaps in care, develop action plans, and implement local interventions to address them. The process was supported by an Innovation Learning Collaborative consisting of 3 learning sessions that brought frontline staff together from across the province to share strategies and learnings. Ongoing data collection allowed teams to determine whether their interventions were effective at each subsequent learning session, and to revisit their interventions if required (the "Plan-Do-Study-Act Cycle"). RESULTS: Future work will report on the impact of the START project on incident PD utilization at a provincial and regional level. LIMITATIONS: The time required to design and implement interventions in practice, as well as the need for multiple PDSA (Plan-Do-Study-Act) cycles to see results, meant that the true potential may not be realized during a relatively short intervention period. Change required buy-in and support from local and provincial leadership and frontline staff. In the absence of accountability for local performance, we relied on the goodwill of participating programs to use the information and resources provided to effect change. Finally, the burden of documentation and data collection for frontline staff was high at baseline. We anticipated that adding supplemental data collection would be difficult. CONCLUSIONS: The START project was a comprehensive, province-wide initiative to maximize the safe and effective use of PD in Alberta, Canada. It standardized the management of incident dialysis patients, leveraged high-quality data to facilitate the reporting of metrics mapped to steps in the process of care that drove incident PD utilization, and helped programs to identify gaps in care and target them for improvement. Future work will report on the impact of the program on incident utilization at the provincial and regional level.

CONTEXTE: La majorité des patients atteints d'insuffisance rénale terminale (IRT) sont traités par dialyze. On s'efforce, partout dans le monde, de promouvoir la dialyze péritonéale (DP) parce qu'elle donne des résultats cliniques équivalents à ceux de l'hémodialyse, mais à moindres coûts. Malheureusement, l'adhésion à la DP demeure faible. OBJECTIFS: Le projet START (The Starting dialysis on Time, At Home, on the Right Therapy) avait deux objectifs principaux : (1) fournir de l'information qui aiderait les programs à accroître l'utilization sûre et efficace de la DP, et (2) réduire l'initiation précoce et inappropriée de la dialyze chez les patients atteints d'insuffisance rénale. Dans cet article, nous nous concentrons sur le premier objectif et nous décrivons la raison d'être de START et les méthodes employées. TYPE D'ÉTUDE: Le projet START était une intervention globale d'amélioration de la qualité à l'échelle provinciale. CADRE: Le projet START a été mis en œuvre au sein de l'Alberta Kidney Care (AKC) ­ South et de l'AKC-North, qui incluent les 7 programs rénaux de la province. SUJETS: Le projet a inclus tous les patients répondant aux critères d'inclusion qui avaient amorcé des traitements de dialyze d'entretien entre le 1er octobre 2015 et le 31 mars 2018 en Alberta (Canada). MESURES: Nous avons rapporté les caractéristiques de base des patients dialysés incidents de façon globale et par site. Notre principal indicateur de performance était la proportion de patients qui ont reçu la DP pendant une période quelconque au cours des 180 jours suivant le premier traitement de dialyze. Les rapports comprenaient également des mesures détaillées concernant les 6 étapes du processus de sélection de la modalité et nous étions en mesure de fournir des données plus précises au besoin. Pour mieux définir la perte de patients sur DP, nous avons rapporté le nombre de patients incidents ayant récupéré une fonction rénale, ayant vécu une défaillance technique, ayant reçu une greffe, ayant été perdus de vue, ayant été transférés à un autre program ou étant décédés. MÉTHODOLOGIE: START a fourni aux programs de dialyze un cadre conceptuel pour comprendre les facteurs d'utilization de la DP. Des données détaillées et de grande qualité ont été recueillies à l'aide d'un outil conçu spécifiquement à cette fin, et ont été mises en correspondance avec les étapes du processus de soins ayant conduit aux résultats d'intérêt. Ainsi, les sites ont pu déceler les lacunes dans les soins, élaborer des plans d'action et mettre en œuvre des interventions locales pour combler ces lacunes. Le processus a été appuyé par une collaboration d'apprentissage innovante constituée de trois séances d'apprentissage qui ont réuni le personnel de première ligne de toute la province afin que ceux-ci partagent leurs stratégies et apprentissages. La collecte continue de données a permis aux équipes de déterminer si leurs interventions étaient efficaces et de revoir leurs interventions si nécessaire (le cycle PDSA: Plan-Do-Study-Act) lors de chaque séance d'apprentissage ultérieure. RÉSULTATS: Les travaux futurs feront état de l'impact du projet START sur l'utilization de la DP à l'échelle provinciale et régionale. LIMITES: Le véritable potentiel du projet pourrait ne pas se révéler lors d'une période d'intervention relativement courte en raison du temps requis pour concevoir les interventions et les mettre en œuvre dans la pratique, et parce que le processus nécessite de procéder à plusieurs cycles PDSA avant de produire des résultats. Le changement exige l'adhésion et le soutien des directions locales et provinciales et du personnel de première ligne. En l'absence de responsabilisation à l'égard des réalisations locales, nous nous sommes appuyés sur la bonne volonté des programs participants à utiliser l'information et les ressources fournies pour faire le changement. Aussi, en début de processus, le fardeau de documenter et de collecter les données s'est avéré lourd pour le personnel de première ligne. Nous avions prévu qu'il serait difficile d'ajouter une collecte de données supplémentaire. CONCLUSION: Le projet START était une initiative globale à l'échelle provinciale qui visait à maximiser l'utilization sécuritaire et efficace de la DP en Alberta, au Canada. Le projet a normalisé la gestion des patients dialysés incidents, a exploité des données de haute qualité pour faciliter la déclaration des indicateurs correspondant aux étapes du processus de soins menant à l'utilization de la DP, et a aidé les programs à déceler les lacunes de soins et à les améliorer. Les travaux futurs feront état de l'impact du program sur l'utilization incidente au niveau régional et provincial.

Defining the Scope of Knowledge Translation Within a National, Patient-Oriented Kidney Research Network.

PURPOSE OF PROGRAM: Integrated knowledge translation (IKT) is a collaborative approach whereby knowledge created through health research is utilized in ways that are relevant to the needs of all stakeholders. However, research teams have limited capacity and know-how for achieving IKT, resulting in a disconnect between the generation and application of knowledge. The goal of this report is to describe how IKT research was achieved across a large-scale, patient-oriented research network, Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD). SOURCES OF INFORMATION: Resources to facilitate knowledge translation (KT) planning across the network were developed by the Can-SOLVE CKD Knowledge User/Knowledge Translation Committee with reference to established Canadian KT and patient engagement tools and frameworks, review of the published and gray literature, and expertise of committee members. METHODS: The Can-SOLVE CKD Knowledge User/Knowledge Translation Committee consisting of patient partners, health care providers, policymakers, and researchers provided oversight of the development and implementation of the network's IKT initiatives. Guided by its strategic framework, the committee developed KT planning templates and review checklists to assist network projects with preparing for dissemination, implementation, and scale and spread of their interventions. The committee has acted in a consultative capacity to facilitate IKT across network initiatives and has supported capacity building through KT activities aimed at network membership and knowledge users more broadly. KEY FINDINGS: The Can-SOLVE CKD Knowledge User/Knowledge Translation Committee established a nation-wide strategy for KT infrastructure and capacity building. Acting as a knowledge intermediary, the committee has connected research teams with knowledge users across Canada to support practices and policies informed by evidence generated by the network. The committee has developed KT initiatives, including a Community of Practice, whereby participants across different regions and disciplines convene regularly to share health research knowledge and communications strategies relevant to the network. Critically, patients are engaged and contribute throughout the research process. Examples of IKT activities from select projects are provided, as well as ways for sustaining the network's KT platform. LIMITATIONS: The KT resources developed by the committee were adapted from other established resources to meet the needs of the network and have not undergone formal evaluation in this context. Given the broad scope of the network, resources to facilitate implementation and knowledge user engagement may not meet the needs of all initiatives and must be tailored accordingly. Knowledge barriers, including a lack of information and skills related to conceptual and practical aspects of KT, among network members provided a rationale for various KT capacity-building initiatives. IMPLICATIONS: The approach described here offers a practical method for achieving IKT, including how to plan, implement, and sustain initiatives across large-scale health research networks. Within the context of Can-SOLVE CKD, these efforts will shorten knowledge-practice gaps through producing and applying relevant research to improve the lives of people living with kidney disease.

OBJECTIF DU PROGRAMME: L'application intégrée des connaissances (AIC) est une approche collaborative à répondre aux besoins de tous les intervenants. Les équipes de recherche ont cependant une capacité et un savoir-faire limités pour réaliser l'AIC, ce qui entraîne un décalage entre la production et l'application des connaissances. L'objectif de cet article est de décrire comment la recherche sur l'AIC a été réalisée dans le cadre d'un vaste réseau de recherche axée sur le patient, le réseau CAN-SOLVE CKD (Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease). SOURCES: Les ressources visant à faciliter la planification de l'application des connaissances (AC) dans l'ensemble du réseau ont été élaborées par le Comité des utilisateurs/de l'application des connaissances (Knowledge User/Knowledge Translation Committee) de Can-SOLVE CKD en se référant à des outils et des cadres d'AC et de participation des patients établis au Canada, à l'examen de la documentation publiée et de la littérature grise et à l'expertise des membres du comité. MÉTHODOLOGIE: Le Comité des utilisateurs/de l'application des connaissances de CAN-SOLVE, constitué de partenaires patients, de fournisseurs de soins, de décideurs et de chercheurs, a supervisé le développement et la mise en œuvre des initiatives d'AIC du réseau. Guidé par son cadre stratégique, le comité a élaboré des modèles de planification pour l'AC et des listes de vérification pour aider les projets du réseau à se préparer à la diffusion et à la mise en œuvre de leurs interventions, de même qu'à leur élargissement et leur diffusion. Le comité a agi à titre consultatif pour faciliter l'AIC dans l'ensemble des initiatives du réseau, et a appuyé le renforcement des capacités par le biais d'activités d'AC destinées aux membres du réseau et, plus largement, aux utilisateurs des connaissances. PRINCIPAUX RÉSULTATS: Le Comité des utilisateurs/de l'application des connaissances de CAN-SOLVE a établi une stratégie nationale pour l'infrastructure et le renforcement des capacités en matière d'AC. En tant qu'intermédiaire, le comité a mis en relation des équipes de recherche et des utilisateurs des connaissances partout au Canada afin d'appuyer les pratiques et les politiques fondées sur les données probantes produites par le réseau. Le comité a élaboré des initiatives d'AC, notamment une communauté de pratique où les participants des différentes régions et disciplines se réunissent sur une base régulière pour partager les connaissances générées en recherche et les stratégies de communication pertinentes pour le réseau. Il est essentiel que les patients s'engagent et contribuent tout au long du processus de recherche. Des exemples d'activités d'AIC tirés de projets sélectionnés sont fournis, de même que des moyens de maintenir la plateforme d'AC du réseau. LIMITES: Les ressources d'AC développées par le comité ont été adaptées à partir de ressources établies pour répondre aux besoins du réseau et, dans ce contexte, n'ont pas fait l'objet d'une évaluation officielle. Compte tenu de la vaste portée du réseau, les ressources destinées à faciliter la mise en œuvre et la participation des utilisateurs des connaissances pourraient ne pas répondre aux besoins de toutes les initiatives et devraient être adaptées en conséquence. Les freins à la connaissance parmi les membres du réseau, notamment le manque d'information et de compétences liées aux aspects conceptuels et pratiques de l'AC, ont servi de justification à diverses initiatives de renforcement des capacités en matière d'AC. CONCLUSION: L'approche décrite offre une méthode pratique pour parvenir à l'AIC, notamment dans la façon de planifier, de mettre en œuvre et d'appuyer des initiatives dans les réseaux de recherche d'envergure. Dans le contexte de CAN-SOLVE CKD, ces efforts permettront de réduire les écarts entre les connaissances et les pratiques, en produisant et en appliquant des recherches visant l'amélioration de la vie des personnes atteintes de néphropathies.

Canadian Senior Renal Leaders Community of Practice: Vulnerable Populations With Chronic Kidney Disease-Evidence to Inform Policy.

PURPOSE: Low socioeconomic status, race, ethnicity, and rural/remote populations are all associated with disparities in access, care, and outcomes for chronic kidney disease (CKD). There have been different interventions supported by Canadian renal programs to address these disparities. This article reviews the evidence for impact of strategies to reduce inequities experienced by vulnerable populations living with or at risk of CKD and to collate and share interprovincial targeted interventions through the newly formed "Canadian Senior Renal Leaders Community of Practice" focused on translating evidence into clinical practice and policy. SOURCE OF INFORMATION: A literature search of Medline, CINAHL, PubMed, and Google Scholar from 2008 to 2018 identified 13 reports of processes and interventions that have been implemented in Australia, Canada, and the United States to reduce inequities in CKD care and can be categorized into 3 broad areas: (1) early screening and prevention, (2) disease management and dialysis, and (3) pretransplant. Web sites from each Canadian jurisdiction and from Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network were used to assess the current state of Canadian initiatives. METHODS: Reviews were completed to gather information on renal initiatives for vulnerable populations, including (1) identification of populations that experience disparities in access to care or in outcomes in the context of CKD prevention and treatment and (2) interventions that have been implemented to reduce disparities in access, care, and outcomes for vulnerable populations with CKD. A current state summary of Canadian initiatives related to vulnerable populations was conducted through a review of publicly available information, including a review of renal program Web sites and a review of current projects related to vulnerable populations that are part of Can-SOLVE CKD. Can-SOLVE CKD is a Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR-SPOR) funded research network to transform the care of people affected by kidney disease. KEY FINDINGS: Interventions to improve inequities in access to CKD screening, disease management, and care are successful when developed with community engagement, provided to the patient in their own environment, and tailored to specific populations. Many provincial renal programs have implemented initiatives to support vulnerable populations with or at risk of CKD. Current projects funded through CIHR SPOR focus on underserved populations and involve partnerships with Indigenous populations. Many renal programs in Canada had or were in the process of implementing interventions to support vulnerable populations with CKD; however, information about the initiatives were not readily available online despite a strong interest and opportunity to support interprovincial knowledge sharing. Despite this common interest, little information is systematically shared between Canadian jurisdictions to support interprovincial sharing to promote evidence-informed policy and program development. Efforts will be made through the newly formed Canadian Senior Renal Leaders Community of Practice to collaborate and share learnings to inform future program and policy development, implementation, and evaluation. LIMITATIONS: As this was not a systematic review, literature search only encompassed studies published in English between 2008 and 2018. It is possible that populations and interventions were overlooked during the search and through the screening process. Furthermore, the controversial definition of "vulnerable" and literature that only came from Canada, the United States, and Australia limits the generalizability of this review.

CONTEXTE ET OBJECTIFS: En contexte d'insuffisance rénale chronique (IRC), le faible statut socioéconomique du patient, sa race, son origine ethnique et le fait d'habiter une région rurale/éloignée sont associés à des iniquités dans l'accès et la qualité des soins et dans les résultats de santé. Ces disparités ont d'ailleurs fait l'objet de différentes interventions de la part des programmes rénaux canadiens. Cet article explore les données probantes sur l'effet de ces stratégies de réduction des inégalités subies par les populations vulnérables atteintes ou susceptibles de développer une néphropathie chronique. L'article vise également à colliger et à partager les interventions ciblées entre les provinces par le biais de la toute nouvelle « Communauté de pratique des hauts dirigeants en néphrologie au Canada ¼, laquelle est axée sur la transposition des données probantes en politiques et pratiques cliniques. SOURCES: Une recherche sur Medline, CINAHL, PubMed et Google Scholar de la littérature publiée entre 2008 et 2018 a permis de répertorier 13 rapports faisant état d'interventions mises en œuvre en Australie, au Canada et aux États-Unis pour réduire les iniquités de soins en IRC. Ces interventions ont été classées selon trois thèmes: 1) prévention et dépistage précoce, 2) prise en charge et dialyse, et 3) pré-transplantation. Les sites Web du réseau Can-SOLVE CKD (Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease) et de chaque province et territoire canadiens ont été consultés pour dresser l'état actuel des stratégies canadiennes. MÉTHODOLOGIE: La revue de la littérature a permis de recenser les populations subissant des inégalités quant à l'accès aux soins ou aux résultats en contexte de prévention et de traitement de l'IRC, et de recueillir de l'information sur les interventions mises en œuvre pour réduire ces inégalités pour les populations vulnérables atteintes d'IRC. Un résumé des stratégies canadiennes actuelles a été rédigé à partir des informations accessibles au public sur les sites Web des différents programmes rénaux et des projets de Can-SOLVE CKD visant les populations vulnérables. Can-SOLVE CKD est un réseau de recherche financé par la Stratégie de recherche axée sur le patient des Instituts de recherche en santé du Canada (SRAP-IRSC) dont l'objectif est de transformer les soins destinés aux personnes atteintes de néphropathie. PRINCIPAUX RÉSULTATS: Les interventions visant à réduire les iniquités dans l'accès au dépistage, à la prise en charge et aux soins en IRC sont efficaces lorsqu'elles sont élaborées avec la participation de la communauté, prodiguées au patient dans son milieu de vie et adaptées en fonction de la population visée. Plusieurs programmes rénaux provinciaux ont déployé des stratégies pour venir en aide aux populations vulnérables atteintes ou susceptibles de développer une IRC. Les projets actuels financés par la SRAP-IRSC se concentrent sur les populations mal desservies et impliquent des partenariats avec les communautés autochtones. Plusieurs programmes rénaux canadiens disposent ou s'affairent à implanter des stratégies pour aider les populations vulnérables atteintes d'IRC. Par contre, malgré un grand intérêt et la possibilité de soutenir un partage interprovincial des connaissances, l'information concernant ces initiatives demeure difficilement accessible en ligne. De même, malgré l'intérêt, peu d'information est partagée systématiquement entre les provinces canadiennes pour soutenir l'élaboration de politiques et de programmes fondés sur les données probantes. La toute nouvelle « Communauté de pratique des hauts dirigeants canadiens en néphrologie ¼ s'efforcera donc de collaborer et de partager l'information afin d'éclairer l'élaboration, la mise en œuvre et l'évaluation des futurs programmes et politiques. LIMITES: Cette étude n'est pas une revue systématique; elle ne visait que les articles publiés en anglais entre 2008 et 2018. Ainsi, certaines populations ou interventions pourraient avoir été mises de côté lors de la recherche et de la sélection des articles. De plus, la définition controversée du terme « vulnérable ¼ et le fait que les articles retenus ne provenaient que du Canada, des États-Unis et de l'Australie rendent nos résultats difficilement généralisables.

Worksite-based cardiovascular risk screening and management: a feasibility study.

BACKGROUND: Established cardiovascular risk factors are highly prevalent and contribute substantially to cardiovascular morbidity and mortality because they remain uncontrolled in many Canadians. Worksite-based cardiovascular risk factor screening and management represent a largely untapped strategy for optimizing risk factor control. METHODS: In a 2-phase collaborative demonstration project between Alberta Health Services (AHS) and the Alberta Newsprint Company (ANC), ANC employees were offered cardiovascular risk factor screening and management. Screening was performed at the worksite by AHS nurses, who collected baseline history, performed automated blood pressure measurement and point-of-care testing for lipids and A1c, and calculated 10-year Framingham risk. Employees with a Framingham risk score of ≥10% and uncontrolled blood pressure, dyslipidemia, or smoking were offered 6 months of pharmacist case management to optimize their risk factor control. RESULTS: In total, 87 of 190 (46%) employees volunteered to undergo cardiovascular risk factor screening. Mean age was 44.5±11.9 years, 73 (83.9%) were male, 14 (16.1%) had hypertension, 4 (4.6%) had diabetes, 12 (13.8%) were current smokers, and 9 (10%) had dyslipidemia. Of 36 employees with an estimated Framingham risk score of ≥10%, 21 (58%) agreed to receive case management and 15 (42%) attended baseline and 6-month follow-up case management visits. Statistically significant reductions in left arm systolic blood pressure (-8.0±12.4 mmHg; p=0.03) and triglyceride levels (-0.8±1.4 mmol/L; p=0.04) occurred following case management. CONCLUSION: These findings demonstrate the feasibility and usefulness of collaborative, worksite-based cardiovascular risk factor screening and management. Expansion of this type of partnership in a cost-effective manner is warranted.

Statin Prescriptions for High-Risk Patients Are Increased by Laboratory-Initiated Framingham Risk Scores: A Quality-Improvement Initiative.

Low rates of cardiovascular preventive therapy with statin medications is a significant public health problem in Canada. There is a pressing need for public health interventions to increase the use of statin medications, especially among high-risk patients. In this article, we present the results of a quality assurance pilot program to provide laboratory-reported Framingham Risk Score (FRS) to physicians. This work was performed in a mixed urban and rural setting in southern Alberta. We provided FRSs and, for high-risk patients, statin treatment recommendations in conjunction with laboratory lipid panel requests. Adhesive labels were supplied to primary care physicians, and space was provided for information necessary for the calculation of the FRS by a laboratory information system. In total, 16 physicians from 4 different clinics participated in the pilot program. Data were collected from October 25, 2014-November 5, 2015, during which time 1266 patients had FRSs from the laboratory. Three hundred twenty-four individuals were identified as high risk for coronary heart disease (≥ 20% 10-year risk) and received a recommendation for treatment with a statin medication in the laboratory result report. These individuals had a 26% relative and a 6.4% absolute increase in statin prescriptions compared with before the pilot program. The laboratory-based provision of FRSs with statin treatment recommendations for high-risk individuals has the potential to significantly increase the use of statin drugs.

Alberta Healthy Living Program--a model for successful integration of chronic disease management services.

The most common presentation of chronic disease is multimorbidity. Disease management strategies are similar across most chronic diseases. Given the prevalence of multimorbidity and the commonality in approaches, fragmented single disease management must be replaced with integrated care of the whole person. The Alberta Healthy Living Program, a community-based chronic disease management program, supports adults with, or at risk for, chronic disease to improve their health and well being. Participants gain confidence and skills in how to manage their chronic disease(s) by learning to understand their health condition, make healthy eating choices, exercise safely and cope emotionally. The program includes 3 service pillars: disease-specific and general health patient education, disease-spanning supervised exercise and Better Choices, Better Health(TM) self-management workshops. Services are delivered in the community by an interprofessional team and can be tailored to target specific diverse and vulnerable populations, such as Aboriginal, ethno-cultural and francophone groups and those experiencing homelessness. Programs may be offered as a partnership between Alberta Health Services, primary care and community organizations. Common standards reduce provincial variation in care, yet maintain sufficient flexibility to meet local and diverse needs and achieve equity in care. The model has been implemented successfully in 108 communities across Alberta. This approach is associated with reduced acute care utilization and improved clinical indicators, and achieves efficiencies through an integrated, disease-spanning patient-centred approach.

Randomized trial of an internet-based computer-tailored expert system for physical activity in patients with heart disease.

BACKGROUND: The CardioFit Internet-based expert system was designed to promote physical activity in patients with coronary heart disease (CHD) who were not participating in cardiac rehabilitation. DESIGN: This randomized controlled trial compared CardioFit to usual care to assess its effects on physical activity following hospitalization for acute coronary syndromes. METHODS: A total of 223 participants were recruited at the University of Ottawa Heart Institute or London Health Sciences Centre and randomly assigned to either CardioFit (n = 115) or usual care (n = 108). The CardioFit group received a personally tailored physical-activity plan upon discharge from the hospital and access to a secure website for activity planning and tracking. They completed five online tutorials over a 6-month period and were in email contact with an exercise specialist. Usual care consisted of physical activity guidance from an attending cardiologist. Physical activity was measured by pedometer and self-reported over a 7-day period, 6 and 12 months after randomization. RESULTS: The CardioFit Internet-based physical activity expert system significantly increased objectively measured (p = 0.023) and self-reported physical activity (p = 0.047) compared to usual care. Emotional (p = 0.038) and physical (p = 0.031) dimensions of heart disease health-related quality of life were also higher with CardioFit compared to usual care. CONCLUSIONS: Patients with CHD using an Internet-based activity prescription with online coaching were more physically active at follow up than those receiving usual care. Use of the CardioFit program could extend the reach of rehabilitation and secondary-prevention services.

Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation.

BACKGROUND: Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. DESIGN: A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. METHOD: One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. RESULTS: Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µ(add) = 0.69, p < 0.05). CONCLUSION: Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes.

Understanding physical activity during home-based cardiac rehabilitation from multiple theoretical perspectives.

OBJECTIVE: : Previous studies have shown that moderate-to-vigorous physical activity (MVPA) levels during home-based cardiac rehabilitation (CR) have been problematic. Consequently, the present study examined the utility of the theory of planned behavior, protection motivation theory, and social cognitive theory in explaining physical activity (PA) during a Canadian home-based CR program. METHODS: : Patients (N = 280, mean age 62.8 years; 95.4% white, 72.5% male, 78.9% married, 52.3% retired, 48.0% income more than $60000; and 33.8% postmyocardial infarction) completed a questionnaire at program onset and a MVPA assessment at 3-month followup. RESULTS: : Path analyses showed that each theory accounted for 28% to 34% of the variance in PA. The theory of planned behavior showed that perceived behavior control was the key predictor of 3-month MVPA (ß = .36), whereas protection motivation theory showed that intention (ß = .30) was the key predictor. Finally, barrier self-efficacy (ß = .21) and the availability of home PA equipment (ß = .15) were the key predictors of 3-month MVPA within social cognitive theory. CONCLUSION: : All 3 theories appeared to be viable options to inform the development of a MVPA intervention during home-based CR. However, the key constructs to target within each theory varied, suggesting the need to potentially use multiple theories to inform intervention development.

Gender differences in satisfaction with life in patients with coronary heart disease: physical activity as a possible mediating factor.

The objective of the present study was to examine if time varying, mediating effect of physical activity plays an important role in the gender-satisfaction with life relationship. Six hundred four male and 197 female patients were included. Principal outcomes of interest were self-report satisfaction with life and physical activity at baseline, 6, 12 and 24 months. The Krull and MacKinnon procedure for hierarchical linear modeling showed that the change in physical activity mediated the gender-satisfaction with life over a 2 year period. Results from the current study suggest that increased physical activity partially explains why males report having increased well-being than females after hospitalization. This suggests that future interventions need to focus on reducing the gender disparity in physical activity to improve differences noted in satisfaction with life. If higher physical activity levels impact satisfaction with life positively, the importance of physical activity for female patients is warranted.

The integration of quality management into chronic disease health services.

Quality management strategies can be integrated into health services and processes to evaluate, measure, and improve the health services delivered to patients. Over a 6-month period, Living Well with a Chronic Condition program, a chronic disease management health service, had its support services evaluated and significantly improved, reducing the delays that participants experienced trying to access education and exercise classes. Through the use of quality management tools, including process mapping, performance data collection and evaluation, and participant feedback, the program intake process was improved significantly. Wait times of up to 90 days, with an average of 45 days, were reduced to less than 1 week. Postimprovement measures continued to demonstrate improved service, indicating that involving the staff and participants in quality management strategies can lead to significant optimization of services to participants.

Demographic and clinical determinants of moderate to vigorous physical activity during home-based cardiac rehabilitation: the home-based determinants of exercise (HOME) study.

PURPOSE: Little is known concerning moderate to vigorous physical activity (MVPA) levels in patients attending home-based cardiac rehabilitation (CR) programs and whether demographic/clinical characteristics moderate these levels. METHODS: Patients (N = 280, 77 female) who were referred to home-based CR, mainly because of myocardial infarction (34%), coronary artery bypass graft (17%), and percutaneous coronary intervention/ stent/atherectomy (32%), completed a questionnaire assessing demographic and clinical characteristics as well as MVPA, measured at the beginning and end of a 3-month home-based CR program. Charts were reviewed for blood work, blood pressure, stress tests, and diagnosis. RESULTS: Patients averaged 88.5 minutes per week of MVPA before starting home-based CR, which increased to 191.1 minutes during the program. Multiple regression analyses showed that patients who were male (beta = -.11), did not have metabolic syndrome (beta = -.14), and were meeting the MVPA guideline before starting home-based CR (beta = .25) engaged in significantly more MVPA during home-based CR than their counterparts. Furthermore, the increase in MVPA was significantly larger for males (beta = -.20), patients without metabolic syndrome (beta = -.13), and patients who did not meet the MVPA guideline at baseline (beta = -.29) than their counterparts. CONCLUSIONS: The MVPA levels of patients attending home-based CR tend to vary depending on gender, whether or not metabolic syndrome was present, and prior MVPA levels, suggesting the need to potentially target these particular groups in future behavioral interventions aimed at increasing MVPA.

Does protection motivation theory explain exercise intentions and behavior during home-based cardiac rehabilitation?

OBJECTIVE: Home-based cardiac rehabilitation (CR) programs have been shown to be effective in increasing exercise capacity, which is a significant predictor of longevity for patients with heart disease. However, adherence to these programs has been problematic. Therefore, it is important to identify key theoretical correlates of exercise for these patients that can be used to inform the development of behavioral interventions to help tackle the adherence problem. The purpose of this study was to determine whether protection motivation theory (PMT) explained significant variation in exercise intentions and behavior in patients receiving home-based CR. METHODS: Patients (N = 76) completed a questionnaire that included PMT constructs at the beginning and midpoint (ie, 3 months) of the program and an exercise scale at 3 and 6 months (ie, at the end of the CR program). RESULTS: Path analyses showed that response efficacy was the sole predictor of 3-month (beta = .53) and 6-month (beta = .32) intentions. However, the indirect effect of baseline response efficacy on 3-month exercise behavior through intention was nonsignificant (beta = -.01), whereas it was significant (beta = .11) for 3-month response efficacy on 6-month exercise behavior. Self-efficacy significantly predicted 3-month (beta = .36) and 6-month (beta = .32) exercise behaviors, whereas 3-month intention significantly predicted 6-month exercise behavior (beta = .23). CONCLUSIONS: Coping appraisal variables (ie, response efficacy and self-efficacy) are potentially useful in explaining exercise behavior during home-based CR.

Who will be active? Predicting exercise stage transitions after hospitalization for coronary artery disease.

We describe transitions between exercise stages of change in people with coronary artery disease (CAD) over a 6-month period following a CAD-related hospitalization and evaluate constructs from Protection Motivation Theory, Theory of Planned Behavior, Social Cognitive Theory, the Ecological Model, and participation in cardiac rehabilitation as correlates of stage transition. Seven hundred eighty-two adults hospitalized with CAD were recruited and administered a baseline survey including assessments of theory-based constructs and exercise stage of change. Mailed surveys were used to gather information concerning exercise stage of change and participation in cardiac rehabilitation 6 months later. Progression from pre-action stages between baseline and 6 month follow-up was associated with greater perceived efficacy of exercise to reduce risk of future disease, fewer barriers to exercise, more access to home exercise equipment, and participation in cardiac rehabilitation. Regression from already active stages between baseline and 6 month follow-up was associated with increased perceived susceptibility to a future CAD-related event, fewer intentions to exercise, lower self-efficacy, and more barriers to exercise.