Browsing by Author "Heckman, George"

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Acceptability of the interRAI Check-Up Self-Report Comprehensive Geriatric Assessment (CGA) Tool: Evaluating Check-Up Acceptability in Assessing Care Needs of Older Adults with Human Immunodeficiency Virus (HIV) in Kampala District of Uganda
(University of Waterloo, 2022-09-02) Kroetsch, Brittany; Heckman, George
Background: The Ugandan healthcare system is ill-equipped to manage the emerging medical and social needs of its aging population. With the high burden of human immunodeficiency virus (HIV), food insecurity, and the erosion of support systems, older adults are limited in their ability to maintain physical and emotional health and well-being. High levels of impairment in activities of daily living, cognition, and frailty associated with HIV coupled with increased multimorbidity for aging Ugandans calls for the revision of healthcare policies and evidence-informed practice. Objectives: This thesis aimed to estimate the association between HIV status and (i) activities of daily living, (ii) cognitive function, (iii) health stability, and (iv) clinical frailty in older persons living in Kampala, Uganda using the interRAI Check-Up self-report assessment instrument. Additionally, this thesis aimed to (v) evaluate assessment acceptability to inform healthcare system planning and care practices. Methods: A mixed methods design was employed. In Phase One, HIV-positive and negative older adults aged ≥60 years were assessed using the interRAI Check-Up self-report in the Nakawa division of Kampala. Patient characteristics were summarized with descriptive statistics, and a logistic regression analysis was used to identify differences in activities of daily living, cognitive function, health stability, and frailty of older persons in the study. In Phase Two, key informant interviews with service providers at the Reach Out Mbuya Community Health Initiative were held to characterize the acceptability of the Check-Up in the Ugandan setting and to explore perceptions of its use. Results: In Phase One, 130 Check-Up assessments were obtained for older persons in the community. HIV status was found to not be statistically significantly associated with the outcomes of interest and age was found to be positively associated with outcome scores for activities of daily living, cognitive performance, and frailty. However, age was not found to be associated with health stability. In Phase Two, 12 interviews were held with service providers at the Reach Out Mbuya Community Health Initiative. The Check-Up was found to be acceptable for use in the Ugandan setting, with minor gaps identified for coverage of economic stability, food security, living arrangement, and the physical environment. Further, challenges with languages offered, the technology required, and length of time to complete was discussed. Discussion: Findings of age-related associations for activities of daily living, cognitive performance, and frailty were conclusive with expectations for the trajectory of health throughout the aging process. Similarities across HIV-positive and negative participants are attributed to participant age, low study sample size, viral suppression, and healthcare service utilization. For Check-Up use in the Ugandan setting, several recommendations are made to address identified gaps including question modifications, further translations, provision of additional tablets, and granted permissions to RAIsoft. Next, capacity training for Check-Up use by service providers is introduced, including the need for sensitization of gender differences and appropriate structuring of assessors in the field. Lastly, a theoretical framework assessment revealed barriers in the ability of the Theoretical Framework of Acceptability to identify key gender and socio-cultural differences in intervention recipients and deliverers. Implications: This thesis provided important information for describing the needs of aging Ugandans and insight into how a standardized instrument can help to support the development of a geriatric-friendly healthcare system across the nation. This was an important step in establishing an interRAI community of practice in East Africa.
Assessing the feasibility of an integrated collection of education modules for fall and fracture prevention (iCARE) for healthcare providers in long term care: A longitudinal study
(Public Library of Science (PLOS), 2024) Rodrigues, Isabel B.; Ioannidis, George; Kane, Lauren L.; Hillier, Loretta M.; Adachi, Jonathan; Heckman, George; Hirdes, John; Holroyd-Leduc, Jayna; Jaglal, Susan; Kaasalainen, Sharon; Marr, Sharon; McArthur, Caitlin; Straus, Sharon; Tarride, Jean-Eric; Abbas, Momina; Costa, Andrew P.; Lau, Arthur N.; Thabane, Lehana; Papaioannou, Alexandra
Falls and hip fractures are a major health concern among older adults in long term care (LTC) with almost 50% of residents experiencing a fall annually. Hip fractures are one of the most important and frequent fall-related injuries in LTC. There is moderate to strong certainty evidence that multifactorial interventions may reduce the risk of falls and fractures; however, there is little evidence to support its implementation. The purpose of this study was to determine the feasibility (recruitment rate and adaptations) with a subobjective to understand facilitators to and barriers of implementing the PREVENT (Person-centred Routine Fracture PreEVENTion) model in practice. The model includes a multifactorial intervention on diet, exercise, environmental adaptations, hip protectors, medications (including calcium and vitamin D), and medication reviews to treat residents at high risk of fracture. Our secondary outcomes were to determine if there was a change in knowledge uptake of the guidelines among healthcare providers and in the proportion of fracture prevention prescriptions post-intervention. We conducted a mixed-methods longitudinal cohort study in three LTC homes across southern Ontario. A local champion was selected to help guide the implementation of the model and promote best practices. We reported recruitment rates using descriptive statistics and challenges to implementation using content analysis. We reported changes in knowledge uptake and in the proportion of fracture prevention medications using the McNemar's test. We recruited three LTC homes and identified one local champion for each home. We required two months to identify and train the local champion over three, 1.5-hour train-the-trainer sessions, and the local champion required three months to deliver the intervention to a team of healthcare professionals. We identified several facilitators, barriers, and adaptations to PREVENT. Benefits of the model include easy access to the Fracture Risk Scale (FRS), clear and succinct educational material catered to each healthcare professional, and an accredited Continuing Medical Educational module for physicians and nurses. Challenges included misperceptions between the differences in fall and fracture prevention strategies, fear of perceived side effects associated with fracture prevention medications, and time barriers with completing the audit report. Our study found an increase knowledge uptake of the guidelines and an increase in the proportion of fracture prevention prescriptions post-intervention.
Clinical pharmacists and nurses' perceptions on implementing anticoagulation therapy recommendations for the frail elderly: An exploratory study based on psychological theory
(University of Waterloo, 2017-05-15) Trinh, Brenda Trang; Heckman, George
Background: Stroke is a leading cause of mortality and disability in Canada. Persons with atrial fibrillation (AF) have a five-fold increased risk of developing a stroke. AF is a significant contributor to stroke at all ages and the prevalence of AF is rising with age. In Canada, the treatment for persons with chronic non-valvular AF is to provide long-term oral anticoagulation therapy (OAT) with warfarin, which has been shown to reduce the risk of stroke by two-thirds. Routine care administered by physicians is often inconvenient because it requires regular doctor visits, a time lag between laboratory testing and follow ups, and frequent ad-hoc dose adjustments to prevent adverse outcomes. These challenges often contribute to poor OAT management to result in an increased risk of bleeding and clotting. These risks are further complicated for people with AF who are older, frail, have multiple co-morbidities and polypharmacy. The solution is to offset these complications through optimizing delivery of OAT using anticoagulation management services (AMS). Research has shown that pharmacist or nurse-led AMS are comparable or better than physician-led care in terms of cost-effectiveness and patient outcomes. Despite this, AMS clinics need to establish a more integrated approach for the optimal delivery of OAT management. Published and available in the literature are clinical recommendations by Garcia et al. (2008) on how to optimize OAT delivery in outpatient AMS settings; however, the deliberate implementation of the guideline remains an issue. Objectives: To address the problem in the context of a frail, aging population, this study explores the pharmacists and nurses’ perceptions of implementing Garcia et al.’s (2008) clinical guideline for optimal OAT management in existing specialized AMS clinics within the Waterloo-Wellington Local Health Integration Network (WWLHIN) community. Specifically, this study uses Michie et al.’s (2005) psychological theory to explore (1) how existing intrinsic and extrinsic factors hindered or supported; and (2) how behavioural changes facilitate the implementation of Garcia et al.’s (2008) clinical guideline for optimal OAT management. Methods: This study used a qualitative, explorative design with a purposive sample of clinicians (key informants) working in AMS clinics within the WWLHIN community: Waterloo-Kitchener, Cambridge and Guelph. Key informants were recruited from family health teams (FHTs) and community pharmacies, and sampled until the point of saturation. Semi-structured interview questions covered 12 domains under a theoretical lens, Michie et al.’s (2005) psychological theory: (1) Knowledge, (2) Skills, (3) Social/professional role and identity, (4) Beliefs about capabilities, (5) Beliefs about consequences, (6) Motivation and goals, (7) Memory, attention and decision processes, (8) Environmental context and resources, (9) Social influences, (10) Emotion, (11) Behavioural regulation, and (12) Nature of the behaviours. These 12 domains represent the relevant factors that influence the implementation of clinical guidelines. Garcia et al. (2008) published a clinical guideline with 9 key recommendations for optimal delivery of OAT management in outpatient AMS settings: (1) Qualifications of Personnel, (2) Supervision, (3) Care Management and Coordination, (4) Documentation, (5) Patient Education, (6) Patient Selection and Assessment, (7) Laboratory Monitoring, (8) Initiation and Stabilization of Warfarin Therapy, and (9) Maintenance of Therapy. Interviews averaged 40 minutes per key informant and produced a total of 108 pages of transcript. Data were coded and analyzed using NVIVO Pro 11 based on the theoretical framework. Results: There were six clinics that participated in the study: three family health teams and three community pharmacies with AMS clinics. Within these six clinics, there were a total of eight key informants: six pharmacists and two registered nurses. The majority of key informants were from the Kitchener-Waterloo region with more than one-year experience in OAT in the community setting. There were five salient themes in the results: (1) Inadequate reimbursement for logistical operation of AMS clinics; (2) Clinicians’ awareness of how to apply knowledge to support practices; (3) Tailored organizational supports for the frail elderly; (4) Engagement of efforts to improve interprofessional communication and collaboration; and (5) Use of compatible software platforms for documentation. Theme 1 hindered, theme 2 and 3 supported, and theme 4 and 5 facilitate the implementation of Garcia et al.’s (2008) clinical guideline for the optimal delivery of OAT management in participating AMS clinics. Discussion: In determining that inadequate funding was a key barrier to implementation, the finding suggests that if key informants cannot cover their costs, they cannot offer optimal OAT management per the clinical guideline. There is currently no coverage of services and materials for OAT management by pharmacists and nurses in Canada, except for Quebec. Instead, Ontario’s pharmacists in community AMS clinics use other means to recover costs for OAT management services. In light of these findings, there needs to be appropriate funding for community AMS to continue their valuable services, otherwise OAT management may fall back to usual care and block optimal practices. Other factors affecting implementation are awareness of how to apply each recommendation of the clinical guideline to support practice and tailored organizational supports for the frail elderly. Although there was general awareness of the recommendations, one exception was the finding that suggests that key informants relied on an incomplete frailty assessment; this finding reflected other work showing that clinicians tend to diagnose frailty syndrome based on chronological age rather than biological age. Furthermore, other work corroborated the finding that tailored organizational supports for the frail elderly, such as physical tools, face-to-face interactions and home visits, enabled the implementation of the clinical guideline via improving medication adherence and monitoring of other health issues. In addition, other studies supported the finding that clinicians should engage in interprofessional communication and collaboration, especially during care transitions to facilitate optimal practices. One strategy was for nurse navigators to act as the focal point of contact for seamless care transitions, but existing pharmacists and nurses can also expand their scope of practice to methodically provide continuity of care and coordination of services in community-based AMS settings. Other work also supported the finding that social networking with experts in the local and wider regions facilitated optimal practices through maintaining competencies and gaining new knowledge. Another facilitator of optimal OAT management was to use compatible software platforms for standardized OAT documentation to integrate a systematic approach to management. However, the selection of an anticoagulation software program is complicated with many considerations, depending on individual clinic’s needs. There needs to be further investigation on the limited literature on the implications of using compatible software platforms for standardized documentation of OAT management. Conclusion: Linking key themes to the domains of Michie et al.’s (2005) psychological theory that influenced the implementation of the clinical guideline: (1) Inadequate reimbursement for logistical operation of AMS clinics was an environmental constraint (domain #8); (2) Clinicians’ awareness of how to apply knowledge to support practices was having the knowledge and skills (domains #1 and 2); (3) Tailored organizational supports for the frail elderly were environmental resources within their context (domain #8); (4) Engagement of efforts to improve interprofessional communication and collaboration was using social influences to prompt behavioural changes (domains #9 and 12); and (5) Use of compatible software platforms for documentation was a proposed system to change the nature of behaviours related to tracking and recording anticoagulation data (domain #12). Using the underlying theory, these key themes represent important factors for the deliberate implementation of the clinical guideline for optimizing delivery of OAT management. Insights on how various factors affect the implementation the clinical guideline can help key stakeholders scale up efforts for a broader, more uniform approach to optimal OAT management for a frail, elderly population.
Cost Effectiveness Analysis of Riluzole for ALS in Ontario Home Care Setting
(University of Waterloo, 2017-06-23) Kim, Yong-Jin; Heckman, George
Objective: To identify the factors associated with the prescription of riluzole and assess its cost-effectiveness for patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) in long stay home care in Ontario, Canada. Method: A retrospective cohort study was conducted using the Ontario Association of Community Care Access Centres – Home Care (OACCAC-HC) data. Assessment records of ALS patients admitted into home care between April 1st, 2005 and March 31st, 2013, who had information on whether or not they used riluzole, were reviewed. Univariate and multiple logistic regressions analysis were used to identify the predictors influencing the receipt of riluzole. Variables included in the analyses were chosen in correlation to the prognostic factors identified in the literature review. For the cost-effectiveness analysis, cost data were obtained from relevant literatures and published information on Canadian Institute for Health Information Patient Cost Estimator accounting for the cost of administration of riluzole, standard supportive home care services, and cost-savings from delay in hospitalization. Effectiveness was measured using time to discharge from home care due to death, placement into long-term care, and hospitalization, controlling for potential confounding variables using propensity score stratification. The incremental cost-effectiveness ratio was calculated based on time spent in different states and the associated utility scores using the stratified population and expressed as cost per life-year gained and quality-adjusted life-year gained. Sensitivity analyses included one-way deterministic sensitivity analysis to investigate the change in ICER due to variations in specific input parameters. Scenario analyses were developed to depict the ICERs in best and worst case scenarios. Resuts: The total study population comprised of 1,351 patients diagnosed with ALS, of which 1,277 patients had information on the use of riluzole. In the multiple logistic regression analysis, older age, moderate – moderate severe impairment in cognitive functions, not being married and geographical locations across LHINs (Champlain, Erie St. Clair, Hamilton Niagara Haldimand Brant, Mississauga Halton, North East, South East, and South West) decreased the likelihood of riluzole prescription. Primary analysis showed that treatment with riluzole was associated with prolonged survival in home care [HR = 0.86; 95% confidence interval: 0.745 – 0.99; p=0.046]. Survival gain associated with riluzole was 1.5 months, while the incremental cost was approximately $5,000 per patient. Thus, the incremental cost-effectiveness ratio of riluzole versus standard supportive home care services was $41,128.85 per life-year gained or $55,579.53 per quality-adjusted life-year gained. One-way deterministic sensitivity analysis suggested an ICER ranging from $50,000 – 78,000 per QALY, while scenario analyses depicting best and worst case scenarios suggested an ICERs of $29,890.36 per QALY and $106,641.52 per QALY. Conclusion: Patient characteristics such as age, cognitive score, geographical location and marital status markedly influenced drug utilization of riluzole. In addition, the findings of this study indicate that riluzole has a borderline or unfavorable cost-effectiveness for patients diagnosed with ALS in home care setting.
Developing and evaluating an integrated rehabilitative model of care for stroke patients in the home and community care sector
(University of Waterloo, 2020-11-02) Afzal, Arsalan; Stolee, Paul; Heckman, George
Background: Stroke is a leading cause of disability and the third leading cause of mortality in Canada. Access to evidence-based rehabilitative care can reduce the risk of disability and improve health outcomes of stroke survivors. Up until recently, stroke survivors in many health regions in Canada did not have access to intensive and timely community-based rehabilitation which followed the recommended Canadian Stroke best practice guidelines. As a result, stroke survivors suffered negative health outcomes and had suboptimal experiences as they transitioned to home from a hospital or a rehabilitation centre. The Waterloo Wellington health region of Ontario re-designed its stroke care system across the continuum of care, including implementation of an integrated community stroke rehabilitation pathway that is in alignment with the Canadian stroke best practices. Significant investments in resources have been made to reorganize and integrate the stroke care system with the intention of improving patient outcomes and patient experience. This study aimed to evaluate the newly implemented model of care by measuring patient’s health outcomes as well as patient experience. The study also compared the psychometric properties of the interResident Assessment Instrument-Home Care (interRAI HC) with other commonly used assessment tools in the stroke rehabilitation population. Research Objectives: This research study consisted of two primary research questions and a third secondary question. The first research objective was to answer the question, “What are the functional and depression related outcomes of stroke survivors that received stroke rehabilitation through the community stroke rehabilitation model of care? The second research objective is to answer the question, “What is the experience of stroke survivors that received care through the community stroke rehabilitation model of care?” The third research objective aims to answer the question, “How do the psychometric properties of responsiveness and construct validity of specific scales embedded in interRAI HC instrument compare with those of the Barthel Index (BI) and Reintegration to Normal Living Index (RNLI) instruments?” Methods: To evaluate functional and depression related outcomes, an observational study with a pre-post design was used. Secondary home care data were extracted on patient assessments during April 2014 to April 2017 using the interRAI HC, BI and RNLI instruments. Outcomes were measured for the ADL and DRS scales. A control group was formed using data from the Canadian Institute for Health Information (CIHI); this group included stroke survivors who received traditional rehabilitative care or no care post hospital discharge in the community elsewhere in Ontario during the same period. Four regression models were created to explore associations between having functional or depression related impairment and the treatment assignment (treatment vs control group). Models were adjusted using a propensity score variable to control for treatment selection bias. To evaluate patient experience, a Patient Experience Survey for Community-based Rehabilitation (PESCR) instrument was developed for this project using a Program Logic Model (PLM) and also through consultations with subject matter experts and stroke survivors. The PESCR was administered in a home care setting to stroke survivors who completed the rehabilitation program, at the 3 months follow up home visit by a community care coordinator. Participants were asked to provide feedback on: 1) patient experience; 2) transitional care; 3) timeliness of access to care; 4) integrated care; and 5) returning to normal activities. Internal consistency reliability was measured using Cronbach’s alpha coefficient. Construct validity was assessed using the correlation of total scores with a global question. Thematic content analysis was used to review the open-ended responses on the survey. To answer the third research question, responsiveness statistics (standardized response mean and effect size) were used to compare the interRAI HC ADL Long Form and DRS with the BI and RNLI respectively. Construct validity was assessed by the correlation between the ADL Long Form and the BI as well as the correlation between the DRS and the RNLI. Results During the period of 2014 and 2017, 479 stroke survivors were placed onto the community stroke rehabilitation pathway for approximately 12 weeks in the Waterloo Wellington health region. Each stroke survivor received an average of 30.5 rehabilitation home visits with an average time of 56 minutes per visit. The mean age of participants was 77.9 (9.5 SD) and 51.2% were females. After adjusting for baseline characteristics and treatment selection bias, participants in the treatment group were three (2.99) times more likely to be independent in ADLs than those in the control group at the 3 months follow up (Adjusted OR = 2.99, 95% CI 1.53 – 5.86, p < 0.01). Participants in the treatment group were 3.8 times more likely to have no difficulty in IADL activities than those in the control group at the 3 months follow up (Adjusted OR = 3.83, 95% CI 1.77 – 8.25, p < 0.001). There was no statistically significant association found between treatment assignment and depression (Adjusted OR = 0.81, 95% CI 0.47 – 1.38, p > 0.05). Four hundred and four (84.3%) individuals that received care through the Waterloo Wellington’s stroke rehabilitation model of care were asked to complete the patient experience survey. Of these, 134 (33.1%) participants responded including 112 (83.5%) stroke survivors and 22 (16.4%) family members/care givers. Of those that completed the survey, 122 (91.0%) participants were satisfied with the care they received in the community. Based on the open-ended responses, many participants felt that the therapy should have continued beyond the 3-month period post hospital discharge. The responses also suggested that clients and families preferred a longer but less intense physical therapy. Some respondents also felt overwhelmed when the community rehabilitation was initiated within 48 hours of hospital discharge. Some respondents felt that community rehabilitation started too early as stroke survivors and families needed time for adjustment as they transitioned back home. The interRAI HC’s ADL Long Form scale and BI were highly correlated and seem to be evaluating their intended constructs. However, the ADL Long Form was not as responsive as the BI particularly in the subpopulation of stroke population with no or minimal levels of impairment in conducting ADLs. The DRS and RNLI were not correlated with each other and appear to measure different aspects of an individual’s psychosocial outcomes. The responsiveness results of our study suggest that the ADL and DRS scales from the interRAI HC instrument perform well in subpopulations with significant impairment, such as those who scored high on ADL scales, but these scales have less discriminatory power among those with less physical or psychosocial impairment, such as those with scores of zero on ADL or DRS scales. Conclusion: Our study adds to the body of evidence suggesting that a community-based rehabilitation program that is timely, well-coordinated and follows the recommended intensity (2-3 rehabilitation visits per week per discipline for up to 12 weeks), can achieve significant improvements in functional outcomes among a large proportion of stroke survivors who are trying to reintegrate back in the community. The participants had a positive experience overall as well as for specific aspects of care delivery. The lower scores in returning to normal activities suggest that some participants might continue to have unmet needs of functional independence. The interRAIHC’s ADL Long form and the DRS are valuable scales that are already part of the existing bundle of standardized geriatric assessment in the home and community care. Information collected using these assessments can be useful in the stroke rehabilitation population. Significance and Knowledge Translation: This study helps establish evidence for whether investments made in stroke community rehabilitative care in the Waterloo Wellington community are resulting in intended patient outcomes and improved patient experience. Results from this study highlight improvement opportunities for the existing model. It is hoped that this study also helps health planners and service providers to implement similar service delivery models in other regions.
Developing the Patient Falls Risk Report: A tool for sharing falls-related clinical information from home care with primary care providers
(University of Waterloo, 2020-08-27) Nova, Amanda Aguilar da; Heckman, George
Background. Due to inadequate information sharing systems, primary care and home care providers in Ontario have some of the lowest rates of communication in Canada and among all OECD countries. As a result, clinicians are frustrated, resources are wasted, and vulnerable patients are put at risk for adverse events such as falls. Introducing a home care-to-primary care information sharing system that prompts primary care providers to address falls risk, namely, the Patient Falls Risk Report may be effective for supporting clinical practices. Research Questions. The research questions in this study are as follows: (1) what are primary care providers views on integrating the Patient Falls Risk Report into their workflow; (2) what impacts do primary care providers believe that the Patient Falls Risk Report would have on patient care; (3) what criticisms, suggestions for improvement, or future developments do primary care providers suggest for the Patient Falls Risk Report; and (4) how usable is the Patient Falls Risk Report? Methods. This mixed-methods intervention development study examined if the Patient Falls Risk Report, a one-page document for sharing falls-related clinical information from the interRAI-HC, is useful to primary care providers using the Behaviour Change Wheel theoretical framework and elements of usability testing. In Phase One, one-on-one qualitative interviews were conducted, and a constructivist approach to thematic analysis was used to answer research questions one, two, and three, and inform revisions of the Patient Falls Risk Report. In Phase Two, self-report surveys based on the System Usability Scale (SUS) were conducted on Qualtrics and the quantitative data was descriptively analyzed with Excel 2004 and SAS University Edition to answer research question four. Results. A sample of 9 interview participants and 27 survey participants was obtained. In the interviews, barriers in opportunity, capability, and motivation were identified which contributed to increased reliance on patient self-report, intuition, and reactive approaches to identifying falls risk. Thus, all participants stated that they would integrate use of the Patient Falls Risk Report in their practices. Due to its utility and usability, most interview participants believed that the Patient Falls Risk Report could support patient care by sharing relevant falls-related information and reminding providers of best-practice falls prevention guidelines. However, various criticisms were identified including lack of clarity in language, insufficient detail, and limited support for shared care planning. After two rounds of revisions and integrating interview participants’ suggestions for improvement, the surveys determined that the Patient Falls Risk Report was highly usable with an overall SUS score of 83.4 (95% CI = 78.7, 88.2). Discussion. Primary care culture, structure, and tradition have a substantial influence on falls prevention approaches and influence the views and actions of primary care providers. The current health-system context, previous implementations, theory, and research suggest that the Patient Falls Risk Report would be feasible to integrate into primary care workflows. However, how and to what extent the report would support a shift toward proactive falls prevention was debated. The ways in which the Patient Falls Risk Report could impact patient care, were examined through an analysis of clinical- and system-level advantages, disadvantages, and limitations. Developments to the Patient Falls Risk Report to enhance its advantages and mitigate disadvantages and limitations included saving space, adding clarity, adding detail, aligning with provider priorities, and emphasizing validity. Some major challenges within the Patient Falls Risk Report could not be mitigated, thus future improvements to the report and health sector overall were suggested. All in all, the Patient Falls Risk Report is useable and will likely support primary care providers in identifying falls-related risk factors and validated care planning options. Future directions. Future research ought to examine the effectiveness of the Patient Falls Risk Report and expand on some important findings in this study. Implementation of the Patient Falls Risk Report will support information sharing in Ontario’s health sector and help keep vulnerable patients from being overlooked.
Diagnosis and Management of Heart Failure: An Investigation to Evaluate a Device to Measure Jugular Venous Pressure
(University of Waterloo, 2016-04-14) Chetram, Vishaka; Heckman, George
Diagnosing and managing heart failure (HF) can be challenging as patients sometimes present atypically with non-specific signs and symptoms. Effective management hinges upon an accurate, timely diagnosis. An important component of physical examination, the assessment of jugular venous pressure (JVP), can assist in the diagnosis and management of HF. Clinical assessment of JVP can be performed at the bedside using the Lewis method whereby the height of the jugular venous pulse above the right atrium is measured. Reliability of the maneuver can be affected by variability related to the appropriate vein to use, reference points, and variable classification of normal versus abnormal. A non-invasive point of care device, the Mespere Venous 1000 Central Venous Pressure (CVP) System, can be used to measure JVP. It has been approved by Health Canada and the Food and Drug Agency for commercial use. The overall aim of this study was to conduct a preliminary evaluation of the feasibility of using the Mespere Venous 1000 CVP System to measure JVP for the diagnosis and management of HF in primary care and long term care (LTC). The study involved two projects: Project I and Project II. Project I was conducted in one primary care and four LTC settings. It sought to gather qualitative information from the physicians and nurses about their perceptions relating to: measurement of JVP, acceptability of the device, perceived ease of use, and perceived barriers of the device. Focus groups and interviews were conducted with six physicians and nine nurses in primary care, and four physicians and ten nurses in LTC. Findings showed that the device was more acceptable and feasible to use for LTC clinicians than it was for primary care clinicians, particularly if its reliability among LTC residents could be demonstrated. Project I revealed that the low acceptability of the device in primary care appears to stem in part from a lack of understanding of the importance of the JVP and patterns of practice that favor transfers of patients to emergency department (ED) for more definitive management. Project II of the study aimed to assess the reliability of the device in the LTC setting. Two LTC physicians, two nurses and thirty six LTC residents participated in the study. The findings showed that the reliability of the device, when used by LTC nurses, was greater than that of physicians’ measures obtained with the Lewis method. In conclusion, the study suggests that the use of the point of care (POC) Mespere Venous CVP 1000 System to measure JVP is acceptable and feasible in the LTC setting, but less so in primary care. In LTC, it provides more reliable measures of the JVP than does clinical assessment by physicians. Additional study is required to further improve the reliability of the device when used by LTC nurses. Further work is also required to develop primary care processes that promote HF management within primary care settings, and whether the device could have a role in such settings.
Investigating Older Adults' Functional Capacity and Clinical Profiles in an Emergency Department in Tehran, Iran
(University of Waterloo, 2019-05-01) Zarrin, Aein; Heckman, George
Introduction: While population aging has been investigated mostly in developed countries, developing nations are also experiencing a demographic shift. Iran is no exception. One of the sectors of healthcare that is affected substantially by population aging is acute care, particularly emergency departments [ED]. However, there is a paucity of information on the profiles of older Iranians in acute care. Therefore, this research project is aiming to investigate older adults’ functional capacity and clinical profiles in an emergency department in Iran. Methods: This project was an observational cohort study. Older ED patients at a large, public teaching hospital in Tehran were assessed using interRAI ED-CA assessment tool. Twenty-eight days following their discharge, adverse outcomes, such as re-admissions and mortality were investigated. Using confidence intervals prevalence estimate of geriatric syndromes were compared with seven other nations that participated in a previous interRAI multinational study. Further, multivariate logistic regression was utilized to identify predictors of post-discharge adverse outcomes. Results and Discussion: There was a bimodal distribution of frailty among older ED patients at Shariati Hospital. Patients were either somewhat frail, whose ED visit could have been potentially prevented through primary care, or extremely frail, indicating an immediate need for stabilization. Similar to other countries, functional decline was common from the pre-morbid to admission stage. However, the prevalence of functional deficits, potential delirium, cardiovascular diseases, and immobility was higher than many developed nations, such as Australia, Canada, and Germany. Geriatric syndromes were found as significant predictors of ED re-admissions and death. Future interventions must prioritize the implementation of primary care, senior-friendly EDs, and community support.
The effect of the COVID-19 pandemic on delirium incidence in Ontario long-term care homes: A retrospective cohort study
(Public Library of Science (PLOS), 2024) Kennedy, Lydia; Hirdes, John P.; Heckman, George; Searle, Samuel D.; McArthur, Caitlin
Objectives To describe delirium incidence before and during the COVID-19 pandemic and examine factors associated with delirium incidence in the long-term care setting. Methods We conducted a retrospective cohort study of Ontario long-term care residents without severe cognitive impairment or baseline delirium with an assessment between February 1, 2029, and March 31, 2021. Data were collected from the interRAI Minimum Data Set (MDS) 2.0. The outcome of interest was delirium development. Selected independent variables were entered into univariate longitudinal generalized estimating equations, followed by multivariate analysis. Odd ratios (ORs) and 95% confidence intervals (CIs) are reported. Results A total of 63,913 residents were included within the comparison sample from February 2019 to February 2020. The pandemic sample consisted of 54,867 residents from March 2020 to March 2021. Incidents of delirium in the comparison sample was 3.4% (2158 residents) compared to 3.2% (1746 residents) in the pandemic sample (P=0.06). Residents who were older, cognitively impaired, and increasingly frail had greater odds of developing delirium. Increased odds were associated with a diagnosis of bipolar disorder (OR 1.27, 95% Cl 1.07-1.51) and anxiolytic use (OR 1.12, 95% Cl 1.01-1.25). Residents who were newly admitted (OR 0.65, 95% Cl 0.60-0.71) and those dependent for activities of daily living (OR 046, 95% Cl 0.33-0.64) had lower odds of delirium development. Conclusions and implications The incidence of delirium did not differ between the year prior to and the first year of the COVID-19 pandemic, indicating that preventative interventions employed by long-term care homes may have been effective. Long-term care residents who are older, frail, cognitively impaired, or had unstable health would benefit from targeted interventions to prevent delirium. Newly admitted residents or those dependent in activities of daily living had lower odds of developing delirium, which could indicate under detection in these groups.
The Long-Term Care Pandemic: International Perspectives on COVID-19 and the Future of Nursing Homes
(Balsillie School of International Affairs, 2020-07-15) Hirdes, John P.; Declercq, Anja; Finne-Soveri, Harriet; Fries, Brant E.; Geffen, Leon; Heckman, George; Lum, Terry; Meehan, Brigette; Millar, Nigel; Morris, John N.
Five major changes to long-term care can protect the elderly from the ravages of infectious disease and provide a greater quality of care and quality of life.