Development of a Novel Care Rehabilitation Pathway for Post-COVID Conditions (Long COVID) in a Provincial Health System in Alberta, Canada.

OBJECTIVE: The purpose of this study was to describe the development and composition of a codesigned, multidisciplinary, integrated, systematic rehabilitation framework for post-COVID conditions (PCC) that spans the care continuum to streamline and standardize rehabilitation services to support persons with PCC in Alberta, Canada. METHODS: A collaborative, consensus-based approach was used involving 2 iterative provincial taskforces in a Canadian provincial health system. The first taskforce (59 multidisciplinary stakeholders) sought to clarify the requisite facets of a sustainable, provincially coordinated rehabilitation approach for post-COVID rehabilitation needs based on available research evidence. The second taskforce (129 multidisciplinary stakeholders) translated that strategy and criteria into an operational framework for provincial implementation. Both taskforces sought to align with operational realities of the provincial health system. RESULTS: The summation of this collaborative consensus approach resulted in the Provincial Post COVID-19 Rehabilitation Response Framework (PCRF). The PCRF includes 3 care pathways across the care continuum specifically targeting in-hospital care, continuing care, and community-based care with 3 key elements: (1) the use of specific symptom screening and assessment tools to systematically identify PCC symptoms and functional impairments, (2) pathways to determine patients' rehabilitation trajectory and guide their transition between care settings, and (3) self-management and education resources for patients and providers. CONCLUSION: The PCRF aligns with international mandates for novel, codesigned, multidisciplinary approaches to systematically address PCC and its myriad manifestations across the care continuum. The PCRF allows for local adaptation and highlights equity considerations, allowing for further spread and scale provincially, nationally, and internationally. IMPACT: The PCRF is a framework for health systems to ensure consistent identification, assessment, and management of the rehabilitation needs of postacute and chronic PCC. Rehabilitation providers and health systems can build from the PCRF for their local communities to reduce unmet needs and advance the standardization of access to rehabilitation services for persons with PCC.

Evaluating the impact of a novel telerehabilitation service to address neurological, musculoskeletal, or coronavirus disease 2019 rehabilitation concerns during the coronavirus disease 2019 pandemic.

Introduction: A novel telerehabilitation service provides wayfinding and self-management advice to persons with neurological, musculoskeletal, or coronavirus disease 2019 related rehabilitation needs. Method: We utilized multiple methods to evaluate the impact of the service. Surveys clarified health outcomes (quality of life, self-efficacy, social support) and patient experience (telehealth usability; general experience) 3-months post-call. We analysed associations between, and within, demographics and survey responses. Secondary analyses described health care utilization during the first 6 months. Results: Sixty-eight callers completed the survey (42% response rate). Self-efficacy was significantly related to quality of life, interpersonal support and becoming productive quickly using the service. Becoming productive quickly was significantly related to quality of life. Education level was related to ethnicity. Survey respondents' satisfaction and whether they followed the therapist's recommendations were not significantly associated with demographics. Administrative data indicated there were 124 callers who visited the emergency department before, on, or after their call. The average (SD) frequency of emergency department visits before was 1.298 times (1.799) compared to 0.863 times (1.428) after. Discussion: This study offers insights into the potential impact of the telerehabilitation service amidst pandemic restrictions. Usability measurements showed that callers were satisfied, corroborating literature from pre-pandemic contexts. The satisfaction and acceptability of the service does not supplant preferences for in-person visits. The survey sample reported lower quality of life compared with the provincial population, conflicting with pre-pandemic research. Findings may be due to added stressors associated with the pandemic. Future research should include population-level comparators to better clarify impact.

Healthy food prescription incentive programme for adults with type 2 diabetes who are experiencing food insecurity: protocol for a randomised controlled trial, modelling and implementation studies.

INTRODUCTION: The high cost of many healthy foods poses a challenge to maintaining optimal blood glucose levels for adults with type 2 diabetes mellitus who are experiencing food insecurity, leading to diabetes complications and excess acute care usage and costs. Healthy food prescription programmes may reduce food insecurity and support patients to improve their diet quality, prevent diabetes complications and avoid acute care use. We will use a type 2 hybrid-effectiveness design to examine the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of a healthy food prescription incentive programme for adults experiencing food insecurity and persistent hyperglycaemia. A randomised controlled trial (RCT) will investigate programme effectiveness via impact on glycosylated haemoglobin (primary outcome), food insecurity, diet quality and other clinical and patient-reported outcomes. A modelling study will estimate longer-term programme effectiveness in reducing diabetes-related complications, resource use and costs. An implementation study will examine all RE-AIM domains to understand determinants of effective implementation and reasons behind programme successes and failures. METHODS AND ANALYSIS: 594 adults who are experiencing food insecurity and persistent hyperglycaemia will be randomised to a healthy food prescription incentive (n=297) or a healthy food prescription comparison group (n=297). Both groups will receive a healthy food prescription. The incentive group will additionally receive a weekly incentive (CDN$10.50/household member) to purchase healthy foods in supermarkets for 6 months. Outcomes will be assessed at baseline and follow-up (6 months) in the RCT and analysed using mixed-effects regression. Longer-term outcomes will be modelled using the UK Prospective Diabetes Study outcomes simulation model-2. Implementation processes and outcomes will be continuously measured via quantitative and qualitative data. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Calgary and the University of Alberta. Findings will be disseminated through reports, lay summaries, policy briefs, academic publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04725630. PROTOCOL VERSION: Version 1.1; February 2022.

Clinical practice recommendations for prehabilitation and post-operative rehabilitation for arthroplasty: A scoping review.

BACKGROUND: The rising need for arthroplasty (joint replacement) has resulted in a significant increase in wait-times. Longer surgical wait-times may further exacerbate functional decline in adults with osteoarthritis as well as delay postoperative functional recovery. This review aims to better inform rehabilitation care provision before (prehabilitation) and after (post-rehabilitation) hip or knee arthroplasty based on recommendations from clinical practice guidelines (CPGs). METHODS: This scoping review used a three-stage process to screen and extract articles, which resulted in 123 articles reviewed for analysis. Included CPGs were in the English language and focussed on rehabilitation interventions or practices involving adult patients preparing for or recuperating from hip and knee arthroplasty (published 2009-2020). RESULTS: Patient assessments, use of assistive devices, as well as self-management and education programs were recommended before and after arthroplasty. Physiotherapy was recommended to support post-operative rehabilitation. Conversely, there was limited evidence supporting recommendations for or against physiotherapy during the prehabilitation phase of the arthroplasty care journey. CONCLUSIONS: The findings from this review highlight the current gap in high-quality evidence supporting hip and knee arthroplasty rehabilitation CPGs before and after surgery. Findings warrant additional research to ensure patients are best prepared for surgery and supported for optimal recovery.

Evaluating Community-Facing Virtual Modalities to Support Complex Neurological Populations During the COVID-19 Pandemic: Protocol for a Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic and concomitant governmental responses have created the need for innovative and collaborative approaches to deliver services, especially for populations that have been inequitably affected. In Alberta, Canada, two novel approaches were created in Spring 2020 to remotely support patients with complex neurological conditions and rehabilitation needs. The first approach is a telehealth service that provides wayfinding and self-management advice to Albertans with physical concerns related to existing neurological or musculoskeletal conditions or post-COVID-19 recovery needs. The second approach is a webinar series aimed at supporting self-management and social connectedness of individuals living with spinal cord injury. OBJECTIVE: The study aims to evaluate the short- and long-term impacts and sustainability of two virtual modalities (telehealth initiative called Rehabilitation Advice Line [RAL] and webinar series called Alberta Spinal Cord Injury Community Interactive Learning Seminars [AB-SCILS]) aimed at advancing self-management, connectedness, and rehabilitation needs during the COVID-19 pandemic and beyond. METHODS: We will use a mixed-methods evaluation approach. Evaluation of the approaches will include one-on-one semistructured interviews and surveys. The evaluation of the telehealth initiative will include secondary data analyses and analysis of call data using artificial intelligence. The evaluation of the webinar series will include analysis of poll questions collected during the webinars and YouTube analytics data. RESULTS: The proposed study describes unique pandemic virtual modalities and our approaches to evaluating them to ensure effectiveness and sustainability. Implementing and evaluating these virtual modalities synchronously allows for the building of knowledge on the complementarity of these methods. At the time of submission, we have completed qualitative and quantitative data collection for the telehealth evaluation. For the webinar series, so far, we have distributed the evaluation survey following three webinars and have conducted five attendee interviews. CONCLUSIONS: Understanding the impact and sustainability of the proposed telehealth modalities is important. The results of the evaluation will provide data that can be actioned and serve to improve other telehealth modalities in the future, since health systems need this information to make decisions on resource allocation, especially in an uncertain pandemic climate. Evaluating the RAL and AB-SCILS to ensure their effectiveness demonstrates that Alberta Health Services and the health system care about ensuring the best practice even after a shift to primarily virtual care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/28267.

Use of Virtual Care for Glycemic Management in People With Types 1 and 2 Diabetes and Diabetes in Pregnancy: A Rapid Review.

Our objective in this study was to answer the main research question: In patients with diabetes, does virtual care vs face-to-face care provide different clinical, patient and practitioner experience or quality outcomes? Articles (2012 to 2020) describing interventions using virtual care with the capability for 2-way, individualized interactions compared with usual care were included. Studies involving any patients with diabetes and outcomes of glycated hemoglobin (A1C), quality of care and/or patient or health-care practitioner experience were included. Systematic reviews, randomized controlled studies, quasi-experimental trials, implementation trials, observational studies and qualitative analyses were reviewed. MEDLINE and McMaster Health Evidence databases searched in June 2020 identified 59 articles. Virtual care, in particular telemonitoring, combined with a means of 2-way communications provided improvement in A1C similar or superior to usual care, with the strongest evidence for type 2 diabetes. Virtual care was generally acceptable to patients, who expressed satisfaction with their care. Health-care providers recognized benefits but raised issues of technical support, workflow and compensation.

Return on investment of the diabetes foot care clinical pathway implementation in Alberta, Canada.

AIMS: Based on best practices, the diabetes foot care clinical pathway (DFCCP) has been developed and implemented in several clinics in Alberta, Canada. We performed a return on investment (ROI) analysis of this implementation. METHODS: We used a cohort design comparing both cost and return (in terms of reduced health services utilization, HSU) between diabetes patients who were exposed and who were unexposed, to the intervention. We used a difference-in-difference approach and a propensity-score-matching technique to minimize biases due to differences in demographic and clinical characteristics between two cohorts. We used a 1-year time-horizon and converted all costs/savings to 2019 Canadian dollars (1 CA$ ~= 0.75 US$). RESULTS: The intervention helped avoid $3500 in costs of HSU per patient-year. Subtracting the intervention cost of $500, the net benefit of intervention was $3000 (ranged $2400-$3700) per patient-year. The ROI ratio was estimated at 7.4 (ranged 6.1 to 8.8) meaning that every invested $1 returned $7.4 (ranged $6.1-$8.8) for the health system. The probability of intervention being cost-saving ranged from 99.5-100%. CONCLUSIONS: The implementation of DFCCP in Alberta is cost-saving. A continuation of the pathway implementation at studied clinics and a spread to other clinics are recommended.

Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada.

BACKGROUND: Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019. METHODS: Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher's exact test or Chi-square test. RESULTS: Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved. CONCLUSION: Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.