APPROACH e-PROM system: a user-centered development and evaluation of an electronic patient-reported outcomes measurement system for management of coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential to inform routine cardiac care and to improve quality of care and patient outcomes. This study describes a user-centered development and evaluation of the Alberta Provincial Project for Outcomes Assessment (APPROACH) electronic Patient Reported Outcomes Measurement (e-PROM) system. This e-PROM system is an electronic system for the administration of PROMs to patients with CAD and the delivery of the summarized information to their care providers to facilitate patient-physician communication and shared decision-making. This electronic platform was designed to be accessible via web-based and hand-held devices. Heuristic and user acceptance evaluation were conducted with patients and attending care providers. RESULTS: The APPROACH e-PROM system was co-developed with patients and care providers, research investigators, informaticians and information technology experts. Five PROMs were selected for inclusion in the online platform after consultations with patient partners, care providers, and PROMs experts: the Seattle Angina Questionnaire, Patient Health Questionnaire, EuroQOL, and Medical Outcomes Study Social Support Survey, and Self-Care of Coronary Heart Disease Inventory. The heuristic evaluation was completed by four design experts who examined the usability of the prototype interfaces. User acceptance testing was completed with 13 patients and 10 cardiologists who evaluated prototype user interfaces of the e-PROM system. CONCLUSION: Both patients and physicians found the APPROACH e-PROM system to be easy to use, understandable, and acceptable. The APPROACH e-PROM system provides a user-informed electronic platform designed to incorporate PROMs into the delivery of individualized cardiac care for persons with CAD.

Change Management Accompanying Implementation of Decision Support for Prevention of Acute Kidney Injury in Cardiac Catheterization Units: Program Report.

Purpose of program: Different models exist to guide successful implementation of electronic health tools into clinical practice. The Contrast Reducing Injury Sustained by Kidneys (Contrast RISK) initiative introduced an electronic decision support tool with physician audit and feedback into all of the cardiac catheterization facilities in Alberta, Canada, with the goal of preventing contrast-associated acute kidney injury (CA-AKI) following coronary angiography and intervention. This report describes the change management approaches used by the initiative and end-user's feedback on these processes. Sources of information and methods: The Canada Health Infoway Change Management model was used to address 6 activities relevant to project implementation: governance and leadership, stakeholder engagement, communications, workflow analysis and integration, training and education, and monitoring and evaluation. Health care providers and invasive cardiologists from all sites completed preimplementation, usability, and postimplementation surveys to assess integration and change success. Key findings: Prior to implementation, 67% of health providers were less than satisfied with processes to determine appropriate contrast dye volumes, 47% were less than satisfied with processes for administering adequate intravenous fluids, and 68% were less than satisfied with processes to ensure follow-up of high-risk patients. 48% of invasive cardiologists were less than satisfied with preprocedural identification of patients at risk of acute kidney injury (AKI). Following implementation, there were significant increases among health providers in the odds of satisfaction with processes for identifying those at high risk of AKI (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.36-6.66, P = .007), quantifying the appropriate level of contrast dye for each patient (OR 6.98, 95% CI 3.06-15.91, P < .001), determining the optimal amount of IV fluid for each patient (OR 1.86, 95% CI 0.88-3.91, P = .102), and following up of kidney function of high risk patients (OR 5.49, 95%CI 2.45-12.30, P < .001). There were also significant increases among physicians in the odds of satisfaction with processes for identifying those at high risk of AKI (OR 19.53, 95% CI 3.21-118.76, P = .001), quantifying the appropriate level of contrast dye for each patient (OR 26.35, 95% CI 4.28-162.27, P < .001), and for following-up kidney function of high-risk patients (OR 7.72, 95% CI 1.62-36.84.30, P = .010). Eighty-nine percent of staff perceived the initiative as being successful in changing clinical practices to reduce the risk of CA-AKI. Physicians uniformly agreed that the system was well-integrated into existing workflows, while 42% of health providers also agreed. Implications: The Canada Health Infoway Change Management model was an effective framework for guiding implementation of an electronic decision support tool and audit and feedback intervention to improve processes for AKI prevention within cardiac catheterization units.

Objectif du program: Il existe différents modèles pour guider la mise en œuvre efficace d'outils électroniques dans la pratique clinique. L'initiative Contrast RISK (Contrast Reducing Injury Sustained by Kidneys) a permis d'introduire un outil électronique d'aide à la décision avec surveillance par le médecin et rétroaction dans tous les établissements de l'Alberta (Canada) pratiquant le cathétérisme cardiaque, dans le but de prévenir les insuffisances rénales aiguës associées aux produits de contraste (IRA-PC) après une coronarographie et une intervention. Le présent rapport décrit les approches de gestion du changement utilisées dans le cadre de l'initiative, ainsi que les commentaires des utilisateurs sur ces processus. Sources de l'information et méthodologie: Le modèle de gestion du changement d'Inforoute Santé du Canada a été employé pour aborder six activités pertinentes pour la mise en œuvre de projets: gouvernance et leadership, engagement des intervenants, communications, analyze du flux de travail et intégration, formation et éducation, surveillance et évaluation. Les prestataires de soins et les cardiologues spécialisés en interventions invasives de tous les sites ont répondu à un sondage avant, pendant et après la mise en œuvre afin d'évaluer le succès de l'intégration et du changement. Principaux résultats: Avant la mise en œuvre, 67% des prestataires de soins étaient insatisfaits des processus pour déterminer les volumes appropriés des produits de contraste, 47% étaient insatisfaits des processus pour administrer l'hydratation intraveineuse et 68% étaient insatisfaits des processus de surveillance des patients présentant un risque élevé. Près de la moitié (48%) des cardiologues spécialisés en interventions invasives étaient insatisfaits du processus d'identification préalable des patients présentant un risque élevé d'IRA. Après la mise en œuvre, on a observé une augmentation significative de la satisfaction des prestataires de soins à l'égard des processus pour identifier les patients présentant un risque élevé d'IRA (rapport de cote [RC]: 3,01; IC 95%: 1,36-6,66; P = .007), quantifier le niveau approprié de produit de contraste pour chaque patient (RC: 6,98; IC 95%: 3,06-15,91; P < .001), déterminer le volume optimal d'hydratation IV pour chaque patient (RC: 1,86, IC 95%: 0,88-3,91; P = .102) et surveiller la fonction rénale chez les patients présentant un risque élevé (RC: 5,49 IC 95%: 2,45-12,30; P < .001). On a également observé une augmentation significative de la satisfaction des médecins à l'égard des processus pour identifier les patients présentant un risque élevé d'IRA (RC: 19,53; IC 95%: 3,21-118,76; P = .001), quantifier le niveau approprié de produit de contraste pour chaque patient (RC: 26,35; IC 95%: 4,28-162,27; P < .001) et surveiller la fonction rénale des patients présentant un risque élevé (RC: 7,72; IC 95%: 1,62-36,84,30; P = .010). Une grande majorité du personnel (89%) était d'avis que l'initiative avait permis de changer les pratiques cliniques visant à réduire le risque d'IRA-PC. L'ensemble des médecins s'entendait pour dire que le système était bien intégré dans les flux de travail existants; 42% des prestataires de soins étaient également de cet avis. Conclusion: Le modèle de gestion du changement d'Inforoute Santé du Canada s'est avéré un cadre efficace pour guider la mise en œuvre d'un outil électronique d'aide à la décision et d'une intervention de surveillance et de rétroaction visant à améliorer les processus de prévention de l'IRA dans les unités de cathétérisme cardiaque.

Preferences of Patients With Chronic Kidney Disease for Invasive Versus Conservative Treatment of Acute Coronary Syndrome: A Discrete Choice Experiment.

Background Patients with chronic kidney disease (CKD) can experience acute coronary syndromes (ACS) with high morbidity and mortality. Early invasive management of ACS is recommended for most high-risk patients; however, choosing between an early invasive versus conservative management approach may be influenced by the unique risk of kidney failure for patients with CKD. Methods and Results This discrete choice experiment measured the preferences of patients with CKD for future cardiovascular events versus acute kidney injury and kidney failure following invasive heart procedures for ACS. The discrete choice experiment, consisting of 8 choice tasks, was administered to adult patients attending 2 CKD clinics in Calgary, Alberta. The part-worth utilities of each attribute were determined using multinomial logit models, and preference heterogeneity was explored using latent class analysis. A total of 140 patients completed the discrete choice experiment. The mean age of patients was 64 years, 52% were male, and mean estimated glomerular filtration rate was 37 mL/min per 1.73 m2. Across the range of levels, risk of mortality was the most important attribute, followed by risk of end-stage kidney disease and risk of recurrent myocardial infarction. Latent class analysis identified 2 distinct preference groups. The largest group included 115 (83%) patients, who placed the greatest value on treatment benefits and expressed the strongest preference for reducing mortality. A second group of 25 (17%) patients was identified who were procedure averse and had a strong preference toward conservative management of ACS and avoiding acute kidney injury requiring dialysis. Conclusions The preferences of most patients with CKD for management of ACS were most influenced by lowering mortality. However, a distinct subgroup of patients was strongly averse to invasive management. This highlights the importance of clarifying patient preferences to ensure treatment decisions are aligned with patient values.

Patient Experience After Risk Stratification and Follow-up for Acute Kidney Injury After Cardiac Catheterization: Patient Survey.

BACKGROUND: Acute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization. METHODS: We implemented an initiative across 3 cardiac catheterization units in Alberta, Canada to provide standardized assessment, followed by guidance for patients at risk of AKI. This was accompanied by communication to primary care providers to improve continuity of care when patients transition from the hospital to the community. A structured survey from a sample of 100 participants at increased risk of AKI determined their perceptions of information provided and experiences with follow-up steps after the initiative was implemented in each cardiac catheterization unit in Alberta. RESULTS: The mean age of participants was 72.4 (SD 10.4) years, 37% were female, and the mean risk of AKI was 8.8%. Most (63%) participants were able to recall the information provided to them about their risk of kidney injury, 68% recalled the education provided on strategies to reduce risk, and 65% believed their primary care practitioner had received enough information to conduct appropriate follow-up care. Eighty-six percent of patients were satisfied with their transition to the community, and 53% were reassured by the information and follow-up care they received. CONCLUSIONS: These findings suggest that communicating risk information to patients, in combination with education and collaboration for follow-up with primary care providers, is associated with positive patient experiences and satisfaction with care.

CONTEXTE: L'insuffisance rénale aiguë (IRA) après un cathétérisme cardiaque est associée à de mauvais résultats en matière de santé. Nous avons voulu décrire l'expérience des patients après qu'on leur ait transmis de l'information standardisée concernant le risque d'IRA et des directives pour les soins de suivi après un cathétérisme cardiaque. MÉTHODOLOGIE: Nous avons mis en place une initiative dans trois unités de cathétérisme cardiaque en Alberta, au Canada, afin de permettre une évaluation standardisée, puis d'offrir des directives concernant les patients à risque d'IRA. Notre initiative comprenait également des communications aux fournisseurs de soins primaires en vue d'améliorer la continuité des soins prodigués aux patients quittant l'hôpital pour retourner en milieu communautaire. Un sondage structuré mené auprès de 100 participants présentant un risque accru d'IRA a permis de connaître leurs perceptions quant à l'information reçue et à leur expérience à l'égard du suivi après la mise en place de l'initiative dans chacune des unités de cathétérisme cardiaque en Alberta. RÉSULTATS: L'âge moyen des participants était de 72,4 ans (écart type : 10,4), 37 % étaient des femmes, et le risque moyen d'IRA était de 8,8 %. La plupart des participants (63 %) étaient en mesure de se souvenir de l'information qui leur avait été transmise au sujet de leur risque d'insuffisance rénale, 68 % se rappelaient la formation reçue concernant les stratégies pour réduire leur risque, et 65 % estimaient que leur médecin de soins primaires avait recueilli suffisamment d'information pour effectuer un suivi adéquat. Quatre-vingt-six pour cent (86 %) des patients étaient satisfaits de leur transition en milieu communautaire, et 53 % étaient rassurés par l'information reçue et le suivi dont ils faisaient l'objet. CONCLUSIONS: Ces résultats suggèrent que le fait de transmettre aux patients de l'information au sujet des risques, en plus de les éduquer et de leur permettre de collaborer avec leur fournisseur de soins primaires pour le suivi est associé à une expérience positive pour le patient et à la satisfaction à l'égard des soins reçus.

Patient and physician perspectives on shared decision-making for coronary procedures in people with chronic kidney disease: a patient-oriented qualitative study.

BACKGROUND: Patients with chronic kidney disease (CKD) and heart disease face challenging treatment decisions. We sought to explore the perceptions of patients and physicians about shared decision-making for coronary procedures for people with CKD, as well as opinions about strategies and tools to improve these decisions. METHODS: We partnered with 4 patients with CKD and 1 caregiver to design and conduct a qualitative descriptive study using semi-structured interviews and content analysis. Patient participants with CKD and either acute coronary syndrome or cardiac catheterization in the preceding year were recruited from a provincial cardiac registry, cardiology wards and clinics in Calgary between March and September 2018. Cardiologists from the region also participated in the study. Data analysis emphasized identifying, organizing and describing themes found within the data. RESULTS: Twenty patients with CKD and 10 cardiologists identified several complexities related to bidirectional information exchange needed for shared decision-making. Themes identified by both patients and physicians included challenges synthesizing best evidence, variable patient knowledge seeking, timeliness in the acute care setting and influence of roles on decision-making. Themes identified by physicians related to processes and tools to help support shared decision-making in this setting included personalization to reflect the variability of risks and heterogeneity of patient preferences as well as allowing for physicians to share their clinical judgment. INTERPRETATION: There are complexities related to bidirectional information exchange between patients with CKD and their physicians for shared decision-making about coronary procedures. Processes and tools to facilitate shared decision-making in this setting require personalization and need to be time sensitive.

Feasibility of a pedometer-based walking program for survivors of breast and head and neck cancer undergoing radiation therapy.

PURPOSE: This pilot study assessed the feasibility and acceptability of a pedometer-based walking program for people with breast cancer and head and neck cancer (HNC) undergoing radiation therapy treatment. METHODS: Participants were given a pedometer and prescribed a home-based walking program that included an individualized weekly step-count goal during the 3- to 5-week course of radiation therapy. Feasibility was determined by calculating recruitment rate, completion rate, and rate of adherence. Secondary outcomes included 6-minute walk test (6MWT) distance, step count, physical activity level, and psychological outcomes of depression, happiness, self-esteem, and sleep quality. RESULTS: A total of 21 participants were recruited. All participants completed the study; adherence to prescribed step counts was 91% at follow-up. Analysis found a significant improvement in happiness, as measured by the Oxford Happiness Questionnaire (mean difference 0.3, p=0.003), and a borderline significant improvement in 6MWT distance (mean difference 35 m, p=0.008). CONCLUSION: This pilot study demonstrated the feasibility of a pedometer-based walking program for survivors of breast cancer and HNC undergoing radiation therapy.

Objet: Cette étude pilote a évalué la faisabilité et l'acceptabilité d'un programme de marche à base de podomètre pour les personnes qui ont un cancer du sein et un cancer de la tête et du cou (CTC), et qui suivent une radiothérapie. Méthodes: Les participants ont reçu un podomètre et on leur a prescrit un programme de marche à domicile comportant un nombre personnalisé de pas par semaine à effectuer au cours de la radiothérapie d'une durée de 3 à 5 semaines. On a déterminé la faisabilité en calculant le taux d'inscription, le taux d'achèvement et le taux d'observation. Les résultats secondaires ont inclus la distance parcourue pendant le test de marche de 6 minutes (TM6M), le nombre de pas, le niveau d'activité physique (AP) et les résultats psychologiques liés à la dépression, au bonheur, à l'estime de soi et à la qualité du sommeil. Résultats: Au total, 21 participants ont été recrutés. Tous les participants ont terminé l'étude et avaient effectué le nombre de pas prescrit dans une proportion de 91% au moment du suivi. L'analyse a révélé une amélioration importante du bonheur mesuré au moyen du questionnaire d'Oxford sur le bonheur (différence moyenne de 0,3, p=0,003) et une amélioration significative limite de la distance parcourue pendant le TM6M (différence moyenne de 35 m, p=0,008). Conclusion: Cette étude pilote a démontré la faisabilité d'un programme de marche à base de podomètre pour les survivants d'un cancer du sein et d'un CTC qui suivent une radiothérapie.