Emergency physician perspectives on initiating buprenorphine/naloxone in the emergency department: A qualitative study.

OBJECTIVES: The objective of this study was to examine the perspectives of Canadian emergency physicians on the care of patients with opioid use disorders in the emergency department (ED), in particular the real-world facilitators to prescribing buprenorphine/naloxone (BUP) in the ED. METHODS: We conducted semistructured qualitative interviews using a multi-site-focused ethnographic design. Purposive sampling via an existing national research network was used to recruit ED physicians. Interviews were conducted by phone using an interview guide and continued until theoretical data saturation was reached. Interviews were transcribed and analyzed using latent content analysis. Interviews took place between June 21, 2019, and February 11, 2020. RESULTS: A total of 32 physicians were included in the analysis. Participants had a median of 10 years of experience, and most (29/32) worked in urban settings. Clinical care of patients with opioid use disorder was found to be variable and physician dependent. Although some physicians reported routinely prescribing BUP, others felt that this was outside the clinical scope of emergency medicine. Access to clinical pathways, incentivized training, dedicated human resources, and follow-up care were identified as critical facilitators for supporting BUP prescribing. Participants also identified a shared responsibility between patients and the ED, including the importance of a patient-centered approach that enhanced patient autonomy. ED BUP prescribing became self-reinforcing over time. CONCLUSIONS: Although there remains practice variability among Canadian emergency physicians, successful implementation of ED BUP prescribing has occurred in some locations. Jurisdictions wanting to facilitate BUP uptake should consider providing incentivized training, treatment protocols, dedicated human resources, and streamlined access to follow-up care.

Awareness as a dimension of health care access: exploring the case of rural palliative care provision in Canada.

OBJECTIVES: In Canada, the rural elderly population is increasing in size, as is their need for palliative care services in these settings. This analysis aims to identify awareness-associated barriers to delivering rural palliative care services, along with suggestions for improving service delivery from the perspective of local health care providers. METHODS: A total of 40 semi-structured interviews with various formal and informal health care providers were conducted in four rural and/or remote Canadian communities with limited palliative care resources. Interview data were thematically coded using Penchansky and Thomas' five dimensions of access (i.e. availability, (geographic) accessibility, accommodation, acceptability and affordability). Saurman's recently added sixth dimension of access - awareness - was also identified while coding and subsequently became the primary focus of this analysis. RESULTS: Identified barriers to palliative care awareness and suggestions on how to enhance this awareness, and ultimately palliative care delivery, corresponded with three key themes arising from the data: limited palliative care knowledge/education, communication and coordination. Participants recognized the need for more palliative care education, open lines of communication and better coordination of palliative care initiatives and local resources in their communities. CONCLUSIONS: These findings suggest that identifying the barriers to palliative care awareness in rural communities may be foundational to addressing barriers to the other five dimensions of access. A thorough understanding of these three areas of awareness knowledge, communication and coordination, as well as the connections between them, may help enhance how rural palliative care is delivered in the future.

Principles, practice, and policy vacuums: Policy actor views on provincial/territorial harm reduction policy in Canada.

INTRODUCTION: Canada is experiencing a new era of harm reduction policymaking and investment. While many provinces and territories are expanding access to these services, harm reduction policy and policymaking varies across the country. The present study, part of the Canadian Harm Reduction Policy Project (CHARPP), described policy actors' views on formal harm reduction policies in Canada's 13 provinces and territories. METHODS: As part of CHARPP's mixed-method, multiple case study, we conducted qualitative interviews with 75 policy actors, including government officials, health system leaders, senior staff at community organizations, and advocates with self-identified lived experience of using drugs. Interviews were conducted in English or French, and recorded and transcribed verbatim. We used latent content analysis to inductively code the data and generate main findings. NVivo 11 was used to organize the transcripts. RESULTS: Participants expressed divergent views on formal provincial/territorial policies and their impact on availability of harm reduction programs and services. While some identified a need to develop new policies or improve existing ones, others resisted bureaucratization of harm reduction or felt the absence of formal policy was instead, advantageous. Instances where harm reduction was advanced outside of formal policymaking were also described. DISCUSSION: Previous CHARPP research documented wide variability in quantity and quality of formal harm reduction policies across Canada, and characterized official policy documents as serving largely rhetorical rather than instrumental functions. The present findings highlight diverse ways that actors used their discretion to navigate these weak policy contexts. Participants' views and experiences sometimes referred to strengthening policy support, but institutionalization of harm reduction was also resisted or rejected. Results suggest that actors adopt a range of pragmatic strategies to advance harm reduction services in response to policy vacuums characteristic of morality policy domains, and challenge assumptions about the utility of formal policies for advancing harm reduction.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Structured Physical Activity in the Management of Juvenile Idiopathic Arthritis.

OBJECTIVE: To create guidelines focused on the use of structured physical activity (PA) in the management of juvenile idiopathic arthritis (JIA). DATA SOURCES: A systematic literature search was conducted using the electronic databases Cochrane Central Register of Controlled Trials, MEDLINE (Ovid), EMBASE (Ovid), and Physiotherapy Evidence Database for all studies related to PA programs for JIA from January 1966 until December 2014, and was updated in May 2015. STUDY SELECTION: Study selection was completed independently by 2 reviewers. Studies were included if they involved individuals aged ≤21 years diagnosed with JIA who were taking part in therapeutic exercise or other PA interventions for which effects of various disease-related outcomes were compared with a control group (eg, no PA program or activity of lower intensity). DATA EXTRACTION: Two reviewers independently extracted information on interventions, comparators, outcomes, time period, and study design. The statistical analysis was reported using the Cochrane Collaboration methods. The quality of the included studies was assessed according to the Physiotherapy Evidence Database Scale. DATA SYNTHESIS: Five randomized controlled trials (RCTs) fit the selection criteria; of these, 4 were high-quality RCTs. The following recommendations were developed: (1) Pilates for improving quality of life, pain, functional ability, and range of motion (ROM) (grade A); (2) home exercise program for improving quality of life and functional ability (grade A); (3) aquatic aerobic fitness for decreasing the number of active joints (grade A); and (4) and cardio-karate aerobic exercise for improving ROM and number of active joints (grade C+). CONCLUSIONS: The Ottawa Panel recommends the following structured exercises and physical activities for the management of JIA: Pilates, cardio-karate, home and aquatic exercises. Pilates showed improvement in a higher number of outcomes.

Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis.

OBJECTIVES: The primary objective is to identify effective land-based therapeutic exercise interventions and provide evidence-based recommendations for managing hip osteoarthritis. A secondary objective is to develop an Ottawa Panel evidence-based clinical practice guideline for hip osteoarthritis. METHODS: The search strategy and modified selection criteria from a Cochrane review were used. Studies included hip osteoarthritis patients in comparative controlled trials with therapeutic exercise interventions. An Expert Panel arrived at a Delphi survey consensus to endorse the recommendations. The Ottawa Panel hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) considered the study design (level I: randomized controlled trial and level II: controlled clinical trial), statistical significance (p < 0.5), and clinical importance (⩾15% improvement). RESULTS: Four high-quality studies were included, which demonstrated that variations of strength training, stretching, and flexibility exercises are generally effective for improving the management of hip osteoarthritis. Strength training exercises displayed the greatest improvements for pain (Grade A), disability (Grades A and C+), physical function (Grade A), stiffness (Grade A), and range of motion (Grade A) within a short time period (8-24 weeks). Stretching also greatly improved physical function (Grade A), and flexibility exercises improved pain (Grade A), range of motion (Grade A), physical function (Grade A), and stiffness (Grade C+). CONCLUSION: The Ottawa Panel recommends land-based therapeutic exercise, notably strength training, for management of hip osteoarthritis in reducing pain, stiffness and self-reported disability, and improving physical function and range of motion.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Foot Care in the Management of Juvenile Idiopathic Arthritis.

OBJECTIVE: To create evidence-based guidelines evaluating foot care interventions for the management of juvenile idiopathic arthritis (JIA). DATA SOURCES: An electronic literature search of the following databases from database inception to May 2015 was conducted: MEDLINE (Ovid), EMBASE (Ovid), Cochrane CENTRAL, and clinicaltrials.gov. STUDY SELECTION: The Ottawa Panel selection criteria targeted studies that assessed foot care or foot orthotic interventions for the management of JIA in those aged 0 to ≤18 years. The Physiotherapy Evidence Database scale was used to evaluate study quality, of which only high-quality studies were included (score, ≥5). A total of 362 records were screened, resulting in 3 full-text articles and 1 additional citation containing supplementary information included for the analysis. DATA EXTRACTION: Two reviewers independently extracted study data (intervention, comparator, outcome, time period, study design) from the included studies by using standardized data extraction forms. Directed by Cochrane Collaboration methodology, the statistical analysis produced figures and graphs representing the strength of intervention outcomes and their corresponding grades (A, B, C+, C, C-, D+, D, D-). Clinical significance was achieved when an improvement of ≥30% between the intervention and control groups was present, whereas P>.05 indicated statistical significance. An expert panel Delphi consensus (≥80%) was required for the endorsement of recommendations. DATA SYNTHESIS: All included studies were of high quality and analyzed the effects of multidisciplinary foot care, customized foot orthotics, and shoe inserts for the management of JIA. Custom-made foot orthotics and prefabricated shoe inserts displayed the greatest improvement in pain intensity, activity limitation, foot pain, and disability reduction (grades A, C+). CONCLUSIONS: The use of customized foot orthotics and prefabricated shoe inserts seems to be a good choice for managing foot pain and function in JIA.

Internet-based implementation of non-pharmacological interventions of the "people getting a grip on arthritis" educational program: an international online knowledge translation randomized controlled trial design protocol.

BACKGROUND: Rheumatoid arthritis (RA) affects 2.1% of the Australian population (1.5% males; 2.6% females), with the highest prevalence from ages 55 to over 75 years (4.4-6.1%). In Canada, RA affects approximately 0.9% of adults, and within 30 years that is expected to increase to 1.3%. With an aging population and a greater number of individuals with modifiable risk factors for chronic diseases, such as arthritis, there is an urgent need for co-care management of arthritic conditions. The increasing trend and present shifts in the health services and policy sectors suggest that digital information delivery is becoming more prominent. Therefore, it is necessary to further investigate the use of online resources for RA information delivery. OBJECTIVE: The objective is to examine the effect of implementing an online program provided to patients with RA, the People Getting a Grip on Arthritis for RA (PGrip-RA) program, using information communication technologies (ie, Facebook and emails) in combination with arthritis health care professional support and electronic educational pamphlets. We believe this can serve as a useful and economical method of knowledge translation (KT). METHODS: This KT randomized controlled trial will use a prospective randomized open-label blinded-endpoint design to compare four different intervention approaches of the PGrip-RA program to a control group receiving general electronic educational pamphlets self-management in RA via email. Depending on group allocation, links to the Arthritis Society PGrip-RA material will be provided either through Facebook or by email. One group will receive feedback online from trained health care professionals. The intervention period is 6 weeks. Participants will have access to the Internet-based material after the completion of the baseline questionnaires until the final follow-up questionnaire at 6 months. We will invite 396 patients from Canadian and Australian Arthritis Consumers' Associations to participate using online recruitment. RESULTS: This study will build on a pilot study using Facebook, which revealed promising effects of knowledge acquisition/integration of the evidence-based self-management PGrip educational program. CONCLUSIONS: The use of online techniques to disseminate knowledge provides an opportunity to reduce health care costs by facilitating self-management of people with arthritis. Study design strengths include the incorporation of randomization and allocation concealment to ensure internal validity. To avoid intergroup contamination, the Facebook group page security settings will be set to "closed", thus allowing only invited participants to access it. Study limitations include the lack of participant blinding due to the characteristics of this KT randomized controlled trial and a potential bias of recruiting patients only online, though this was proven effective in the previous pilot study. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000397617; http://www.anzctr.org.au/TrialSearch.aspx (Archived by WebCite at http://www.webcitation.org/6PrP0kQf8).