Examining the impact of the COVID-19 pandemic on homecare services among individuals with traumatic and non-traumatic spinal cord injuries.

STUDY DESIGN: Descriptive repeated-cross sectional retrospective longitudinal cohort study. OBJECTIVE: To investigate the impact of the COVID-19 pandemic on homecare services in individuals with traumatic or non-traumatic Spinal Cord Injury (SCI). SETTING: Health administrative database in Ontario, Canada. METHODS: A repeated cross-sectional study using linked health administrative databases from March 2015 to June 2022. Monthly homecare utilization was assessed in 3381 adults with SCI using Autoregressive Integrated Moving Average (ARIMA) models. RESULTS: Compared to pre-pandemic levels, between March 2020 to June 2022, the traumatic group experienced a decrease in personal and/or homemaking services, as well as an increase in nursing visits from April 2020-March 2022 and June 2022. Case management increased at various times for the traumatic group, however therapies decreased in May 2020 only. The non-traumatic group experienced a decrease in personal and/or homemaking services in July 2020, as well as an increase in nursing visits from March 2020 to February 2021 and sporadically throughout 2020. Case management also increased at certain points for the non-traumatic group, but therapies decreased in April 2020, July 2020, and September 2021. CONCLUSION: The traumatic group had decreases in personal and/or homemaking services. Both groups had increases in nursing services, increases in case management, and minimal decreases in therapies at varying times during the pandemic. Investigation is warranted to understand the root cause of these changes, and if they resulted in adverse outcomes.

Health utility in community-dwelling adults with dysvascular lower limb loss.

PURPOSE: Adults with dysvascular lower extremity amputation (LEA) experience a large number of secondary health conditions yet there is a gap in the literature on health utility scores for this population. A health utility score relates to a person's state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). This study aimed to provide a descriptive account of health utility scores in community-dwelling adults with dysvascular LEA. METHODS: Participants were adults with dysvascular LEA who were 3 months post-amputation. Data collected included socio-demographic characteristics, the Special Interest Group in Amputee Medicine (SIGAM) grades, the dysvascular conditions scale (DCS), which is a scale developed for this study, and the Short Form-36 (SF-36). SF-6D health utility scores were derived from the SF-36 using a software algorithm. Participants were grouped into low-impact and high-impact groups based on self-reported severity of symptoms using the DCS. Health utility scores were compared between the low-impact and high-impact groups using independent t-tests. RESULTS: A total of 231 participants were enrolled in the study. The mean SF-6D health utility score was 0.689 (0.127). A significant association was found between health utility score and SIGAM grade (p < 0.001, η2 = .09). Health utility was positively associated with age (r = 0.137, p = 0.037) and months post-amputation (r = 0.141, p = 0.032), and negatively associated with DCS severity (r = -0.526, p < 0.001). Health utility scores were lower for participants in the DCS high-impact groups for conditions such as diabetes mellitus, phantom limb pain, musculoskeletal pain, back pain, psychological distress, depression, vision problems, and other pain. CONCLUSION: Cost-utility analyses rely on health utility estimates and our findings provide data for future economic evaluations that may assist policy makers in evidence informed allocation of healthcare resources for this population.

Corruption risks in health procurement during the COVID-19 pandemic and anti-corruption, transparency and accountability (ACTA) mechanisms to reduce these risks: a rapid review.

BACKGROUND: Health systems are often susceptible to corruption risks. Corruption within health systems has been found to negatively affect the efficacy, safety, and, significantly, equitable distribution of health products. Enforcing effective anti-corruption mechanisms is important to reduce the risks of corruption but requires first an understanding of the ways in which corruption manifests. When there are public health crises, such as the COVID-19 pandemic, corruption risks can increase due to the need for accelerated rates of resource deployment that may result in the bypassing of standard operating procedures. MAIN BODY: A rapid review was conducted to examine factors that increased corruption risks during the COVID-19 pandemic as well as potential anti-corruption, transparency and accountability (ACTA) mechanisms to reduce these risks. A search was conducted including terms related to corruption, COVID-19, and health systems from January 2020 until January 2022. In addition, relevant grey literature websites were hand searched for items. A single reviewer screened the search results removing those that did not meet the inclusion criteria. This reviewer then extracted data relevant to the research objectives from the included articles. 20 academic articles and 17 grey literature pieces were included in this review. Majority of the included articles described cases of substandard and falsified products. Several papers attributed shortages of these products as a major factor for the emergence of falsified versions. Majority of described corruption instances occurred in low- and middle-income countries. The main affected products identified were chloroquine tablets, personal protective equipment, COVID-19 vaccine, and diagnostic tests. Half of the articles were able to offer potential anti-corruption strategies. CONCLUSION: Shortages of health products during the COVID-19 pandemic seemed to be associated with increased corruption risks. We found that low- and middle-income countries are particularly vulnerable to corruption during global emergencies. Lastly, there is a need for additional research on effective anti-corruption mechanisms.

Examining the impact of COVID-19 on health care utilization among persons with chronic spinal cord injury/dysfunction: a population study.

STUDY DESIGN: A retrospective longitudinal cohort time-series analysis study. OBJECTIVES: To examine healthcare utilization and delivery during the COVID-19 pandemic in individuals with spinal cord injury/dysfunction (SCI/D). SETTING: Health administrative database in Ontario, Canada. METHODS: In 5754 individuals with SCI/D diagnosed from 2004-2014 and living in the community, healthcare utilization (physician visits, primary care visits, specialist visits, urologist visits, physiatrist visits, emergency department (ED) visits, and hospital admissions) and delivery (total, in-person, virtual) were determined at the (1) pre-pandemic period (March 2015 to February 2020), (2) initial pandemic onset period (March 2020-May 2020), and (3) pandemic period (June 2020 to March 2022). Autoregressive integrated moving average (ARIMA) modelling was conducted to determine the impact of the pandemic on monthly healthcare utilization and delivery. RESULTS: The initial pandemic onset period had a significant reduction of 24% in physicians (p = 0.0081), 35% in specialists (p < 0.0001), and 30% in urologist (p < 0.0001) visits, compared to pre-pandemic levels, with a partial recovery as the pandemic progressed. In April 2020, compared to the pre-pandemic period, a significant increase (p < 0.0001) in virtual visits for physicians, specialists, urologists, and primary care was found. The initial pandemic onset period had a 58% decrease in hospital admissions (p = 0.0011), compared to the pre-pandemic period. CONCLUSION: Healthcare utilization dropped in the initial pandemic onset period as physicians, specialists, and urologists, as well as hospitalization visits decreased significantly (p < 0.05) versus pre-pandemic levels. Virtual visit increases compensated for in-person visit decreases as the pandemic progressed to allow for total visits to partially recover.

Experiences and Outcomes of Using e-Prescribing for Opioids: Rapid Scoping Review.

BACKGROUND: e-Prescribing is designed to assist in facilitating safe and appropriate prescriptions for patients. Currently, it is unknown to what extent e-prescribing for opioids influences experiences and outcomes. To address this gap, a rapid scoping review was conducted. OBJECTIVE: This rapid scoping review aims to (1) explore how e-prescribing has been used clinically; (2) examine the effects of e-prescribing on clinical outcomes, the patient or clinician experience, service delivery, and policy; and (3) identify current gaps in the present literature to inform future studies and recommendations. METHODS: A rapid scoping review was conducted following the guidance of the JBI 2020 scoping review methodology and the World Health Organization guide to rapid reviews. A comprehensive literature search was completed by an expert librarian from inception until November 16, 2022. Three databases were electronically searched: MEDLINE (Ovid), Embase (Ovid), and Scopus (Elsevier). The search criteria were as follows: (1) e-prescribing programs targeted to the use or misuse of opioids, including those that were complemented or accompanied by clinically focused initiatives, and (2) a primary research study of experimental, quasi-experimental, observational, qualitative, or mixed methods design. An additional criterion of an ambulatory component of e-prescribing (eg, e-prescribing occurred upon discharge from acute care) was added at the full-text stage. No language limitations or filters were applied. All articles were double screened by trained reviewers. Gray literature was manually searched by a single reviewer. Data were synthesized using a descriptive approach. RESULTS: Upon completing screening, 34 articles met the inclusion criteria: 32 (94%) peer-reviewed studies and 2 (6%) gray literature documents (1 thesis study and 1 report). All 33 studies had a quantitative component, with most highlighting e-prescribing from acute care settings to community settings (n=12, 36%). Only 1 (3%) of the 34 articles provided evidence on e-prescribing in a primary care setting. Minimal prescriber, pharmacist, and clinical population characteristics were reported. The main outcomes identified were related to opioid prescribing rates, alerts (eg, adverse drug events and drug-drug interactions), the quantity and duration of opioid prescriptions, the adoption of e-prescribing technology, attitudes toward e-prescribing, and potential challenges with the implementation of e-prescribing into clinical practice. e-Prescribing, including key features such as alerts and dose order sets, may reduce prescribing errors. CONCLUSIONS: This rapid scoping review highlights initial promising results with e-prescribing and opioid therapy management. It is important that future work explores the experience of prescribers, pharmacists, and patients using e-prescribing for opioid therapy management with an emphasis on prescribers in the community and primary care. Developing a common set of quality indicators for e-prescribing of opioids will help build a stronger evidence base. Understanding implementation considerations will be of importance as the technology is integrated into clinical practice and health systems.

Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada.

BACKGROUND: Older adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture. METHODS: This descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: A total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings. CONCLUSIONS: Our findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.

A qualitative study exploring hospital-based team dynamics in discharge planning for patients experiencing delayed care transitions in Ontario, Canada.

BACKGROUND: In attempt to improve continuity of patient care and reduce length of stay, hospitals have placed an increased focus on reducing delayed discharges through discharge planning. Several benefits and challenges to team-based approaches for discharge planning have been identified. Despite this, professional hierarchies and power dynamics are common challenges experienced by healthcare providers who are trying to work as a team when dealing with delayed discharges. The objective of this study was to explore what was working well with formal care team-based discharge processes, as well as challenges experienced, in order to outline how teams can function to better support transitions for patients experiencing a delayed discharge.  METHODS: We conducted a descriptive qualitative study with hospital-based healthcare providers, managers and organizational leaders who had experience with delayed discharges. Participants were recruited from two diverse health regions in Ontario, Canada. In-depth, semi-structured interviews were conducted in-person, by telephone or teleconference between December 2019 and October 2020. All interviews were recorded and transcribed. A codebook was developed by the research team and applied to all transcripts. Data were analyzed inductively, as well as deductively through directed content analysis. RESULTS: We organized our findings into three main categories - (1) collaboration with physicians makes a difference; (2) leadership should meaningfully engage with frontline providers and (3) partnerships across sectors are critical. Regular physician engagement, as equal members of the team, was recommended to improve consistent communication, relationship building between providers, accessibility, and in-person communication. Participants highlighted the need for a dedicated senior leader who ensured members of the team were treated as equals and advocated for the team. Improved partnerships across sectors included the enhanced integration of community-based providers into discharge planning by placing more focus on collaborative practice, combined discharge planning meetings, and having embedded and physically accessible care coordinators in the hospital. CONCLUSIONS: Team-based approaches for delayed discharge can offer benefits. However, to optimize how teams function in supporting these processes, it is important to consistently collaborate with physicians, ensure senior leadership engage with and seek feedback from frontline providers through co-design, and actively integrate the community sector in discharge planning.

"We could be good partners if we work together": the perspectives of health and social service providers on the barriers to forming collaborative partnerships with social housing providers for older adults.

BACKGROUND: Many older adults are aging-at-home in social housing. However, the lack of integration between housing and health services makes it difficult for older tenants to access needed supports. We examined barriers and facilitators health and social service providers face providing on-site services to older tenants. METHODS: We conducted semi-structured qualitative interviews and focus groups with health and social service professionals (n = 58) in Toronto, Canada who provide community programs in support of older tenants who live in non-profit, rent-geared-to-income social housing. Interviews examined the barriers they faced in providing on-site services to older tenants. FINDINGS: Service providers strongly believed that collaboration with on-site housing staff led to better health and housing outcomes for older tenants. Despite the recognized benefits of partnering with housing staff, service providers felt that their ability to work effectively in the building was dependent on the staff (particularly the superintendent) assigned to that building. They also identified other barriers that made it difficult to work collaboratively with the housing provider, including staffing challenges such as high staff turnover and confusion about staff roles, a lack of understanding among housing staff about the link between housing and health, challenges sharing confidential information across sectors, and complex and inefficient partnership processes. CONCLUSION: Older adult tenants are increasingly vulnerable and in need of supports but the housing provider has a long history of ineffective partnerships with service providers driven by complex and inefficient staffing models, and an organizational culture that questions the role of and need for partnerships. Findings highlight the need for more effective integration of housing and health services. Simplified processes for establishing partnerships with service agencies and more opportunities for communication and collaboration with housing staff would ensure that services are reaching the most vulnerable tenants.

Examination of the Relationships Among Social Networks and Loneliness on Health and Life Satisfaction in People with Spinal Cord Injury/Dysfunction.

OBJECTIVE: To examine the associations among social networks and loneliness on health and life satisfaction in adults with chronic spinal cord injury/dysfunction (SCI/D). DESIGN: Cross-sectional telephone survey study. SETTING: Tertiary spinal cord injury rehabilitation center in Ontario, Canada. PARTICIPANTS: Community-dwelling adults with chronic SCI/D (N=170). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The main outcome measures were the Short-Form 36 to assess health and the Life Satisfaction-11 to assess life satisfaction. RESULTS: A hierarchical regression model predicting physical health accounted for 24% (P<.001) of the variance. The only social network variable to significantly contribute to the model was having a higher proportion of network members living in one's household (P<.05). A model predicting mental health accounted for 44% (P<.001) of the variance, with having a higher proportion of network members living in one's household (P<.05) and lower feelings of loneliness (P<.001) associated with better mental health. Finally, the model predicting life satisfaction accounted for 62% (P<.001) of the variance, with lower greater levels of social network intimacy (P<.01) and lower feelings of loneliness (P<.001) being significant predictors. CONCLUSIONS: These findings highlight the importance of having access to network members in one's home for better physical and mental health after SCI/D as well as the negative association between loneliness and mental health and life satisfaction. There is a need for approaches to ensure that people with SCI/D in the community feel supported to mitigate feelings of loneliness to optimize their health and wellbeing.

Prevalence of Prescribed Opioid Claims Among Persons With Traumatic Spinal Cord Injury in Ontario, Canada: A Population-Based Retrospective Cohort Study.

OBJECTIVES: To examine prescription opioid claims among individuals with traumatic spinal cord injury (SCI) and to identify factors associated with both chronic opioid and chronic high-dose opioid use. DESIGN: Retrospective cohort study using population-level administrative data. SETTING: Ontario, Canada. PARTICIPANTS: Individuals (N=1842) with traumatic SCI between April 1, 2004 and March 31, 2015. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of cohort with chronic opioid use (≥90d supply) and proportion with chronic high-dose opioid use (≥90d supply exceeding 90 mg morphine equivalent) between April 1, 2016 and March 31, 2017 (observation period). RESULTS: A total of 1842 individuals with traumatic SCI were identified (74% men), with a median age of 51 years (interquartile range [IQR], 34-64y) and median duration of injury of 6 years (IQR, 4-9y). During the observation period, 35% were dispensed at least 1 opioid and 19.8% received chronic opioids, 39% of whom received more than 90 mg daily (chronic high dose). The median daily morphine equivalent dose was 212 mg morphine equivalent (IQR, 135.5-345.3 mg) for chronic high-dose users. Significant risk factors for chronic opioid use were male sex; age between 40 and 60 years; lower income; multimorbidity; thoracic, lumbar, or sacral level of injury; and having a previous diagnosis of osteoarthritis. Risk factors for chronic high-dose opioid use were an extended time since injury, age between 40 and 50 years, and increasing comorbidity. CONCLUSIONS: A large proportion of individuals with traumatic SCI were dispensed an opioid in a recent 1-year period. A substantial proportion were dispensed more than 90 mg of morphine equivalents, which is the maximum recommended by the Canadian opioid guideline. Further research is needed to understand the risk factors associated with chronic, high-dose opioid use in this population.

A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada.

BACKGROUND: Older adults, especially those with physical and social complexities are at risk of hospital-associated deconditioning. Hospital-associated deconditioning is linked to increased length of stay in hospital, stress, and readmission rates. To date, there is a paucity of research on the experiences and implications of deconditioning in hospital from different perspectives. Therefore, the objectives of this exploratory, descriptive qualitative study were to explore hospital-associated deconditioning from the views of different stakeholders and to develop an understanding of deconditioning from physical, social, and cognitive perspectives. METHODS: Between August 2018 and July 2019, in-depth, semi-structured interviews were conducted with patients 50 years or older, who had a hip fracture or delay in discharge, as well as caregivers, providers, and decision-makers who provided support or impacted care processes for these patients. Participants were recruited from one urban and one rural health region located in Ontario, Canada. All interviews were audio-recorded, transcribed, and analyzed using a constant comparison approach. RESULTS: A total of 80 individuals participated in this study. Participants described insufficient activities in hospital leading to boredom and mental and physical deconditioning. Patients were frustrated with experiencing deconditioning and their decline in function seemed to impact their sense of self and identity. Deconditioning had substantive impacts on patients' ability to leave hospital to their next point of care. Providers and decision-makers understood the potential for deconditioning but felt constrained by factors beyond their control. Factors that appeared to impact deconditioning included the hospital's built environment and social capital resources (e.g., family, roommates, volunteers, staff). CONCLUSIONS: Participants described a substantial lack of physical, cognitive, and social activities, which led to deconditioning. Recommendations to address deconditioning include: (1) measuring physical/psychological function and well-being throughout hospitalization; (2) redesigning hospital environments (e.g., create social spaces); and (3) increasing access to rehabilitation during acute hospital stays, while patients wait for the next point-of-care.

Prevalence of prescribed opioid claims among persons with nontraumatic spinal cord dysfunction in Ontario, Canada: a population-based retrospective cohort study.

STUDY DESIGN: Cohort study. OBJECTIVE: To determine the prevalence and to identify predictors of prescription opioid use among persons with nontraumatic spinal cord dysfunction within 1 year after discharge from inpatient rehabilitation. SETTING: Ontario, Canada. METHODS: We conducted a retrospective cohort study using administrative data to determine predictors of receiving prescription opioids during the 1 year after discharge from inpatient rehabilitation among persons with nontraumatic spinal cord dysfunction between April 1, 2004 and March 31, 2015. We modeled the outcome using a Poisson multivariable regression and reported relative risks with 95% confidence intervals. RESULTS: We identified 3468 individuals with nontraumatic spinal cord dysfunction (50% male) with 67% who were aged ≥66. Over half of the cohort (60%) received opioids during the observation period. Older adults (≥66 years old) were significantly more likely to experience comorbidities (p < 0.05) but less likely to be dispensed opioids following rehabilitation discharge. Being female, previous opioid use before rehabilitation, experiencing lower continuity of care, increasing comorbidity level, low functional status, and having a previous diagnosis of osteoarthritis or mental illness were significant risk factors for receiving opioids after discharge, as shown in a multivariable analysis. Increasing length of rehabilitation stay and higher income were protective against opioid receipt after discharge. CONCLUSION: Many individuals with nontraumatic spinal cord dysfunction in Ontario are prescribed opioids after discharge from inpatient rehabilitation. This may be problematic due to the number of severe complications that may arise from opioid use and their use in this population warrants future research.

Prescription medications dispensed following a nontraumatic spinal cord dysfunction: a retrospective population-based study in Ontario, Canada.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To examine the prevalence of polypharmacy for individuals with nontraumatic spinal cord dysfunction (NTSCD) following inpatient rehabilitation and to determine associated risk factors. SETTING: Ontario, Canada. METHODS: Administrative data housed at ICES, Toronto, Ontario were used. Between 2004 and 2015, we investigated prescription medications dispensed over a 1-year period for persons following an NTSCD-related inpatient rehabilitation admission. Descriptive and analytical statistics were conducted. Using a robust Poisson multivariable regression model, relative risks related to polypharmacy (ten or more drug classes) were calculated. Main independent variables were sex, age, income quintile, and continuity of care with outpatient physician visits. RESULTS: We identified 3468 persons with NTSCD during the observation window. The mean number of drug classes taken post-inpatient rehabilitation was 11.7 (SD = 6.0), with 4.0 different prescribers (SD = 2.5) and 1.8 unique pharmacies (SD = 1.0). Significant predictors for post-discharge polypharmacy were: being female, lower income, higher comorbidities prior to admission, lower Functional Independence Measure at discharge, previous number of medication classes dispensed in year prior to admission, and lower continuity of care with outpatient physician visits. The most common drugs dispensed post-inpatient rehabilitation were antihypertensives (70.0%), laxatives (61.6%), opioids (59.5%), and antibiotics (57.8%). CONCLUSION: Similar to previous research with traumatic spinal cord injury, our results indicate that polypharmacy is prevalent among persons with NTSCD. Additional research examining medication therapy management for NTSCD is suggested.

"The strategies are the same, the problems may be different": a qualitative study exploring the experiences of healthcare and service providers with medication therapy management for individuals with spinal cord injury/dysfunction.

BACKGROUND: Persons with spinal cord injury/dysfunction (SCI/D) often take multiple medications to treat their secondary complications and chronic conditions (multimorbidity). Multiple healthcare and service providers are often involved in care, which can result in increased risk of fragmentation of care. Optimal medication therapy management (MTM) is essential to ensure therapeutic benefit from medication regimens. However, little is known about the experiences of providers in supporting persons with SCI/D with MTM. METHODS: Telephone interviews were conducted to explore healthcare and service providers' experiences with MTM for persons with SCI/D. Participants were recruited through clinical organizations and researchers' personal contacts. Participants were purposefully selected for diversity in profession and were required to be English speaking and to have provided care to at least one person with SCI/D. The qualitative interviews followed a semi-structured interview guide. Data display matrices were used in a constant comparative process for descriptive and interpretive analysis. RESULTS: Thirty-two interviews were conducted from April to December 2018. Each profession had distinct views on their roles in facilitating MTM for persons with SCI/D, which aligned with their respective scopes of practice. Shared provider tasks included tailoring medications, providing education, and exploring medication alternatives. Most participants felt that the care they provided for persons with SCI/D was similar to the care that they provided to other patients, with some differences relating to the physical limitations and medical complexity associated with SCI/D. Five factors were identified that impacted participants' abilities to provide MTM for persons with SCI/D: patient self-management skills, provider knowledge and confidence, provider-patient relationships, interprofessional collaboration, and provider funding models including the use of technology-supported consultations. CONCLUSION: While participants described commonalities in the barriers and enablers associated with providing MTM to persons with SCI/D and other populations, there were unique considerations identified. These SCI/D-specific considerations resulted in recommendations for improvements in MTM for this population. Future research should include perspectives from persons with SCI/D.

Exploring transitions in care from pulmonary rehabilitation to home for persons with chronic obstructive pulmonary disease: A descriptive qualitative study.

BACKGROUND: Individuals with chronic obstructive pulmonary disease (COPD) often experience high health-care utilization following pulmonary rehabilitation, suggesting suboptimal transitions to home. OBJECTIVE: To understand the experiences of persons with COPD and health-care professionals regarding transitions from pulmonary rehabilitation to home, including factors impacting these transitions. DESIGN: A descriptive qualitative study. SETTING AND PARTICIPANTS: Health-care professionals working at, and persons with COPD who attended, an inpatient or outpatient pulmonary rehabilitation programme at one large, urban health-care centre. The centre is located in Ontario, Canada. MAIN VARIABLE STUDIED: Experiences of participants with care transitions between pulmonary rehabilitation and home. Semi-structured interviews were audio-recorded, transcribed verbatim, and thematically analysed. RESULTS: Ten patients and eight health-care professionals participated. Four main themes were identified around the overall experiences with pulmonary rehabilitation and transitions to home: (a) pulmonary rehabilitation as a safe environment; (b) pulmonary rehabilitation as a highly structured environment; (c) contrasting perceptions of the role of pulmonary rehabilitation; and (d) dependency on pulmonary rehabilitation programmes. Persons with COPD and health-care professionals identified three key factors that influenced this transition: (a) patients' social support, (b) application of self-management strategies prior to discharge, and (c) patients' physical and mental health. CONCLUSION: Participants agreed that some patients with COPD experienced suboptimal transitions from pulmonary rehabilitation to home that were characterized by suboptimal self-management. Further research is needed to develop and evaluate interventions to improve transitions. Such interventions should include strategies to elicit long-term behaviour change to assist patients when they return into the community.

Understanding perceptions of involving community pharmacy within an integrated care model: a qualitative study.

BACKGROUND: Over the past several years, there has been more emphasis on integration within health care. Community pharmacy is often under-represented within integrated care models. This study explored stakeholder perceptions and enablers of including community pharmacy within an integrated care model. METHODS: A qualitative study was undertaken. Participants were recruited through professional networks and social media, as well as snowball recruitment from other participants. They included community pharmacists, clinicians, and decision-makers working in Ontario, Canada. Data were collected using telephone interviews completed with a semi-structured interview guide based on Consolidated Framework for Implementation Research from June to September 2018. Data were analysed inductively and deductively following the Qualitative Analysis Guide of Leuven. An additional theoretical framework (Rainbow Model of Integrated Care) was used to categorize enablers. RESULTS: Twenty-two participants were interviewed including nine pharmacists, seven clinicians, and six decision-makers. Three key themes were identified: 1) Positive value of including pharmacy in integrated care models; 2) One model does not fit all; and 3) Conflict of interest. Four key enablers were identified reflecting functional and normative factors: functional - 1) remuneration, 2) technology; normative - 3) engagement, and 4) relationships. While both functional and normative factors were discussed, the latter seemed to be more important to facilitate the inclusion of community pharmacy. Many participants characterized community pharmacists' lack of skills or confidence to provide patient care. CONCLUSIONS: This study confirms previously known views about concerns with community pharmacy's conflict of interest. However, discordant perceptions of conflict of interest and negative perceptions about capabilities of community pharmacy need to be addressed for successful integration. Normative enablers, such as culture, are likely important for organizational integration and require additional inquiry.

A developmental evaluation of an intraprofessional Pharmacy Communication Partnership (PROMPT) to improve transitions in care from hospital to community: A mixed-methods study.

BACKGROUND: People transitioning from hospital- to community-based care are at increased risk of experiencing medication problems that can lead to adverse drug events and poor health outcomes. Community pharmacists provide medication expertise and support during care transitions yet are not routinely included in communications between hospitals and other primary health care providers. The PhaRmacy COMmunication ParTnership (PROMPT) intervention facilitates medication management by optimizing information sharing between pharmacists across care settings. This developmental evaluation sought to assess the feasibility and acceptability of implementing the PROMPT intervention, and to explore how contextual factors influenced its implementation. METHODS: PROMPT was implemented for 14 weeks (January-April, 2018) in the general internal medicine units at two teaching hospitals in Toronto, Canada. PROMPT featured two contact points between hospital and community pharmacists around patient discharge: (1) faxing an enhanced discharge prescription and discharge summary to a patient's community pharmacy and (2) a follow-up phone call from the hospital pharmacist to the community pharmacist. Our mixed-method evaluation involved electronic patient records, process measures using tracking forms, telephone surveys and semi-structured interviews with participating community and hospital pharmacists. RESULTS: The intervention involved 45 patients with communication between 12 hospital and 45 community pharmacists. Overall, the intervention had challenges with feasibility. Issues with fidelity included challenges with the medical discharge summary being available at the time of faxing and hospital pharmacists' difficulties with incorporating novel elements of the program into their existing practices. However, both community and hospital pharmacists recognized the potential benefits to patient care that PROMPT offered, and both groups proposed recommendations for further improvements. Suggestions included enhancing hospital staffing and resources. CONCLUSION: Improving intraprofessional collaboration, through interventions such as PROMPT, positions pharmacists as leaders of medication management services across care settings and has the potential to improve patient care; however, more co-design work is needed to enhance the intervention and its fidelity.

Prescription medication cost, insurance coverage, and cost-related nonadherence among people with spinal cord injury in Canada.

STUDY DESIGN: Observational cross-sectional study. OBJECTIVES: To describe the most common prescription medications used and the extent of out-of-pocket cost, insurance coverage, and cost-related nonadherence (CRNA) for those medications by people with spinal cord injury (SCI) in Canada. SETTING: Community in Canada. METHODS: It was an observational study wherein data were collected through a cross-sectional online survey from individuals living with an SCI in Canada. We used descriptive statistics to describe the extent of drug cost, insurance coverage and CRNA among study sample, and analytical statistics to find association of CRNA with sociodemographic, injury-related and medication-related characteristics of the sample. RESULTS: Individuals with an SCI (n = 160) used an average of five medications and spent a median of $49 (interquartile range: $234.75) per month on their medications. More than 90% of participants had some form of drug insurance, though 37% reported CRNA. The most common medications that were forgone due to cost included opioids, antidepressants, and drugs for genitourinary and muscular spasms. Individuals with paraplegia and nontraumatic SCI had higher drug costs, though injury-related characteristics did not influence CRNA. Sex, monthly drug expenditure, and monthly additional healthcare costs were significantly associated with CRNA. CONCLUSIONS: People with SCIs are at risk of experiencing CRNA to their prescription medications despite having insurance coverage. Decision makers for the national pharmacare in Canada should account for their concerns judiciously.

"Clearly they are in the circle of care, but . . .": A qualitative study exploring perceptions of personal health information sharing with community pharmacists in an integrated care model.

BACKGROUND: Ontario's Health Links approach to care is an integrated care model designed to optimize care for patients with complex needs. Currently, community pharmacists have no formalized role. This study aimed to explore stakeholders' perceptions about privacy and its impact on community pharmacists' involvement with integrated care models. METHODS: A qualitative study using semistructured telephone-based interviews was conducted. Participants worked in Ontario as pharmacists, providers in Health Links or team-based models or decision-makers in Health Links or health regions. Thematic analysis followed the Qualitative Analysis Guide of Leuven. RESULTS: Twenty-two participants were interviewed, and all but one commented on privacy or information sharing in integrating community pharmacists with integrated care models. The 4 themes identified were as follows: 1) what does the circle of care look like? 2) value of sharing information, 3) uncertainty of what information to share and 4) perceptions on how to share information. INTERPRETATION: The concerns surrounding privacy of personal health information and who is included in the circle of care represented an important barrier for integration. Enablers to mitigate privacy concerns included relationship building between community pharmacists, patients and other health care professionals and mutual access to information-sharing platforms such as electronic health records. CONCLUSION: Providers' and decision-makers' perceptions about community pharmacists and privacy affect information sharing and are incongruent with Ontario's Personal Health Information Protection Act. Education is needed for health care professionals on legislation, especially as health systems move towards integrated care models to improve care. Can Pharm J (Ott) 2020;153:xx-xx.

The impact of hospital harm on length of stay, costs of care and length of person-centred episodes of care: a retrospective cohort study.

BACKGROUND: There is a lack of data in Canada on the longitudinal effects of adverse events that occur in hospital, specifically in the period after discharge. Our objective was to quantify the impact of adverse events on hospital length of stay, length of person-centred episodes of care (PCEs) and costs of PCEs, as well as their impact on the total health system. METHODS: We conducted a population-based, retrospective cohort study using linked health administrative databases. We included adults in Ontario who had an acute hospital admission between Apr. 1, 2015, and Mar. 31, 2016. We grouped hospital admissions into 1 of 9 episode types and used the Canadian Institute for Health Information methodology for hospital harm to measure adverse events. We specified generalized linear models to estimate the impact of hospital harm on the following: incremental length of index acute hospital admission, incremental length of the PCE, and incremental costs of the PCE. RESULTS: Out of 610 979 hospital admissions, 36 004 (5.9%) involved an occurrence of harm. The impact of harm on the incremental length of hospital stay ranged from 0.4 to 24.2 days (p < 0.001); the incremental length of the PCE ranged from 0.3 to 30.2 days (p < 0.001); and the incremental costs of the PCE ranged from $800 to $51 067 (p < 0.001). Total hospital days attributable to hospital harm amounted to 407 696, and the total attributable cost to the Ontario health system amounted to $1 088 330 376. INTERPRETATION: We found that experiencing harm in hospital significantly affects both in-hospital and post-discharge use of health services and costs of care, and constitutes an enormous expense to Ontario's publicly funded health system.