Technology-Enabled Collaborative Care for Concurrent Diabetes and Distress Management During the COVID-19 Pandemic: Protocol for a Mixed Methods Feasibility Study.

BACKGROUND: The COVID-19 pandemic disrupted the delivery of diabetes care and worsened mental health among many patients with type 2 diabetes (T2D). This disruption puts patients with T2D at risk for poor diabetes outcomes, especially those who experience social disadvantage due to socioeconomic class, rurality, or ethnicity. The appropriate use of communication technology could reduce these gaps in diabetes care created by the pandemic and also provide support for psychological distress. OBJECTIVE: The purpose of this study is to test the feasibility of an innovative co-designed Technology-Enabled Collaborative Care (TECC) model for diabetes management and mental health support among adults with T2D. METHODS: We will recruit 30 adults with T2D residing in Ontario, Canada, to participate in our sequential explanatory mixed methods study. They will participate in 8 weekly web-based health coaching sessions with a registered nurse, who is a certified diabetes educator, who will be supported by a digital care team (ie, a peer mentor, an addictions specialist, a dietitian, a psychiatrist, and a psychotherapist). Assessments will be completed at baseline, 4 weeks, and 8 weeks, with a 12-week follow-up. Our primary outcome is the feasibility and acceptability of the intervention, as evident by the participant recruitment and retention rates. Key secondary outcomes include assessment completion and delivery of the intervention. Exploratory outcomes consist of changes in mental health, substance use, and physical health behaviors. Stakeholder experience and satisfaction will be explored through a qualitative descriptive study using one-on-one interviews. RESULTS: This paper describes the protocol of the study. The recruitment commenced in June 2021. This study was registered on October 29, 2020, on ClinicalTrials.gov (Registry ID: NCT04607915). As of June 2022, all participants have been recruited. It is anticipated that data analysis will be complete by the end of 2022, with study findings available by the end of 2023. CONCLUSIONS: The development of an innovative, technology-enabled model will provide necessary support for individuals living with T2D and mental health challenges. This TECC program will determine the feasibility of TECC for patients with T2D and mental health issues. TRIAL REGISTRATION: ClinicalTrials.gov NCT04607915; https://clinicaltrials.gov/ct2/show/NCT04607915. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39724.

Technology-enabled collaborative care for youth with early psychosis: Results of a feasibility study to improve physical health behaviours.

AIM: Psychotic disorders are associated with excess morbidity and premature mortality. Contributing factors include tobacco smoking, low physical activity, and poor nutrition. This study tested a Technology-Enabled Collaborative Care model to improve health behaviours among youth with early psychosis. METHODS: A feasibility study among youth (ages 16-29) with early psychosis in Ontario, Canada. Participants were randomized to either a health coach supervised by a virtual care team (high intensity, n = 29), or self-directed learning (low intensity, n = 23) for 12 weeks. The primary outcome was participant engagement, defined as self-perceived benefit of changing health behaviours. Secondary outcomes were measures of health behaviours and programme-use metrics. RESULTS: Engagement was higher for high intensity participants for physical activity (adjusted group difference in change at 24 weeks = 3.4, CI95% = 1.9-4.9, p < .001) and nutrition (adjusted difference = 2.9, CI95% = 1.2-4.6, p = .001). No change was observed in health behaviours. Sixty two percent of participants completed 6 or more of the 12 weekly remote individualized health coaching sessions. Nine (39%) low intensity and 12 (41%) high intensity participants completed the final follow-up. CONCLUSIONS: Personalized health coaching for youth with psychosis is feasible and may have sustained benefits. However, retention with this population for 12 weeks is challenging.

Engaging a person with lived experience of mental illness in a collaborative care model feasibility study.

Researchers have explored different types of treatment to help people with a mental illness with other problems they might be experiencing, such as their health condition and quality of life. Care models that involve many different health care providers working together to provide complete physical and mental health care are becoming popular. There has been a push from the research community to understand the value of including people with lived experience in such programs. While research suggests that people with lived experience may help a patient's treatment, there is little evidence on including them in a team based program. This paper describes how our research team included a person with lived experience of psychosis in both the research and care process. We list some guiding principles we used to work through some of the common challenges that are mentioned in research. Lastly, experiences from the research team, lessons learned, and a personal statement from the person with lived experience (AA) are provided to help future researchers and people with lived experience collaborate in research and healthcare. Background In our current healthcare system, people with a mental illness experience poorer physical health and early mortality in part due to the inconsistent collaboration between primary care and specialized mental health care. In efforts to bridge this gap, hospitals and primary care settings have begun to take an integrated approach to care by implementing collaborative care models to treat a variety of conditions in the past decade. The collaborative care model addresses common barriers to treatment, such as geographical distance and lack of individualized, evidence-based, measurement-based treatment. Person(s) with lived experience (PWLE) are regarded as 'experts by experience' in the scope of their first-hand experience with a diagnosis or health condition. Research suggests that including PWLE in a patient's care and treatment has significant contributions to the patient's treatment and overall outcome. However, there is minimal evidence of including PWLE in collaborative care models. This paper describes the inclusion of a PWLE in a research study and collaborative care team for youth with early psychosis. Aims To discuss the active involvement of a PWLE on the research and collaborative care team and to describe the research team's experiences and perspectives to facilitate future collaborations. Method This paper describes the inclusion of a PWLE on our research team. We provide a selective review of the literature on several global initiatives of including PWLE in different facets of the healthcare system. Additionally, we outline multiple challenges of involving PWLE in research and service delivery. Examples are provided on how recruitment and involvement was facilitated, with the guidance of several principles. Lastly, we have included a narrative note from the PWLE included in our study, who is also a contributing author to this paper (AA), where she comments on her experience in the research study. Conclusion Including PWLE in active roles in research studies and collaborative care teams can enhance the experience of the researchers, collaborative care team members, and PWLE. We showcase our method to empower other researchers and service providers to continue to seek guidance from PWLE to provide more comprehensive, collaborative care with better health outcomes for the patient, and a more satisfying care experience for the provider.

Technology-enabled collaborative care for youth with early psychosis: A protocol for a feasibility study to improve physical health behaviours.

AIM: Individuals with psychotic disorders have poorer health outcomes and die earlier due to cardiovascular diseases when compared to healthy populations. Contributing factors include low levels of physical activity, poor nutrition and tobacco smoking. Currently, patients navigate a fragmented health-care system to seek physical and mental health services, often without access to evidence-based health promotion interventions, especially in non-academic settings or rural areas, increasing client barriers at the individual and provider level. To address these gaps, we wish to test the feasibility and impact of a Technology-Enabled Collaborative Care for Youth (TECC-Y) model to improve healthy behaviours among youth with early psychosis. The model addresses geographical barriers and maldistribution of physical and mental health care. METHODS: A randomized controlled trial, including youth (ages of 16-29) with early psychosis (diagnosed in the past 5 years) residing in Ontario, Canada. Our primary outcome is client engagement. Secondary outcomes include smoking status, physical health and nutrition. Participants are randomly assigned to either a health coach supervised by a virtual care team, or a self-directed learning group (e-platform with psychoeducational materials). Assessments are conducted at baseline, 6, 12 and 24 weeks. RESULTS: This paper presents the protocol of the study. Recruitment commenced in August 2018. This study was registered on 16 July 2018 on clinicaltrials.gov (Registry ID: NCT03610087). CONCLUSIONS: TECC-Y will determine if a technology-based collaborative care model engages youth with early psychosis, and whether this will be associated with changes in smoking, physical health and nutrition.

Prescription opioid dispensing in Canada: an update on recent developments to 2018.

Canada has been home to comparatively extreme developments in prescription opioid (PO) availability and related harms (e.g. morbidity, mortality) post-2000. Following persistent pan-Canadian increases in PO use, select control measures were implemented and PO dispensing levels-while only inconsistently by province-inverted, and began to plateau or decrease post-2012. We examined annual PO dispensing levels in Canada up until 2018, based on representative prescription sample data from community-based retail pharmacies. Annual prescription-based dispensing data were converted into defined daily doses/1000 population/day by province, and mainly categorized into 'weak' and 'strong' opioids. All provinces indicated decreasing trends in strong PO levels in most recent years, yet with inter-provincial differences of up to one magnitude in 2018; in about half the provinces, dispensing fell to below-2005 levels. British Columbia had the largest decline in strong PO dispensing from its peak rate (- 48.5%) in 2011. Weak opioid dispensing trends remained more inconsistent and bifurcated across Canada. The distinct effects of individual-including many provincially initiated and governed-PO control measures urgently need to be evaluated. In the meantime, recent reductions in general PO availability across Canada appear to have contributed to shortages in opioid supply for existent, sizable (including non-medical) user populations and may have contributed to recent marked increases in illicit opioid use and harms (including rising deaths).

'Safer opioid distribution' as an essential public health intervention for the opioid mortality crisis - Considerations, options and examples towards broad-based implementation.

•Canada experiences excessive opioid mortality, mainly from toxic opioid exposure.•Many interventions have been implemented, but are limited in reach and impact.•'Safer opioid distribution' (SOD) is a crucial preventive measure for overdose.•SOD needs to be implemented for a large, 'at-risk' opioid user population.•Other community-based public health interventions may guide SOD organization.

Patterns, Changes, and Trends in Prescription Opioid Dispensing in Canada, 2005-2016.

BACKGROUND: Levels of prescription opioid (PO) dispensing have been rising in Canada - also in global comparison - since the mid-2000s, and are co-occurring with extensive PO-related morbidity and mortality. Previous analyses have demonstrated correlations between PO dispensing and related harm levels, yet also distinct heterogeneous interprovincial PO-dispensing patterns, in regards to quantities and individual PO formulations. Several system-level interventions have been implemented recently (since 2012) to address high PO-use levels and related harms in Canada; the effects of these interventions on PO-dispensing levels remain largely unexamined. OBJECTIVES: Our aim was to examine over-time patterns and trends of levels of PO dispensing quantitatively (in defined daily doses [DDDs]) for 'strong' and 'weak' opioids and qualitatively (by individual PO formulations) by province and Canada total, for the period of 2005-2016. METHODS: We examined annual PO-dispensing levels, by 'weak' and 'strong' POs (individual PO formulations, but excluding methadone), by province and for Canada total, from 2005-2016. Raw dispensing information for POs were obtained from IMSQuintiles CompuScript [new name: IQVIA], based on monthly retail dispensing data from a representative sample of community pharmacies covering about 80% of all dispensing episodes in Canada. These data were converted into annual dispensing values in DDDs (DDD/1,000 population/day), based on standard methodology, for the PO formulation groups of interest. Patterns and trends of 'strong' and 'weak' POs and individual PO formulations were examined descriptively, aided by segmented regression analyses to identify significant break-points in over-time trends. In addition, changes in 'strong'/'weak' PO dispensing ratios between 2005 and 2016 were examined. RESULTS: 'Weak' PO use remained largely stable across Canada over the study period. For 'strong' PO dispensing, half of the provinces featured consistent increases, while remaining provinces presented initial increases with subsequently reverting downward trends at divergent levels. Dispensing of individual 'strong' PO formulations varied interprovincially; specifically, substantial decreases for oxycodone co-occurred with increases in other 'strong' PO formulations. The dispensing ratios for 'strong'/'weak' POs increased significantly across jurisdictions between 2005 and 2016 (P < .05). LIMITATIONS: Retail pharmacy-based data do not cover the total - but the large majority - of PO dispensing in Canada. There are limitations to DDD/1,000 population/day as a comparative measurement unit for PO dispensing. The causal contribution of interventions associated with changes in PO dispensing observed cannot be verified with the data available. CONCLUSIONS: Heterogeneous trends for PO dispensing, driven mostly by variations in 'strong' PO use, continue to be observed provincially across Canada. Recent changes in PO dispensing are likely influenced by recent intervention efforts (e.g., PO de-scheduling, monitoring, guidelines) aiming to reduce PO-related harms, which, however, have shown limited impact on PO-dispensing levels to date. KEY WORDS: Opioids, prescribing, dispensing, interventions, policy, population, monitoring, Canada.

The 'fentanyl epidemic' in Canada - Some cautionary observations focusing on opioid-related mortality.

In Canada, opioid-related overdose mortality has steeply increased in recent years; as a substantial number of opioid-related deaths are related to fentanyl products, this phenomenon has widely been described as the 'fentanyl epidemic', also implying that these deaths are largely caused by clandestinely produced illicit fentanyl products. We examined numbers and rates of opioid- and fentanyl-related deaths in six pan-Canadian provinces with respective (coroner-based) data available from 2010 to 2016. While fentanyl-related deaths are clearly increasing from relatively low levels in all provinces, those increases are strongest in the two Western provinces (e.g., British Columbia, where fentanyl accounts for the majority of opioid deaths in 2016 and Alberta), and, to some extent, Ontario. However, fentanyl-related deaths remain a minority of deaths in Ontario (40%) and the remaining provinces (<25%). Furthermore, it is uncertain what proportion of fentanyl-related deaths is actually related to illicit fentanyl products. We conclude that fentanyl-related overdose deaths have risen - most strongly in the West - due to both a high availability of medical fentanyl products, as well as an influx of illegal fentanyl products. In most provinces, the majority of opioid deaths remain associated with other (non-fentanyl) products. Appropriate (prevention, treatment and policy) interventions need to be targeted at the full range of opioid deaths from different sources. Overall, a realistic framing of the social (e.g., media) discourse about the nature of the 'opioid overdose death crisis' is required, which is not exclusively an 'illicit fentanyl death crisis' even though this may be a socio-politically appealing image.