Ambulatory Parathyroidectomy for Secondary Hyperparathyroidism at a Large Dialysis Program in Toronto: A Program Report.

Purpose of program: Operative wait times for non-oncology-related procedures continue to rise in Canada, and this was further exacerbated by the COVID-19 pandemic. These challenges will remain prevalent beyond the pandemic given the limited number of acute care beds and resources required to care for patients. As a result, the need for innovative approaches to optimize the utilization of health care resources while maintaining equitable and timely access is needed. In this report, we describe the development of a collaborative ambulatory parathyroidectomy program between two centers in Toronto, allowing for more expedient surgical treatment of secondary hyperparathyroidism among patients from a large dialysis program. Sources of information: The need for expanded access to surgical care for secondary hyperparathyroidism was identified through interdepartmental communication between referring nephrologists and surgeons at Sunnybrook Health Sciences Centre and Women's College Hospital, respectively. Methods: A multidisciplinary ambulatory parathyroidectomy planning team was formed that included nephrologists, endocrine surgeons, nurses, and patient care managers to conduct a needs assessment. It was identified that patients had long wait times, and to address that gap in care, a protocol was developed to identify suitable patients requiring treatment. The teams created a plan to coordinate patient care and transfers. A clinical tool and protocol for post-operative management of hypocalcemia was developed using a Delphi model, gathering input from many members of the care team. The Delphi process to finalize the protocol included a series of virtual meetings over a period of about 4 months with various stakeholders and included input from two departmental heads (medicine and surgery), three nephrologists, a nurse practitioner, a patient care manager, and two nurse educators. Meetings involved core members of the Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre and finalized protocol was agreed upon by members of this group at a quarterly meeting. Key findings: In this article, we describe the development, initial deployment, and planned assessment of the ambulatory parathyroidectomy program at the Women's College Hospital and Sunnybrook Health Sciences Centre. The primary aim of the program is to increase accessibility to parathyroidectomy for secondary hyperparathyroidism. A secondary aim was to allow patients to have streamlined care with a team that is well versed with maintenance dialysis needs and optimizing treatment of post operative hypocalcemia through standardized protocols. Limitations: Ambulatory parathyroidectomy relies on effective communication, flow, and availability of acute care beds. It is anticipated that occasionally, unexpected hospital demands, and health care disruptions may occur, which can limit efficiency of the program. We will also need to examine the cost-effectiveness of this program as it may improve access but increase costs related to the procedure. As the program is implemented, useful adaptations and policies to our protocol to help mitigate these limitations will be documented and published in our outcomes report. Implications: Ontario residents with chronic kidney disease with secondary hyperparathyroidism who have failed medical management will have increased and timely access to parathyroidectomy.

Objectif du program: Les temps d'attente pour les interventions non oncologiques continuent d'augmenter au Canada, une situation qui s'est aggravée avec la pandémie de COVID-19. Ce problème persistera au-delà de la pandémie en raison du nombre limité de lits en soins aigus et de ressources pour soigner les patients. Par conséquent, l'adoption d'approches novatrices pour optimiser l'utilisation des ressources en santé, tout en maintenant un accès équitable et opportun, est nécessaire. Dans ce rapport, nous décrivons l'élaboration d'un programme collaboratif de parathyroïdectomie ambulatoire entre deux centres de Toronto, lequel permettra le traitement chirurgical plus rapide de l'hyperparathyroïdie secondaire chez les patients d'un important programme de dialyse. Sources: Le besoin d'élargir l'accès aux soins chirurgicaux pour l'hyperparathyroïdie secondaire a été révélé grâce à la communication interservices entre les néphrologues traitants du Sunnybrook Health Sciences Centre et les chirurgiens de l'Hôpital Women's College. Méthodologie: Une équipe multidisciplinaire de planification de la parathyroïdectomie ambulatoire composée de néphrologues, de chirurgiens-endocrinologues, d'infirmières et de gestionnaires de soins aux patients a été formée pour procéder à une évaluation des besoins. Il a été établi que les patients expérimentaient de longs temps d'attente et, pour combler cette lacune, un protocole a été mis au point pour identifier adéquatement les patients nécessitant un traitement. Les équipes ont créé un plan pour coordonner les soins aux patients et les transferts. Un outil clinique et un protocole de prise en charge postopératoire de l'hypocalcémie ont été mis au point à l'aide d'un modèle Delphi impliquant la participation plusieurs membres de l'équipe soignante. Le processus Delphi de finalisation du protocole a comporté, sur une période de quatre mois, une série de réunions virtuelles avec divers intervenants, ainsi que la participation de deux chefs de service (médecine et chirurgie), de trois néphrologues, d'une infirmière praticienne, d'un gestionnaire des soins aux patients et de deux formateurs en soins infirmiers. Ces rencontres ont réuni les principaux membres du Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre, et ces derniers ont convenu d'un protocole finalisé lors d'une réunion trimestrielle. Principaux resultants: Cet article décrit l'élaboration, le déploiement initial et l'évaluation prévue du programme de parathyroïdectomie ambulatoire du Women's College Hospital et du Sunnybrook Health Sciences Centre. Le principal objectif du programme est d'accroître l'accessibilité à la parathyroïdectomie pour les patients souffrant d'hyperparathyroïdie secondaire. Les autres objectifs étaient de permettre aux patients de bénéficier de soins rationalisés, grâce à une équipe qui connaît parfaitement les besoins en dialyse d'entretien, et d'optimiser le traitement de l'hypocalcémie postopératoire grâce à des protocoles normalisés. Limites: La parathyroïdectomie ambulatoire repose sur l'efficacité du flux et de la communication, et sur la disponibilité des lits en soins aigus. Il est attendu que des demandes hospitalières inattendues et des perturbations se produiront de temps à autre, ce qui pourrait limiter l'efficacité du programme. Nous devrons également examiner la rentabilité du programme, car l'amélioration de l'accès pourrait se traduire par une augmentation des coûts liés à la procédure. Au fur et à mesure de la mise en œuvre du programme, des adaptations et politiques utiles à notre protocole seront documentées et publiées dans notre rapport sur les résultats, afin d'aider à atténuer ces limites. Conclusion: Les résidents de l'Ontario atteints d'insuffisance rénale chronique et d'hyperparathyroïdie secondaire dont la prise en charge médicale a échoué auront un accès accru et opportun à la parathyroïdectomie.

Automated digital counselling with social network support as a novel intervention for patients with heart failure: protocol for randomised controlled trial.

INTRODUCTION: Heart failure (HF) symptoms improve through self-care, for which adherence remains low among patients despite the provision of education for these behaviours by clinical teams. Open Access Digital Community Promoting Self-Care, Peer Support and Health Literacy (ODYSSEE-vCHAT) combines automated digital counselling with social network support to improve mortality and morbidity, engagement with self-care materials, and health-related quality of life. METHODS AND ANALYSIS: Use of ODYSSEE-vCHAT via Internet-connected personal computer by 162 HF patients will be compared with a control condition over 22 months. The primary outcome is a composite index score of all-cause mortality, all-cause emergency department visits, and HF-related hospitalisation at trial completion. Secondary outcomes include individual components of the composite index, engagement with self-care materials, and patient-reported measures of physical and psychosocial well-being, disease management, health literacy, and substance use. Patients are recruited from tertiary care hospitals in Toronto, Canada and randomised on a 1:1 ratio to both arms of the trial. Online assessments occur at baseline (t=0), months 4, 8 and 12, and trial completion. Ordinal logistic regression analyses and generalised linear models will evaluate primary and secondary outcomes. ETHICS AND DISSEMINATION: The trial has been approved by the research ethics boards at the University Health Network (20-5960), Sunnybrook Hospital (5117), and Mount Sinai Hospital (21-022-E). Informed consent of eligible patients occurs in person or online. Findings will be shared with key stakeholders and the public. Results will allow for the preparation of a Canada-wide phase III trial to evaluate the efficacy of ODYSSEE-vCHAT in improving clinical outcomes and raising the standard of outpatient care. TRIAL REGISTRATION NUMBER: NCT04966104.

Are adverse events in newly trained home dialysis patients related to learning styles? A single-centre retrospective study from Toronto, Canada.

OBJECTIVES: Home haemodialysis (HD) and peritoneal dialysis (PD) have seen growth in utilisation around the globe over the last few years. However, home dialysis, with its attendant technical complexity and risk of adverse events continues to pose challenges for wider adoption. We examined whether differences in patients' learning styles are associated with differing risk of adverse events in both home HD and PD patients. DESIGN: Retrospective cohort study. SETTING: Tertiary care hospital in Toronto, Ontario, Canada. PARTICIPANTS: One hundred and eighteen prevalent adult (≥18 years) home dialysis patients (40 PD and 78 home HD) were enrolled. Patients on home dialysis for less than 6 months or receiving home nursing assistance for dialysis were excluded from the study. INTERVENTIONS: Enrolled patients completed (VARK) Visual, Aural, Reading-writing and Kinesthetic questionnaires to determine learning styles. PRIMARY AND SECONDARY OUTCOME MEASURES: Home HD and PD adverse events were identified within 6 months of completing home dialysis training. Event rates were then stratified and compared according to learning styles. RESULTS: Thirty patients had a total of 53 adverse events. We used logistic regression analysis to determine unadjusted and adjusted ORs for a single adverse event. Non-visual learners were 4.35 times more likely to have an adverse event (p=0.001). After adjusting for age, gender, dialysis modality, training duration, dialysis vintage, prior renal replacement therapy, visual impairment, education and literacy, an adverse event was still four times more likely among non-visual learners compared to visual learners (p=0.008). A subgroup analysis of home HD patients showed adverse events were more likely among non-visual learners (OR 11.1; p=0.003), whereas PD patients showed a trend for more adverse events in non-visual learners (OR: 1.60; p=0.694). CONCLUSIONS: Different learning styles in home dialysis patients exist. Visual learning styles are associated with fewer adverse events in home dialysis patients within the first 6 months of completing training. Individualisation of home dialysis training by learning style is warranted.