BETTER LIFE- guidelines for chronic disease preventive care for people aged 18-39 years: a literature review.

BACKGROUND: The original 'BETTER' (Building on Existing Tools To Improve Chronic Disease Prevention and Screening in Primary Care) approach consisted of a prevention-focused visit between participants aged 40-65 years and a "Prevention Practitioner" (PP), who empowered the participant to set achievable prevention and screening goals for cancers and chronic diseases. BETTER was successfully adapted for economically deprived communities (BETTER HEALTH) in Canada. Our objective was to conduct a review of guidelines in preparation for adapting the 'BETTER HEALTH' approach for younger adults aged 18-39 years living with lower income, a group known to have earlier mortality due to a higher prevalence of preventable chronic diseases than their peers with higher income. METHODS: We searched multiple electronic databases and grey literature for clinical practice guidelines on prevention/screening and included those that met the following criteria: published in English from 2008-2020 in Canada or any of the following countries (Australia, Ireland, New Zealand, Scotland, United States and England); and addressed prevention or screening. We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and extracted data (publication details, recommendations, and Quality/Level of evidence as reported by authors) from sources with overall scores of 5 or higher. Final recommendations were compiled after harmonization with input from diverse stakeholders (co-investigators, PPs, and the Community Advisory Committee). RESULTS: We included a total of 85 guidelines, and developed a final list of 42 recommendations for 18-39 year-olds across 21 topics. Specific recommendations fell under the following topics: cancers, cardiovascular disease, diabetes, obesity, lifestyle (alcohol; healthy nutrition/physical activity); healthy relationships and healthy sexuality, immunization, oral health, social determinants of health, and substance use. CONCLUSION: We identified evidence-based guidelines on individual-level prevention/screening actions for adults 18-39 years old and relevant for those living with lower income which will directly inform development and implementation of the BETTER LIFE intervention.

Implementing Multifactorial Risk Assessment with Polygenic Risk Scores for Personalized Breast Cancer Screening in the Population Setting: Challenges and Opportunities.

Risk-stratified breast screening has been proposed as a strategy to overcome the limitations of age-based screening. A prospective cohort study was undertaken within the PERSPECTIVE I&I project, which will generate the first Canadian evidence on multifactorial breast cancer risk assessment in the population setting to inform the implementation of risk-stratified screening. Recruited females aged 40-69 unaffected by breast cancer, with a previous mammogram, underwent multifactorial breast cancer risk assessment. The adoption of multifactorial risk assessment, the effectiveness of methods for collecting risk factor information and the costs of risk assessment were examined. Associations between participant characteristics and study sites, as well as data collection methods, were assessed using logistic regression; all p-values are two-sided. Of the 4246 participants recruited, 88.4% completed a risk assessment, with 79.8%, 15.7% and 4.4% estimated at average, higher than average and high risk, respectively. The total per-participant cost for risk assessment was CAD 315. Participants who chose to provide risk factor information on paper/telephone (27.2%) vs. online were more likely to be older (p = 0.021), not born in Canada (p = 0.043), visible minorities (p = 0.01) and have a lower attained education (p < 0.0001) and perceived fair/poor health (p < 0.001). The 34.4% of participants requiring risk factor verification for missing/unusual values were more likely to be visible minorities (p = 0.009) and have a lower attained education (p ≤ 0.006). This study demonstrates the feasibility of risk assessment for risk-stratified screening at the population level. Implementation should incorporate an equity lens to ensure cancer-screening disparities are not widened.

Wait times and breast cancer survival: a population-based retrospective cohort study using CanIMPACT data.

PURPOSE: The time from breast cancer surgery to chemotherapy has been shown to affect survival outcomes; however, the effect of time from first breast cancer-related healthcare contact to first cancer specialist consultation, or the time from first breast cancer-related healthcare contact to adjuvant chemotherapy on survival has not been well explored. We aimed to determine whether various wait times along the breast cancer treatment pathway (contact-to-consultation, contact-to-chemotherapy, surgery-to-chemotherapy) were associated with overall survival in women within the Canadian province of Ontario. METHODS: We performed a population-based retrospective cohort study of women diagnosed with stage I-III breast cancer in Ontario between 2007 and 2011 who received surgery and adjuvant chemotherapy. This was the Ontario cohort of a larger, nationwide study (the Canadian Team to improve Community-Based Cancer Care along the Continuum - CanIMPACT). We used Cox-proportional hazards regression to determine the association between the contact-to-consultation, contact-to-chemotherapy, and surgery-to-chemotherapy intervals and overall survival while adjusting for cancer stage, age, comorbidity, neighborhood income, immigration status, surgery type, and method of cancer detection. RESULTS: Among 12,782 breast cancer patients, longer surgery-to-chemotherapy intervals (HR 1.13, 95% CI 1.03-1.18 per 30-day increase), but not the contact-to-consultation (HR 0.979, 95% CI 0.95-1.01 per 30-day increase), nor the more comprehensive contact-to-chemotherapy intervals (HR 1.00, 95% CI 0.98-1.02 per 30-day increase) were associated with decreased survival in our adjusted analyses. CONCLUSION: Our findings emphasize the prognostic importance of a shorter surgery-to-chemotherapy interval, whereas the contact-to-consultation and contact-to-chemotherapy intervals have less impact on survival outcomes.

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care.

BACKGROUND: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. METHODS: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40-69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. RESULTS: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40-69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. CONCLUSIONS: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial.

OBJECTIVE: Building on Existing Tools To improvE chronic disease pRevention and screening in primary care Wellness of cancer survIvorS and patiEnts (BETTER WISE) was designed to assess the effectiveness of a cancer and chronic disease prevention and screening (CCDPS) programme. Here, we compare outcomes in participants living with and without financial difficulty. DESIGN: Secondary analysis of a cluster-randomised controlled trial. SETTING: Patients of 59 physicians from 13 clinics enrolled between September 2018 and August 2019. PARTICIPANTS: 596 of 1005 trial participants who responded to a financial difficulty screening question at enrolment. INTERVENTION: 1-hour CCDPS visit versus usual care. OUTCOME MEASURES: Eligibility for a possible 24 CCDPS actions was assessed at baseline and the primary outcome was the percentage of eligible items that were completed at 12-month follow-up. We also compared the change in response to the financial difficulty screening question between baseline and follow-up. RESULTS: 55 of 265 participants (20.7%) in the control group and 69 of 331 participants (20.8%) in the intervention group reported living with financial difficulty. The primary outcome was 29% (95% CI 26% to 33%) for intervention and 23% (95% CI 21% to 26%) for control participants without financial difficulty (p=0.01). Intervention and control participants with financial difficulty scored 28% (95% CI 24% to 32%) and 32% (95% CI 27% to 38%), respectively (p=0.14). In participants who responded to the financial difficulty question at both time points (n=302), there was a net decrease in the percentage of participants who reported financial difficulty between baseline (21%) and follow-up (12%, p<0.001) which was similar in the control and intervention groups. The response rate to this question was only 51% at follow-up. CONCLUSION: The BETTER intervention improved uptake of CCDPS manoeuvres in participants without financial difficulty, but not in those living with financial difficulty. Improving CCDPS for people living with financial difficulty may require a different clinical approach or that social determinants be addressed concurrently with clinical and lifestyle needs or both. TRIAL REGISTRATION NUMBER: ISRCTN21333761.

Risk-based lung cancer screening performance in a universal healthcare setting.

Globally, lung cancer is the leading cause of cancer death. Previous trials demonstrated that low-dose computed tomography lung cancer screening of high-risk individuals can reduce lung cancer mortality by 20% or more. Lung cancer screening has been approved by major guidelines in the United States, and over 4,000 sites offer screening. Adoption of lung screening outside the United States has, until recently, been slow. Between June 2017 and May 2019, the Ontario Lung Cancer Screening Pilot successfully recruited 7,768 individuals at high risk identified by using the PLCOm2012noRace lung cancer risk prediction model. In total, 4,451 participants were successfully screened, retained and provided with high-quality follow-up, including appropriate treatment. In the Ontario Lung Cancer Screening Pilot, the lung cancer detection rate and the proportion of early-stage cancers were 2.4% and 79.2%, respectively; serious harms were infrequent; and sensitivity to detect lung cancers was 95.3% or more. With abnormal scans defined as ones leading to diagnostic investigation, specificity was 95.5% (positive predictive value, 35.1%), and adherence to annual recall and early surveillance scans and clinical investigations were high (>85%). The Ontario Lung Cancer Screening Pilot provides insights into how a risk-based organized lung screening program can be implemented in a large, diverse, populous geographic area within a universal healthcare system.

Stage of diagnosis and survival for prostate cancer among immigrant men in Ontario, Canada.

INTRODUCTION: We previously identified specific immigrant groups (West African and Caribbean) with increased incidence of prostate cancer in Ontario, Canada. In this population-level retrospective cohort study, we used administrative databases to compare stage of diagnosis, 5-year overall survival and prostate cancer-specific survival for immigrants versus long-term residents of Ontario. METHODS: We linked several provincial-level databases available at ICES, an independent, non-profit research institute. We included all male Ontario residents 20-105 years of age who had an incident prostate cancer diagnosis date between March 31, 2008 and March 31, 2017, stratified into immigrants vs. long-term residents. We used multivariable logistic regression to determine the odds of early (stage I-II) vs. late (III-IV) stage of diagnosis, adjusting for age, co-morbidities, neighbourhood income and continuity of care. We produced Kaplan-Meier curves for 5-year overall survival and for 5-year prostate cancer-specific survival. RESULTS: Compared to long-term residents, men from West Africa (adjusted odds ratio 1.66 [95% CI 1.16-2.38], East Africa (AOR 1.54 [95% CI 1.02-2.33]) and the Caribbean (AOR 1.22 [95% CI 1.01-1.47]) had a diagnostic stage advantage, and men from South Asia were most likely to be diagnosed at a late stage. In both unadjusted and adjusted analyses, overall and prostate cancer-specific survival were higher for immigrants than long-term residents. The highest five-year overall survival was seen for men from Sub-Saharan Africa and the Caribbean, and the lowest was seen for South Asian men, where 11.7% died within five years of diagnosis. CONCLUSION: Immigrant men in Ontario with prostate cancer are more likely to be diagnosed at an early stage and to survive for 5 years than long-term residents. Among immigrant men, men from the Caribbean and Sub-Saharan Africa have the greatest stage and survival advantage and South Asian men the least. Differences in awareness, diagnostic suspicion, genetic predisposition, and social factors may play a role in these findings.

Protocol for the ONLOOP trial: pragmatic randomized trial evaluating a province-wide system of personalized reminders for evidence-based surveillance tests in adult survivors of childhood cancer in Ontario.

BACKGROUND: Childhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time. METHODS: This is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP's impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants' consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later. The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed. DISCUSSION: The results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05832138.

Access to cancer clinical trials for racialised older adults: an equity-focused rapid scoping review protocol.

BACKGROUND: The intersection of race and older age compounds existing health disparities experienced by historically marginalised communities. Therefore, racialised older adults with cancer are more disadvantaged in their access to cancer clinical trials compared with age-matched counterparts. To determine what has already been published in this area, the rapid scoping review question are: what are the barriers, facilitators and potential solutions for enhancing access to cancer clinical trials among racialised older adults? METHODS: We will use a rapid scoping review methodology in which we follow the six-step framework of Arksey and O'Malley, including a systematic search of the literature with abstract and full-text screening to be conducted by two independent reviewers, data abstraction by one reviewer and verification by a second reviewer using an Excel data abstraction sheet. Articles focusing on persons aged 18 and over who identify as a racialised person with cancer, that describe therapies/therapeutic interventions/prevention/outcomes related to barriers, facilitators and solutions to enhancing access to and equity in cancer clinical trials will be eligible for inclusion in this rapid scoping review. ETHICS AND DISSEMINATION: All data will be extracted from published literature. Hence, ethical approval and patient informed consent are not required. The findings of the scoping review will be submitted for publication in a peer-reviewed journal and presentation at international conferences.

Surviving the Storm: The Impact of COVID-19 on Cervical Cancer Screening in Low- and Middle-Income Countries.

According to the Center for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program, the cervical cancer screening rate dropped by 84% soon after the declaration of the COVID-19 pandemic. The challenges facing cervical cancer screening were largely attributed to the required in-person nature of the screening process and the measures implemented to control the spread of the virus. While the impact of the COVID-19 pandemic on cancer screening is well-documented in high-income countries, less is known about the low- and middle-income countries that bear 90% of the global burden of cervical cancer deaths. In this paper, we aim to offer a comprehensive view of the impact of COVID-19 on cervical cancer screening in LMICs. Using our study, "Prevention of Cervical Cancer in India through Self-Sampling" (PCCIS), as a case example, we present the challenges COVID-19 has exerted on patients, healthcare practitioners, and health systems, as well as potential opportunities to mitigate these challenges.

Recommandations pour des soins préventifs pour promouvoir l'équité en matière de santé.

CONTEXTE: Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d'observer des disparités évitables en matière de santé au Canada. L'équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l'équité en matière de santé par la priorisation des interventions efficaces à l'intention des groupes défavorisés. MÉTHODES: La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d'un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d'autres études pertinentes sur l'efficacité du dépistage et de la prise en charge. Nous avons utilisé l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d'experts en contenu avant d'être distribuées à des intervenants à l'échelle nationale pour approbation. RECOMMANDATIONS: Nous avons formulé 15 recommandations concernant le dépistage et d'autres soins préventifs et 1 recommandation de nature politique visant à améliorer l'accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l'âge de 45 ans et pour l'évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l'autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l'interféron γ pour l'infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d'accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées. INTERPRÉTATION: Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s'ils veulent promouvoir l'équité en matière de santé partout au Canada.

Breast Cancer Screening Among Females With and Without Schizophrenia.

Importance: Breast cancer screening with mammography is recommended in Ontario, Canada, for females 50 years or older. Females with schizophrenia are at higher risk of breast cancer, but in Ontario it is currently unknown whether breast cancer screening completion differs between those with vs without schizophrenia and whether primary care payment models are a factor. Objective: To compare breast cancer screening completion within 2 years after the 50th birthday among females with and without schizophrenia, and to identify the association between breast cancer screening completion and different primary care payment models. Design, Setting, and Participants: This case-control study analyzed Ontario-wide administrative data on females with and without schizophrenia who turned 50 years of age between January 1, 2010, and December 31, 2019. Those with schizophrenia (cases) were matched 1:10 to those without schizophrenia (controls) on local health integration network, income quintile, rural residence, birth dates, and weighted Aggregated Diagnosis Group score. Data analysis was performed from November 2021 to February 2023. Exposures: Exposures were schizophrenia and primary care payment models. Main Outcomes and Measures: Outcomes included breast cancer screening completion among cases and controls within 2 years after their 50th birthday and the association with receipt of care from primary care physicians enrolled in different primary care payment models, which were analyzed using logistic regression and reported as odds ratios (ORs) and 95% CIs. Results: The study included 11 631 females with schizophrenia who turned 50 years of age during the study period and a matched cohort of 115 959 females without schizophrenia, for a total of 127 590 patients. Overall, 69.3% of cases and 77.1% of controls had a mammogram within 2 years after their 50th birthday. Cases had lower odds of breast cancer screening completion within 2 years after their 50th birthday (OR, 0.67; 95% CI, 0.64-0.70). Cases who received care from a primary care physician in a fee-for-service (OR, 0.57; 95% CI, 0.53-0.60) or enhanced fee-for-service (OR, 0.79; 95% CI, 0.75-0.82) payment model had lower odds of having a mammogram than cases whose physicians were paid under a Family Health Team model. Conclusions and Relevance: This case-control study found that, in Ontario, Canada, breast cancer screening completion was lower among females with schizophrenia, and differences from those without schizophrenia may partially be explained by differences in primary care payment models. Widening the availability of team-based primary care for females with schizophrenia may play a role in increased breast cancer screening rates.

Cancer Screening Disparities Before and After the COVID-19 Pandemic.

Importance: Breast, cervical, and colorectal cancer-screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic. Objective: To assess whether changes in screening from before the pandemic to after the pandemic varied for immigrants and for people with limited income. Design, Setting, and Participants: This population-based, cross-sectional study, using data from March 31, 2019, and March 31, 2022, included adults in Ontario, Canada, the country's most populous province, with more than 14 million people, almost 30% of whom are immigrants. At both dates, the screening-eligible population for each cancer type was assessed. Exposures: Neighborhood income quintile, immigrant status, and primary care model type. Main Outcomes and Measures: For each cancer screening type, the main outcome was whether the screening-eligible population was up to date on screening (a binary outcome) on March 31, 2019, and March 31, 2022. Up to date on screening was defined as having had a mammogram in the previous 2 years, a Papanicolaou test in the previous 3 years, and a fecal test in the previous 2 years or a flexible sigmoidoscopy or colonoscopy in the previous 10 years. Results: The overall cohort on March 31, 2019, included 1 666 943 women (100%) eligible for breast screening (mean [SD] age, 59.9 [5.1] years), 3 918 225 women (100%) eligible for cervical screening (mean [SD] age, 45.5 [13.2] years), and 3 886 345 people eligible for colorectal screening (51.4% female; mean [SD] age, 61.8 [6.4] years). The proportion of people up to date on screening in Ontario decreased for breast, cervical, and colorectal cancers, with the largest decrease for breast screening (from 61.1% before the pandemic to 51.7% [difference, -9.4 percentage points]) and the smallest decrease for colorectal screening (from 65.9% to 62.0% [difference, -3.9 percentage points]). Preexisting disparities in screening for people living in low-income neighborhoods and for immigrants widened for breast screening and colorectal screening. For breast screening, compared with income quintile 5 (highest), the ß estimate for income quintile 1 (lowest) was -1.16 (95% CI, -1.56 to -0.77); for immigrant vs nonimmigrant, the ß estimate was -1.51 (95% CI, -1.84 to -1.18). For colorectal screening, compared with income quintile 5, the ß estimate for quntile 1 was -1.29 (95% CI, 16 -1.53 to -1.06); for immigrant vs nonimmigrant, the ß estimate was -1.41 (95% CI, -1.61 to -1.21). The lowest screening rates both before and after the COVID-19 pandemic were for people who had no identifiable family physician (eg, moving from 11.3% in 2019 to 9.6% in 2022 up to date for breast cancer). In addition, patients of interprofessional, team-based primary care models had significantly smaller reductions in ß estimates for breast (2.14 [95% CI, 1.79 to 2.49]), cervical (1.72 [95% CI, 1.46 to 1.98]), and colorectal (2.15 [95% CI, 1.95 to 2.36]) postpandemic screening and higher uptake of screening in general compared with patients of other primary care models. Conclusions and Relevance: In this cross-sectional study in Ontario that included 2 time points, widening disparities before compared with after the COVID-19 pandemic were found for breast cancer and colorectal cancer screening based on income and immigrant status, but smaller declines in disparities were found among patients of interprofessional, team-based primary care models than among their counterparts. Policy makers should investigate the value of prioritizing and investing in improving access to team-based primary care for people who are immigrants and/or with limited income.

Multi-level strategies to improve equitable timely person-centred osteoarthritis care for diverse women: qualitative interviews with women and healthcare professionals.

BACKGROUND: Women are more likely to develop osteoarthritis (OA), and have greater OA pain and disability compared with men, but are less likely to receive guideline-recommended management, particularly racialized women. OA care of diverse women, and strategies to improve the quality of their OA care is understudied. The purpose of this study was to explore strategies to overcome barriers of access to OA care for diverse women. METHODS: We conducted qualitative interviews with key informants and used content analysis to identify themes regarding what constitutes person-centred OA care, barriers of OA care, and strategies to support equitable timely access to person-centred OA care. RESULTS: We interviewed 27 women who varied by ethno-cultural group (e.g. African or Caribbean Black, Chinese, Filipino, Indian, Pakistani, Caucasian), age, region of Canada, level of education, location of OA and years with OA; and 31 healthcare professionals who varied by profession (e.g. family physician, nurse practitioner, community pharmacist, physio- and occupational therapists, chiropractors, healthcare executives, policy-makers), career stage, region of Canada and type of organization. Participants within and across groups largely agreed on approaches for person-centred OA care across six domains: foster a healing relationship, exchange information, address emotions, manage uncertainty, share decisions and enable self-management. Participants identified 22 barriers of access and 18 strategies to overcome barriers at the patient- (e.g. educational sessions and materials that accommodate cultural norms offered in different languages and formats for persons affected by OA), healthcare professional- (e.g. medical and continuing education on OA and on providing OA care tailored to intersectional factors) and system- (e.g. public health campaigns to raise awareness of OA, and how to prevent and manage it; self-referral to and public funding for therapy, greater number and ethno-cultural diversity of healthcare professionals, healthcare policies that address the needs of diverse women, dedicated inter-professional OA clinics, and a national strategy to coordinate OA care) levels. CONCLUSIONS: This research contributes to a gap in knowledge of how to optimize OA care for disadvantaged groups including diverse women. Ongoing efforts are needed to examine how best to implement these strategies, which will require multi-sector collaboration and must engage diverse women.

Identifying strategies that support equitable person-centred osteoarthritis care for diverse women: content analysis of guidelines.

INTRODUCTION: Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access early diagnosis and management, or experience OA care tailored through person-centred approaches to their needs and preferences, particularly racialized women. One way to support clinicians in optimizing OA care is through clinical guidelines. We aimed to examine the content of OA guidelines for guidance on providing equitable, person-centred care to disadvantaged groups including women. METHODS: We searched indexed databases and websites for English-language OA-relevant guidelines published in 2000 or later by non-profit organizations. We used manifest content analysis to extract data, and summary statistics and text to describe guideline characteristics, person-centred care (PCC) using a six-domain PCC framework, OA prevalence or barriers by intersectional factors, and strategies to improve equitable access to OA care. RESULTS: We included 36 OA guidelines published from 2003 to 2021 in 8 regions or countries. Few (39%) development panels included patients. While most (81%) guidelines included at least one PCC domain, guidance was often brief or vague, few addressed exchange information, respond to emotions and manage uncertainty, and none referred to fostering a healing relationship. Few (39%) guidelines acknowledged or described greater prevalence of OA among particular groups; only 3 (8%) noted that socioeconomic status was a barrier to OA care, and only 2 (6%) offered guidance to clinicians on how to improve equitable access to OA care: assess acceptability, availability, accessibility, and affordability of self-management interventions; and employ risk assessment tools to identify patients without means to cope well at home after surgery. CONCLUSIONS: This study revealed that OA guidelines do not support clinicians in caring for diverse persons with OA who face disadvantages due to intersectional factors that influence access to and quality of care. Developers could strengthen OA guidelines by incorporating guidance for PCC and for equity that could be drawn from existing frameworks and tools, and by including diverse persons with OA on guideline development panels. Future research is needed to identify multi-level (patient, clinician, system) strategies that could be implemented via guidelines or in other ways to improve equitable, person-centred OA care. PATIENT OR PUBLIC CONTRIBUTION: This study was informed by a team of researchers, collaborators, and thirteen diverse women with lived experience, who contributed to planning, and data collection, analysis and interpretation by reviewing study materials and providing verbal (during meetings) and written (via email) feedback.

Integration of the social determinants of health into quality indicators for colorectal cancer surgery: a scoping review protocol.

INTRODUCTION: Quality monitoring is a critical component of high-performing cancer care systems. Quality indicators (QIs) are standardised, evidence-based measures of healthcare quality that allow healthcare systems to track performance, identify gaps in healthcare delivery and inform areas of priority for strategic planning. Social structures and economic systems that allow for unequal access to power and resources that shape health and health inequities can be described through the social determinants of health (SDoH) framework. Therefore, granular analysis of healthcare quality through SDoH frameworks is required to identify patient subgroups who may experience health inequity. Given the high burden of disease of colorectal cancer (CRC) and well-defined cancer care pathways, CRC is often the first disease site targeted by health systems for quality improvement. The objective of this review is to examine how SDoH have been integrated into QIs for CRC surgery. This review aims to address three primary questions: (1) Have SDoH been integrated into the development, reporting and assessment of CRC surgery QIs? (2) When integrated, what measures and statistical methods have been applied? (3) In which direction do individual SDoH influence QIs outputs? METHODS: This review will follow Arksey and O'Malley frameworks for scoping reviews. We will search MEDLINE, EMBASE, HealthSTAR databases for papers that examine QIs for CRC surgery applicable to healthcare systems from database inception until January 2023. Interventional trials, prospective and retrospective observational studies, reviews, case series and qualitative study designs will be included. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria. ETHICS & DISSEMINATION: No ethics approval is required for this review. Results will be disseminated through scientific presentation and relevant conferences targeted for researchers examining healthcare quality and equity in cancer care. REGISTRATION DETAILS: osf.io/vfzd3-Open Science Framework.

Preventive care recommendations to promote health equity.

BACKGROUND: Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages. METHODS: The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders. RECOMMENDATIONS: We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-γ release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages. INTERPRETATION: Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada.

Results from the BETTER WISE trial: a pragmatic cluster two arm parallel randomized controlled trial for primary prevention and screening in primary care during the COVID-19 pandemic.

BACKGROUND: Cancer and chronic diseases are a major cost to the healthcare system and multidisciplinary models with access to prevention and screening resources have demonstrated improvements in chronic disease management and prevention. Research demonstrated that a trained Prevention Practitioner (PP) in multidisciplinary team settings can improve achievement of patient level prevention and screening actions seven months after the intervention. METHODS: We tested the effectiveness of the PP intervention in a pragmatic two-arm cluster randomized controlled trial. Patients aged 40-65 were randomized at the physician level to an intervention group or to a wait-list control group. The intervention consisted of a patient visit with a PP. The PP received training in prevention and screening and use of the BETTER WISE tool kit. The effectiveness of the intervention was assessed using a composite outcome of the proportion of the eligible prevention and screening actions achieved between intervention and control groups at 12-months. RESULTS: Fifty-nine physicians were recruited in Alberta, Ontario, and Newfoundland and Labrador. Of the 1,005 patients enrolled, 733 (72.9%) completed the 12-month analysis. The COVID-19 pandemic occurred during the study time frame at which time nonessential prevention and screening services were not available and in-person visits with the PP were not allowed. Many patients and sites did not receive the intervention as planned. The mean composite score was not significantly higher in patients receiving the PP intervention as compared to the control group. To understand the impact of COVID on the project, we also considered a subset of patients who had received the intervention and who attended the 12-month follow-up visit before COVID-19. This assessment demonstrated the effectiveness of the BETTER visits, similar to the findings in previous BETTER studies. CONCLUSIONS: We did not observe an improvement in cancer and chronic disease prevention and screening (CCDPS) outcomes at 12 months after a BETTER WISE prevention visit: due to the COVID-19 pandemic, the study was not implemented as planned. Though benefits were described in those who received the intervention before COVID-19, the sample size was too small to make conclusions. This study may be a harbinger of a substantial decrease and delay in CCDPS activities under COVID restrictions. TRIAL REGISTRATION: ISRCTN21333761. Registered on 19/12/2016. http://www.isrctn.com/ISRCTN21333761 .

Medication self-management toolkits for adults with multiple sclerosis: A scoping review.

Background: Multiple sclerosis (MS) is an autoimmune disease that is often treated with multiple medications. Managing multiple medications, also known as polypharmacy, can be challenging for persons with MS. Toolkits are instructional resources designed to promote behaviour change. Toolkits may support medication self-management for adults with MS, as they have been useful in other populations with chronic conditions. Objective: The main purpose of this review was to identify and summarize medication self-management toolkits for MS, as related to the design, delivery, components, and measures used to evaluate implementation and/or outcomes. Methods: A scoping review was conducted following guidelines by JBI. Articles were included if they focused on adults (18 years or older) with MS. Results: Six articles reporting on four unique toolkits were included. Most toolkits were technology-based, including mobile or online applications, with only one toolkit being paper-based. The toolkits varied in type, frequency, and duration of medication management support. Varying outcomes were also identified, but there were improvements reported in symptom management, medication adherence, decision-making, and quality of life. The six studies were quantitative in design, with no studies exploring the user experience from a qualitative or mixed-methods design. Conclusions: There is limited research on medication self-management toolkits among adults with MS. Future development, implementation, and evaluation mixed-methods research are needed to explore user experiences and overall design of toolkits.

Implementation of a Cervical Cancer Screening Intervention for Under- or Never-Screened Women in Ontario, Canada: Understanding the Acceptability of HPV Self-Sampling.

With appropriate screening, cervical cancer can be prevented. In Ontario, Canada, some groups of women have low screening rates. South Asian, Middle Eastern and North African women are particularly at risk of under-screening. Currently, cytology-based screening is used in Ontario, although the growing evidence and adoption of HPV testing for cervical screening has encouraged many jurisdictions around the world to move towards HPV testing, with the option of self-sampling. We conducted an intervention beginning in June 2018, where we recruited over 100 under- or never-screened (UNS) women who identify as South or West Asian, Middle Eastern or North African from the Greater Toronto Area, to understand the uptake and acceptability of HPV self-sampling as an alternative to a Pap test. Participants self-selected if they tried the kit or not and completed both quantitative and qualitative research activities. This paper focuses on the qualitative arm of the study, where follow-ups and five focus groups were conducted with those who tried the kit (three groups) and those who did not (two groups), as well as eight key informant interviews with community champions and others who were involved in our recruitment. We used the Consolidated Framework for Implementation Research (CFIR) to guide our data collection and analysis. Major themes around convenience, privacy and comfort came from the data as important drivers of the uptake of the intervention. The role of community champions and peers in engaging and educating UNS women, as well as having self-confidence to collect the sample, also came out as factors impacting uptake and plans for continued use. Overall, the intervention showed that HPV self-sampling is an acceptable alternative to a Pap test for some but not all UNS women in Ontario.