Development and Implementation of a Medical Respite Program for People Experiencing Homelessness: An Analysis of a Cross-sectoral Partnership.

People with lived experience of homelessness (PWLEH) undergo worse health outcomes despite frequent acute care use, often because their functional and social needs remain unmet. In response, a homeless shelter and the provincial health authority formed a partnership to implement a medical respite program. We describe this collaboration by conducting a qualitative study, interviewing people involved in planning and implementing the program (n=25). Thematic analysis was performed. Stakeholders were motivated by a common desire to address the health inequities experienced by PWLEH, and frontline service providers felt a sense of teamwork. However, due to logistical limitations, an evolution of partnerships, and lack of role clarity, there was no singular program vision, resulting in lack of stakeholder support and conflicts between partner organizations. Health care for PWLEH must be multidisciplinary and cross-sectoral. The synergies and challenges described shed light on how future partnerships can be navigated.

Are stress-related pathways of social status differentiation more important determinants of health inequities in countries with higher levels of income inequality?

We explored socioeconomic gradients in self-rated overall health (SROH) using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial perspectives (subjective social status (SSS)) among adults living in countries with varying levels of income inequality, and the importance of psychosocial stress in mediating these associations. If psychosocial processes at the individual and societal levels correspond, associations between SSS and SROH should be higher among adults in countries with higher income inequality, and psychosocial stress should be a more important mediator of these associations. We used multigroup structural equation models to analyse cross-sectional data from the International Food Policy Study of adults (n = 22,824) in Australia, Canada, Mexico, the UK and the United States. Associations between SSS and SROH were not higher in more unequal countries, nor was psychosocial stress a more important mediator of these associations. Inequities in SROH in more unequal countries may not predominantly reflect stress-related pathways of social status differentiation.

Stress-Related Poor Diet Quality Does Not Explain Socioeconomic Inequities in Health: A Structural Equation Mediation Analysis of Gender-Specific Pathways.

BACKGROUND: Psychosocial stress and diet quality individually mediate associations between socioeconomic position (SEP) and health; however, it is not known whether they jointly mediate these associations. This is an important question because stress-related unhealthy eating is often invoked as an explanation for diet-related health inequities, particularly among women, seemingly with no empirical justification. OBJECTIVE: This study examined whether psychosocial stress and diet quality jointly mediated associations between SEP and self-rated health in women and men. DESIGN: Multiple mediating pathways were modeled using data from the cross-sectional International Food Policy Study. PARTICIPANTS AND SETTING: Data were collected from 5,645 adults (aged 18 years or older) in Canada during 2018 and 2019. MAIN OUTCOME MEASURES: Participants reported SEP using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial pathways (subjective social status), along with psychosocial stress, dietary intake (to assess overall diet quality via Healthy Eating Index-2015 scores), and self-rated health. STATISTICAL ANALYSES PERFORMED: Structural equation modeling modeled pathways linking SEP (ie, educational attainment, perceived income adequacy, and subjective social status) with self-rated health mediated by psychosocial stress and diet quality, stratified by gender. RESULTS: There was no evidence that psychosocial stress and diet quality jointly mediated associations between SEP and self-rated health in women or men. Diet quality mediated associations between educational attainment and self-rated health in women and men, with some evidence that it mediated associations between subjective social status and self-rated health in men (P = 0.051). Psychosocial stress mediated associations between perceived income adequacy and self-rated health in women and men, and between subjective social status and self-rated health in women. CONCLUSIONS: Although often invoked as an explanation for diet-related health inequities, stress-related poor diet quality did not mediate associations between SEP and self-rated health in women or men. Psychosocial stress and diet quality individually mediated some of these associations, with some differences by gender.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol.

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

Patient navigation programs in Alberta, Canada: an environmental scan.

BACKGROUND: Patient navigation is a complex intervention that has garnered substantial interest and investment across Canada. We conducted an environmental scan to understand the landscape of patient navigation programs within the health care system in Alberta, Canada. METHODS: We included patient navigation programs within Alberta Health Services (AHS) and Alberta's Primary Care Networks (PCNs). Key informants were asked in October 2016 to identify existing programs and their corresponding program contacts. These program contacts were invited to complete a telephone-based survey from October 2016 to July 2017, to provide program descriptions and eligibility criteria, and to identify gaps in navigation. Programs were included if they engaged patients on an individual basis, and either facilitated continuity of care or promoted patient and family empowerment. We tabulated results and calculated summary statistics for program characteristics. RESULTS: Ninety-five potentially eligible programs were identified by key informants. The response rate to the study survey was 73% (n = 69). After excluding programs not meeting inclusion criteria, we included a total of 58 programs in the study: 43 AHS programs and 15 PCN programs. Nearly all programs (93%, n = 54) delivered navigation via an individual acting as a navigator. A minority of programs also included nonnavigator components, such as Web-based resources (7%, n = 4) and process or structural changes to facilitate navigation (22%, n = 13). Certain patient subgroups were particularly well-served by patient navigation; these included patients with cancer, substance use disorders or mental health concerns, and pediatric patients. Gaps identified in navigation fell under 4 domains: awareness, resources, geographic distribution and integration. INTERPRETATION: Patient navigation programs are common and have extended beyond cancer care, from which the construct originated; however, gaps include a lack of awareness and inequitable access to the programs. These findings will be of interest to those developing and implementing patient navigation interventions in Alberta and other jurisdictions.

Impact of Telehealth Interventions on Processes and Quality of Care for Patients With ESRD.

Caring for patients with end-stage renal disease (ESRD) requiring dialysis is intensive and expensive. Telehealth may improve the access and efficiency of ESRD care. For this perspective, we systematically reviewed studies that examined the effectiveness of telehealth versus or in addition to usual care for ESRD management. 10 studies were identified, including 7 randomized trials and 3 cohort studies. Study populations, modes of delivery (including telephone, telemetry, or videoconferencing), and the outcomes evaluated varied substantially between studies. Two studies examined telehealth interventions versus standard ESRD care and demonstrated mixed results on processes of care, no differences in laboratory surrogate markers of ESRD care, and reduced or similar rates of hospitalization. Eight studies evaluated the addition of telehealth to usual care and demonstrated no significant improvements in processes of care or surrogate laboratory measures, variable impacts on hospitalization rates, and mixed impacts on some domains of quality of life, including improvement in mental health. Although potential benefits of telehealth in ESRD care have been reported, optimal designs for delivery and elements of care that may be improved through telehealth remain uncertain.

An exploration of the subjective social status construct in patients with acute coronary syndrome.

BACKGROUND: Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Our objectives were to determine whether low SSS in society was associated with barriers to access to care or hospital readmission in patients with established cardiovascular disease, and whether perceptions of discordantly high SSS in the community modified this association. METHODS: We conducted a prospective cohort study from 2009 to 2013 in Canada, United States, and Switzerland in patients admitted to hospital with acute coronary syndrome (ACS). Data on access to care and SSS variables were obtained at baseline. Readmission data were obtained 12 months post-discharge. We conducted multivariable logistic regression to model the odds of access to care and readmission outcomes in those with low versus high societal SSS. RESULTS: One thousand ninety patients admitted with ACS provided both societal and community SSS rankings. The low societal SSS cohort had greater odds of reporting that their health was affected by lack of health care access (OR 1.48, 95% CI 1.11, 1.97) and of experiencing cardiac readmissions (1.88, 95% CI 1.15, 3.06). Within the low societal SSS cohort, there was a trend toward fewer access to care barriers for those with discordantly high community SSS though findings varied based on the outcome variable. There were no statistically significant differences in readmissions based on community SSS rankings. CONCLUSION: Low societal SSS is associated with increased barriers to access to care and cardiac readmissions. Though attenuated, these trends remained even when adjusting for clinical and sociodemographic factors, suggesting that perceived low societal SSS has health effects above and beyond objective socioeconomic factors. Furthermore, high community SSS may potentially mitigate the risk of experiencing barriers to access to health care in those with low societal SSS, though these associations were not statistically significant. Subjective social status relative to society versus relative to the community seem to represent distinct concepts. Insight into the differences between these two SSS constructs is imperative in the understanding of cardiovascular health and future development of public health policies.

A systematic review of the cost and cost-effectiveness of electronic discharge communications.

BACKGROUND: The transition between acute care and community care can be a vulnerable period in a patients' treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered. OBJECTIVE: To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider. METHODS: We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis. RESULTS: One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes. DISCUSSION: Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care.

Association between subjective social status and cardiovascular disease and cardiovascular risk factors: a systematic review and meta-analysis.

OBJECTIVE: To determine the association between subjective social status (SSS), or the individual's perception of his or her position in the social hierarchy, and the odds of coronary artery disease (CAD), hypertension, diabetes, obesity and dyslipidaemia. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We searched PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, SocINDEX, Web of Science and reference lists of all included studies up to October 2014, with a verification search in July 2015. Inclusion criteria were original studies in adults that reported odds, risk or hazard ratios of at least one outcome of interest (CAD, hypertension, diabetes, obesity or dyslipidaemia), comparing 'lower' versus 'higher' SSS groups, where SSS is measured on a self-anchoring ladder. ORs were pooled using a random-effects model. RESULTS: 10 studies were included in the systematic review; 9 of these were included in the meta-analysis. In analyses unadjusted for objective socioeconomic status (SES) measures such as income, education or occupation, the pooled OR comparing the bottom versus the top of the SSS ladder was 1.82 (95% CI 1.10 to 2.99) for CAD, 1.88 (95% CI 1.27 to 2.79) for hypertension, 1.90 (95% CI 1.25 to 2.87) for diabetes, 3.68 (95% CI 2.03 to 6.64) for dyslipidaemia and 1.57 (95% CI 0.95 to 2.59) for obesity. These associations were attenuated when adjusting for objective SES measures, with the only statistically significant association remaining for dyslipidaemia (OR 2.10, 95% CI 1.09 to 4.06), though all ORs remained greater than 1. CONCLUSIONS: Lower SSS is associated with significantly increased odds of CAD, hypertension, diabetes and dyslipidaemia, with a trend towards increased odds of obesity. These trends are consistently present, though the effects attenuated when adjusting for SES, suggesting that perception of one's own status on a social hierarchy has health effects above and beyond one's actual income, occupation and education.

A systematic review of value-based insurance design in chronic diseases.

OBJECTIVES: Value-based insurance design (V-BID) is an insurance cost-sharing model in which patients pay less for medications deemed to be of higher value. Our objective was to determine the association between V-BID and medication adherence, clinical outcomes, healthcare utilization, and spending in patients with or at risk for cardiovascular chronic diseases, compared with no differential lowering of drug co-payments. STUDY DESIGN: Systematic review. METHODS: We searched PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Controlled Trials Register, Current Controlled Trials, and reference lists of included studies and relevant reviews up to September 2012. Two reviewers independently identified primary research studies with the following study designs: randomized controlled trial, interrupted time series, and controlled before-after studies. Two reviewers independently extracted data and assessed quality. RESULTS: Ten studies were identified: 1 high-quality randomized controlled trial, 1 interrupted time series analysis, and 8 controlled before-and-after studies. Heterogeneity in study populations and interventions, overall low study quality, and lack of standard error reporting precluded meta-analysis. All reported improvement in medication adherence for medications subject to V-BID, of between 2 and 5 percentage points. Impact on clinical outcomes was unclear, with only 1 study reporting on this, noting no difference in the primary outcome, but a reduction in adverse secondary outcomes with V-BID. Of the four studies that examined the impact of VBID on healthcare expenditures, V-BID tended to increase overall prescription drug spending, though three of the four studies reported similar overall healthcare costs due to decreased non drug medical spending. CONCLUSIONS: V-BID is associated with improved medication adherence but its effects on clinical outcomes, healthcare utilization, and spending remain uncertain.

Association between drug insurance cost sharing strategies and outcomes in patients with chronic diseases: a systematic review.

BACKGROUND: Prescription drugs are used in people with hypertension, diabetes, and cardiovascular disease to manage their illness. Patient cost sharing strategies such as copayments and deductibles are often employed to lower expenditures for prescription drug insurance plans, but the impact on health outcomes in these patients is unclear. OBJECTIVE: To determine the association between drug insurance and patient cost sharing strategies on medication adherence, clinical and economic outcomes in those with chronic diseases (defined herein as diabetes, hypertension, hypercholesterolemia, coronary artery disease, and cerebrovascular disease). METHODS: Studies were included if they examined various cost sharing strategies including copayments, coinsurance, fixed copayments, deductibles and maximum out-of-pocket expenditures. Value-based insurance design and reference based pricing studies were excluded. Two reviewers independently identified original intervention studies (randomized controlled trials, interrupted time series, and controlled before-after designs). MEDLINE, EMBASE, Cochrane Library, CINAHL, and relevant reference lists were searched until March 2013. Two reviewers independently assessed studies for inclusion, quality, and extracted data. Eleven studies, assessing the impact of seven policy changes, were included: 2 separate reports of one randomized controlled trial, 4 interrupted time series, and 5 controlled before-after studies. FINDINGS: Outcomes included medication adherence, clinical events (myocardial infarction, stroke, death), quality of life, healthcare utilization, or cost. The heterogeneity among the studies precluded meta-analysis. Few studies reported the impact of cost sharing strategies on mortality, clinical and economic outcomes. The association between patient copayments and medication adherence varied across studies, ranging from no difference to significantly lower adherence, depending on the amount of the copayment. CONCLUSION: Lowering cost sharing in patients with chronic diseases may improve adherence, but the impact on clinical and economic outcomes is uncertain.

Assessing accumulated solvent near a macromolecular solute by preferential interaction coefficients.

Biological macromolecules are often studied in mixed solvents. To understand cosolvent-macromolecule interactions, the preferential interaction coefficient, Gamma(3), may help determine surface solvent compositions. Gamma(3) measures the amounts of water, B(1), and cosolvent, B(3), within the "local domain," the (possibly far-reaching) region surrounding the macromolecule where the solvent is non-bulk-like. The local domain's boundary is, however, vague and it is unclear which molecules are counted in B(i). It is useful to explore a simple model system to make B(i) more concrete and to understand which aspects of the surface solvent distribution, rho(x), are sampled by Gamma(3). We performed computer simulations on a two-dimensional (2D) system consisting of a hard-wall solute (the macromolecule) in a mixed solvent (hard disks of different radii). We simultaneously calculated Gamma(3) and rho(x). We found that 1) in practice, the local domain's boundary is demarked by the outer limit of the first cosolvent (not water) layer; B(i) mainly counts the solvent near the macromolecule; 2) assuming B(1) to count only the waters within the first water layer is a poor approximation; 3) when determining B(1) and B(3), water and cosolvent molecules must be counted from the same region of space. We speculate that these 2D results may serve as a first-order approximation for the dominant contributions to Gamma(3) even in three dimensions, so long as the cosolvent is not strongly excluded from the macromolecular surface and there is no significant long-ranged solvent structure.