Evaluation of BASE eConsult Manitoba: patient perspectives on the use of electronic consultation to improve access to specialty advice in Manitoba.

BACKGROUND: The burden of waiting to access specialist expertise may contribute to poorer health outcomes and causes distress for patients and providers. One solution to improve access to specialist care is to use innovative tools such as remote asynchronous electronic consultation (eConsult). Modeled after the Champlain BASE™ (Building Access to Specialist Advice) eConsult service, BASE™ eConsult Manitoba was launched in 2017 to help address long waits for patients to access specialist advice. OBJECTIVE: We aimed to evaluate patients' experiences after obtaining a BASE™ eConsult Manitoba service in their primary care setting. METHODS: Patients whose Primary Care Providers (PCPs) used BASE™ eConsult as part of their care were asked to participate and complete a telephone-based or online 29-question survey between January 2021 and October 2021. The survey questions were created in consultation with patient partners and based on questions asked in studies done in other jurisdictions. RESULTS: Of the 36 patients who chose to participate, 29 completed the entire survey (80%). Two-thirds (n = 22) agreed that eConsult has been helpful in their situation, and over 80% (n = 24) of participants agreed that eConsult was an acceptable way to access specialist care. During the visit when their PCP sent the eConsult, 7 patients were expecting to be referred to a specialist for a face-to-face consultation. Over half of all respondents (n = 15) reported that before the eConsult occurred, their PCP asked them what questions they wanted to be answered by the specialist. Almost all of these respondents' questions were fully answered by the eConsult. All of the respondents were satisfied with the experience of receiving an eConsult. CONCLUSION: Using eConsult is an acceptable way to improve access to specialist advice from patients' perspectives. Consideration should be given to expanding the use of eConsult services to improve access to specialist expertise for PCPs and their patients.

Key factors for national spread and scale-up of an eConsult innovation.

BACKGROUND: Expanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada. METHODS: We conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research. RESULTS: This study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes. CONCLUSIONS: Efforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.

Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada.

BACKGROUND: Hospital readmission is costly and potentially avoidable. The concept of virtual wards as a new model of care is intended to reduce hospital readmissions by providing short-term transitional care to high-risk and complex patients in the community. In order to provide information regarding the development of virtual wards in the Winnipeg Health Region, Canada, this study used spatial statistics to identify geographic variations of hospital readmissions in 25 neighborhood clusters. METHODS: The data were obtained from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. We used a Bayesian Disease Mapping approach which applied Markov chain Monte Carlo (MCMC) for cluster detection. RESULTS: Between 2005/06 and 2008/09, 123,842 patients were hospitalized in all Winnipeg hospitals. Of these, 41,551 (33%) were readmitted to hospital in the year following discharge. Most of these readmitted patients (89.4%) had 1-2 readmissions, while 11.6% of readmitted patients had more than 2 readmissions after initial discharge. The smoothed age- and sex- adjusted relative risk rates of hospital readmission in 25 Winnipeg neighborhood clusters ranged between 0.73 and 1.27. We found that there were spatial cluster variations of hospital readmission across the Winnipeg Health Region. Seven neighborhood clusters are more likely to be significant potential clusters for hospital readmissions (p < .05), while six neighborhood clusters are less likely to be significant potential clusters. CONCLUSIONS: This study provides the foundation and implementation guide for the Winnipeg Regional Health Authority virtual ward program. The findings will also help to improve long-term condition management in community settings and will help program planners to assure the efficient use of healthcare resources.

Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority.

BACKGROUND: Existing literature demonstrating the negative impact of delayed hip fracture surgery on mortality consists largely of observational studies prone to selection bias and may overestimate the negative effects of delay. We conducted an intervention study to assess initiatives aimed at meeting a 48-hour benchmark for hip fracture surgery to determine if the intervention achieved a reduction in time to surgery, and if a general reduction in time to surgery improved mortality and length of stay. METHODS: We compared time to surgery, length of stay and mortality between pre- and postintervention patients with a hip fracture using the Kaplan-Meier estimator and Cox proportional hazards model adjusting for age, sex, comorbidities, type of surgery and year. RESULTS: We included 3525 pre- and 3007 postintervention patients aged 50 years or older. The proportion of patients receiving surgery within the benchmark increased from 66.8% to 84.6%, median length of stay decreased from 13.5 to 9.7 days, and crude in-hospital mortality decreased from 9.6% to 6.8% (all p < 0.001). Adjusted analyses revealed reduced mortality in hospital (hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.57-0.81) and at 1 year (HR 0.87, 95%CI 0.79-0.96). Independent of the intervention period, having surgery within 48 hours demonstrated decreased adjusted risk of death in hospital (HR 0.51, 95%CI 0.41-0.63) and at 1 year postsurgery (HR 0.72, 95% CI 0.64-0.80). CONCLUSION: Coordinated, region-wide efforts to improve timeliness of hip fracture surgery can successfully reduce time to surgery and appears to reduce length of stay and adjusted mortality in hospital and at 1 year.

CONTEXTE: La littérature actuelle qui démontre l'impact négatif d'un report de la chirurgie pour fracture de la hanche sur la mortalité repose en bonne partie sur des études d'observation sujettes à des biais de sélection et pourrait surestimer cet impact négatif. Nous avons réalisé une étude interventionnelle pour évaluer des mesures visant à faire respecter un délai maximum de 48 heures avant l'intervention pour fracture de la hanche afin de voir si elles avaient effectivement raccourci le délai avant la chirurgie et si l'abrègement général du délai avant la chirurgie avait réduit la mortalité et la durée du séjour hospitalier. MÉTHODES: Nous avons comparé le délai avant la chirurgie, la durée du séjour hospitalier et la mortalité des patients victimes d'une fracture de la hanche avant et après l'imposition des mesures, à l'aide d'un estimateur de Kaplan­Meier et d'un modèle de risques proportionnels de Cox, en tenant compte de l'âge, du sexe, des comorbidités, du type de chirurgie et de l'année. RÉSULTATS: Nous avons recruté respectivement 3525 et 3007 patients de 50 ans ou plus, avant et après l'imposition des mesures. La proportion de patients qui ont été opérés à l'intérieur du délai préconisé a augmenté de 66,8 % à 84,6 %, la durée médiane du séjour hospitalier a diminué de 13,5 à 9,7 jours et le taux brut de mortalité perhospitalière a diminué de 9,6 % à 6,8 % (tous, p < 0,001). Les analyses ajustées ont révélé une réduction de la mortalité perhospitalière (risque relatif [RR] 0,68, intervalle de confiance [IC] de 95 % 0,57­0,81) et à 1 an (RR 0,87, IC de 95 % 0,79­0,96). Indépendamment de la période (avant ou après l'imposition des mesures), le fait d'être opéré dans les 48 heures s'est accompagné d'une diminution du risque ajusté de mortalité en cours d'hospitalisation (RR = 0,51, IC de 95 % 0,41­0,63) et dans l'année suivant la chirurgie (RR 0,72, IC de 95 % 0,64­0,80). CONCLUSION: Des efforts coordonnés à l'échelle des régions visant à accélérer l'accès à la chirurgie pour fracture de la hanche peuvent réduire avec succès le délai avant la chirurgie et abréger le séjour hospitalier, en plus de diminuer la mortalité ajustée en cours d'hospitalisation et après 1 an.

Enabling patient-centred policy for electronic consultations: A qualitative analysis of discussions from a stakeholder meeting.

INTRODUCTION: To support the expansion of a successful regional electronic consultation (eConsult) service, we hosted a full-day national eConsult Policy Think Tank, connecting health-services researchers, clinicians, patients and policymakers to discuss policy considerations related to eConsult. In this paper, we assess the discussion arising from the Think Tank to identify and understand the policy enablers and barriers to the national spread and scale of eConsult services across Canada. METHODS: We conducted a constant comparative thematic analysis of stakeholder discussions captured during the Think Tank held in Ottawa, Canada, on 5 December 2016. Forty-seven participants attended and debated the following topic areas: (a) delivery of services and standards; (b) payment considerations; and (c) equitable access. The meeting was recorded, and verbatim transcripts were analysed using qualitative approaches. RESULTS: We identified four themes affecting spread and scale of eConsult innovation from a policy perspective: (a) patient-centredness; (b) value; (c) regulation; and (d) considerations for spread and scale. Patient-centredness was viewed as a foundational principle upon which policy shifts should be guided. Active participation of patient partners transitioned the discussions and resulting recommendations from provider-centred to patient-centred thinking around the relevant policy issues, explicitly demonstrating the importance of patient involvement in healthcare policy decision making. DISCUSSION: eConsult was viewed as a high-value, disruptive innovation with great potential to transform access to specialists in Canada. A patient-centred approach to policy change (and not just healthcare delivery) was identified as a novel yet critical enabler to the scale and spread of eConsult across Canada.

Supporting the spread and scale-up of electronic consultation across Canada: cross-sectional analysis.

OBJECTIVE: To examine the process of implementing an electronic consultation (eConsult) service and evaluate its impact along key metrics outlined by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. DESIGN: Cross-sectional study. SETTING: Clinics using eConsult in four provinces across Canada: Alberta, Manitoba, Quebec and Newfoundland and Labrador. PARTICIPANTS: All eConsult cases submitted in four participating provinces were included. INTERVENTION: The eConsult service is a secure online application that allows primary care providers and specialists to communicate regarding a patient's care. We measured the impact using system utilisation data and mandatory close-out surveys completed at the end of each eConsult. MAIN OUTCOME MEASURES: Implementation progress and impact were examined using the five categories outlined by the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance. RESULTS: Four provinces provided data from different periods, ranging from 4 years (Alberta) to 10 months (Manitoba). Total cases completed ranged from 96 (Manitoba) to 6885 (Alberta). Newfoundland had the largest menu of available specialties (n=35), while Alberta and Quebec had the smallest (n=22). The most frequently requested groups varied across provinces, with only endocrinology appearing in the top five for all provinces. The average specialist response time ranged from 3 days (Manitoba) to 16.7 days (Alberta). Between 54% (Newfoundland) and 66% (Manitoba) of cases resulted in new or additional information. Primary care providers avoided completing referrals they had originally considered in 36% (Newfoundland) to 53% of cases (Manitoba), while only between 27 % (Quebec) and 29% (Newfoundland) of cases resulted in a referral. In every province, services demonstrated higher rates of usage in their last quarter of data than their first. CONCLUSIONS: eConsult was successfully implemented in four new provinces across Canada. Implementation strategies and scope varied, but services demonstrated substantial consistency on several key metrics, most notably on whether new information was learnt and impact on decision to refer.

Development and validation of a predictive model for all-cause hospital readmissions in Winnipeg, Canada.

OBJECTIVE: A number of predictive models have been developed to identify patients at risk of hospital readmission. Most of these have focused on readmission within 30 days of discharge. We used population-based health administrative data to develop a predictive model for hospital readmission within 12 months of discharge in Winnipeg, Canada. METHODS: This was a retrospective cohort study with derivation and validation data sets. Multivariable logistic regression analyses were performed and factors significantly associated with readmission were selected to construct a risk scoring tool. RESULTS: Several variables were identified that predicted readmission (i.e. older age, male, at least one hospital admission in the previous two years, an emergent (index) hospital admission, Charlson comorbidity score >0 and length of stay). Discrimination power was acceptable (C statistic =0.701). At a median risk score threshold, the sensitivity, specificity, positive and negative predictive values were 45.5%, 79%, 68.8% and 58.6%. CONCLUSIONS: This predictive model demonstrated that hospital readmission within 12 months of discharge can be reasonably well predicted based on administrative data. It will help health care providers target interventions to prevent unnecessary hospital readmissions.

Agent based modeling of "crowdinforming" as a means of load balancing at emergency departments.

This work extends ongoing development of a framework for modeling the spread of contact-transmission infectious diseases. The framework is built upon Agent Based Modeling (ABM), with emphasis on urban scale modelling integrated with institutional models of hospital emergency departments. The method presented here includes ABM modeling an outbreak of influenza-like illness (ILI) with concomitant surges at hospital emergency departments, and illustrates the preliminary modeling of 'crowdinforming' as an intervention. 'Crowdinforming', a component of 'crowdsourcing', is characterized as the dissemination of collected and processed information back to the 'crowd' via public access. The objective of the simulation is to allow for effective policy evaluation to better inform the public of expected wait times as part of their decision making process in attending an emergency department or clinic. In effect, this is a means of providing additional decision support garnered from a simulation, prior to real world implementation. The conjecture is that more optimal service delivery can be achieved under balanced patient loads, compared to situations where some emergency departments are overextended while others are underutilized. Load balancing optimization is a common notion in many operations, and the simulation illustrates that 'crowdinforming' is a potential tool when used as a process control parameter to balance the load at emergency departments as well as serving as an effective means to direct patients during an ILI outbreak with temporary clinics deployed. The information provided in the 'crowdinforming' model is readily available in a local context, although it requires thoughtful consideration in its interpretation. The extension to a wider dissemination of information via a web service is readily achievable and presents no technical obstacles, although political obstacles may be present. The 'crowdinforming' simulation is not limited to arrivals of patients at emergency departments due to ILI; it applies equally to any scenarios where patients arrive in any arrival pattern that may cause disparity in the waiting times at multiple facilities.

Reactividad vascular pulmonar y formación de edema en presencia de inhibidores de prostaglandinas en el lóbulo canino aislado / Pulmonary vascular reactivity and edema formation in the presence of prostaglandins' inhibitors. Study in isolated canine pulmonary lobule

El propósito de este trabajao es el estudio de la reactividad vascular pulmonar y la formación de edema al acentuar la vasoconstricción arterial pulmonar a la hipoxia mediante un inhibidor de la producción de prostaglandinas: el ácido tiaprofénico. Se utilizó un modelo experimental ex-vivo de lóbulo canino aislado. La formación de edema fue cuantificada utilizando el método de espectrofotometría, previamente publicado por nosotros. Se estudiaron 6 lóbulos caninos, todos bajo dos condiciones: normoxia (FIO2 21 por ciento) e hipoxia (FIO2 5 por ciento); en cuatro de los seis experimentos de iniciaron con el periodo de normoxia y en dos en condición de hipoxia. El ácido tiaprofénico se administró en los 6 perros en forma intravenosa 2 horas antes de extraer los lóbulos. Resultados: No se observó con cambios significativos en la tasa de filtración, periodo de normoxia: 0.42 ñ 0.41, periodo de hipoxia: 0.37 ñ 0.51 ml/min/100 g de tejido pulmonar. La presión arterial pulmonar se incrementó significativamente, normoxia basal: 25.1 ñ 6.21 y durante la hipoxia: 37 ñ 7.19 cm de agua (delta de presión 12.0 ñ 1.2) con P< 0.001. Conclusiones: la reactividad vascular en hipoxia se acentuó significativamente con la administración de ácido tiaprofénico, no se demostró incremento en la permeabilidad vascular pulmonar o incremento en las tasas de filtración capilar

Espectrofotometría continua como método para el estudio del edema pulmonar en una preparación de lóbulo pulmonar canino aislado / Continuous spectrophotometry as a method to study pulmonary edema in an isolated canine pulmonary lobe

El objeto del presente trabajo es dar a conocer el método espectrofotométrico para la cuantificación de edema pulmonar en un modelo de lóbulo pulmonar canino aislado ex vivo. Este método espectrofotométrico se basa en la medición continua de la transmisión de la luz en una columna de sangre, la que es proporcional a los cambio en el hematocrito. Usando una segunda fuente de luz con distinta longitud de onda, se logró cuantificar en forma continua la concentración plasmática de proteínas teñidas con azul de Evans y así calcular las características del líquido filtrado y obtener el coeficiente de reflexión de las proteínas a su paso por la membrana. La cantidad de edema pulmonar se cuantificó en 10 lóbulos caninos aislados ex vivo. El coeficiente filtración al máximo nivel de presión capilar fue de 0.6 ñ 0.4 ml/min (1.3 ñ 0.9 ml/min/100 g de tejido pulmonar) y el coeficiente de relfexión de las proteínas fue de 0.53 ñ 0.07. Tenemos ahora la capacidad de seguir y cuantificar la producción de edema pulmonar en un modelo de lóbulo pulmonar aislado ex vivo, utilizando el método espectrofotométrico. Este método tiene la ventaja de una gran exactitud, de ser independiente de cambios vasculares y además de tener la posibilidad de medir el transporte de solutos a nivel de la membrana capilar