Community paramedicine: A systematic review of program descriptions and training.

OBJECTIVES: The aim of this study is to identify the types of community paramedicine programs and the training for each. METHODS: A systematic review of MEDLINE, Embase, grey literature, and bibliographies followed a search strategy using common community paramedicine terms. All studies published in English up to January 22, 2018, were captured. Screening and extraction were completed in duplicate by two independent reviewers. The Mixed Methods Appraisal Tool (MMAT) was used to assess studies' methodological quality (full methodology on PROSPERO: CRD42017051774). RESULTS: From 3,004 papers, there were 64 papers identified (58 unique community paramedicine programs). Of the papers with an appraisable study design (40.6%), the median MMAT score was 3 of 4 criteria met, suggesting moderate quality. Programs most often served frequent 911 callers (48.3%) and individuals at risk for emergency department admission, readmission, or hospitalization (41.4%); and 70.7% of programs were preventive home visits. Common services provided were home assessment (29.5%), medication management (39.7%), and referral and/or transport to community services (37.9%); and 77.6% of programs involved interprofessional collaboration. Community paramedicine training was described by 57% of programs and expanded upon traditional paramedicine training and emphasized technical skills. Study heterogeneity prevented meta-analysis. CONCLUSION: Community paramedicine programs and training were diverse and allowed community paramedics to address a spectrum of population health and social needs. Training was poorly described. Enabling more programs to assess and report on program and training outcomes would support community paramedicine growth and the development of formalized training or education frameworks.

OBJECTIF: L'étude visait à relever les différents types de programmes de paramédecine communautaire et à décrire la formation donnée dans chacun d'eux. MÉTHODE: Une revue systématique des bases de données MEDLINE et Embase, de la documentation parallèle ainsi que de bibliographies a été entreprise à la suite d'une stratégie de recherche élaborée à l'aide de termes utilisés souvent en paramédecine communautaire. Ont été saisies toutes les études publiées en anglais jusqu'au 22 janvier 2018. Le tri et l'extraction des données ont été faits en double, par deux examinateurs indépendants. L'évaluation de la qualité méthodologique des études a été réalisée à l'aide de l'instrument Mixed Methods Appraisal Tool (MMAT) (description complète de la méthode dans PROSPERO : CRD42017051774). RÉSULTATS: Sur 3004 articles relevés, 64 ont été retenus (58 programmes distincts de paramédecine communautaire). Le score médian MMAT des articles présentant un plan d'étude susceptible d'évaluation (40,6%) était de 3 sur 4 quant au respect des critères établis, résultat évocateur d'une qualité moyenne. Les programmes avaient surtout pour cible les usagers fréquents du service 911 (48,3%) et les personnes susceptibles d'admission ou de réadmission au service des urgences, ou encore d'hospitalisation (41,4%); 70,7% des programmes portaient sur les visites préventives à domicile. Les services fréquemment offerts étaient les évaluations à domicile (29,5%), le contrôle de la pharmacothérapie (39,7%) et l'orientation ou le transport des malades vers des services communautaires (37,9%); 77,6% des programmes incluaient un volet de collaboration interprofessionnelle. La formation en paramédecine communautaire a été décrite par 57% des programmes et étendu sur le champ de pratique habituel de la paramédecine traditionnelle et visait l'acquisition de compétences techniques. Enfin, il n'a pas été possible de procéder à une méta-analyse en raison de l'hétérogénéité des études. CONCLUSION: Les programmes de paramédecine communautaire et la formation afférente sont diversifiés et permettent, de ce fait, aux professionnels du domaine de répondre à un large éventail de besoins sociaux et de besoins en matière de santé de la population. Pour ce qui est des descriptions de la formation donnée, elles étaient insuffisantes. Si les responsables de programmes étaient tenus d'évaluer les programmes et la formation offerte et de faire état des résultats obtenus, cela favoriserait le développement de la paramédecine communautaire et l'élaboration de cadres structurés d'études ou de formation.

Patterns of health service use in community living older adults with dementia and comorbid conditions: a population-based retrospective cohort study in Ontario, Canada.

BACKGROUND: Patients with dementia have increased healthcare utilization and often have comorbid chronic conditions. It is not clear if the increase in utilization is driven by dementia, the comorbidities or both. The objective of this study was to describe the number and types of comorbid conditions in a population-based cohort of older adults with dementia and how the level of comorbidity impacts dementia-related and non-dementia-related health service utilization. METHODS: This study is a retrospective cohort study using multiple linked administrative databases to examine health service utilization and costs of 100,630 community-living older adults living with pre-existing dementia in Ontario, Canada. Comorbid conditions and health service utilization were measured using administrative data (physician visits, emergency department visits, hospitalizations, and homecare contacts). RESULTS: Nearly all, 96.3 %, had at least one comorbid condition, while 18.4 % had five or more comorbid conditions. The most common comorbid conditions were hypertension (77.8 %), and arthritis (66.2 %). All types of utilization increased consistently with the number of comorbid conditions. The average number of dementia-related services tended to be similar across all levels of comorbidity while the average number of non-dementia related visits tended to increase with the level of comorbidity. CONCLUSIONS: Comorbidities in community-living older adults with dementia are common and account for a substantial proportion of health service use and costs in this population. Our results suggest that comprehensive programs that take a holistic view to identify the needs of patients in the context of other comorbidities are required for persons with dementia living in the community.

Accessing health care utilization databases for health research: a Canadian longitudinal study on aging feasibility study.

ABSTRACTOne of the keys to the success of the Canadian Longitudinal Study on Aging (CLSA) will be the leveraging of secondary data sources, particularly health care utilization (HCU) data. To examine the practical, methodological, and ethical aspects of accessing HCU data, one-on-one qualitative interviews were conducted with 53 data stewards and privacy commissioners/ombudsmen from across Canada. Study participants indicated that obtaining permission to access HCU data is generally possible; however, they noted that this will be a complex and lengthy process requiring considerable and meticulous preparatory work to ensure proper documentation and compliance with jurisdictional variations along legislative and policy lines.

Survey of interventions for the prevention and treatment of acute respiratory distress syndrome.

OBJECTIVE: To determine physicians' opinions and practices related to the management of patients with acute respiratory distress syndrome. DESIGN: Cross-sectional mail survey. SETTING: Province of Ontario, Canada. PARTICIPANTS: Physicians treating patients with acute respiratory distress syndrome at university-affiliated and unaffiliated hospitals. INTERVENTIONS: We searched the literature and consulted experts to generate a list of potential interventions for acute respiratory distress syndrome. Eight intensive care unit physicians selected the most relevant, available, and controversial of these interventions for prevention (n = 5) and treatment (n = 30). Fourteen physicians reviewed the questionnaire before administration to ensure clarity, realism, and clinical sensibility. We asked participants to report their views on a) the efficacy of each intervention; b) published research evaluating efficacy; c) the frequency with which they use each intervention; and d) determinants of utilization. MEASUREMENTS AND MAIN RESULTS: One hundred ten of 194 eligible physicians responded. Respondents varied considerably in their reported use of the 35 interventions. Although physicians cited published research findings as the most powerful determinant of prescribing these interventions, they were unaware of many relevant trials. Physicians also commonly cited "usual local practice" as a determinant of use, although formal practice guidelines were rarely in operation. Other variables directly associated with use of these interventions included increasing frequency of exposure to acute respiratory distress syndrome (p <.0001), increasing size of the intensive care unit in which physicians work (p =.004), and the presence of residents in the intensive care unit (p =.02). CONCLUSIONS: Wide variation in the management of acute respiratory distress syndrome appears related to limited awareness of relevant research, conflicting interpretations of research findings, and adherence to varying local practice patterns. Given physicians' desire to tailor their practice to research findings and to practice in a manner that is consistent with their local intensive care unit colleagues, future research and educational efforts related to evidence-based protocols for the management of patients with acute respiratory distress syndrome might be worthwhile.

Meta-analyses of therapies for postmenopausal osteoporosis. VII. Meta-analysis of calcium supplementation for the prevention of postmenopausal osteoporosis.

OBJECTIVE: To summarize controlled trials examining the effect of calcium on bone density and fractures in postmenopausal women. DATA SOURCE: We searched MEDLINE and EMBASE up to 1998 and the Cochrane Controlled Register up to 2000, and we examined citations of relevant articles and proceedings of international meetings. We contacted osteoporosis investigators to identify additional studies, and primary authors for unpublished data. STUDY SELECTION: We included 15 trials (1806 patients) that randomized postmenopausal women to calcium supplementation or usual calcium intake in the diet and reported bone mineral density of the total body, vertebral spine, hip, or forearm, or recorded the number of fractures, and followed patients for at least 1 yr. DATA EXTRACTION: For each trial, three independent reviewers assessed the methodological quality and extracted data. DATA SYNTHESIS: We found calcium to be more effective than placebo in reducing rates of bone loss after two or more years of treatment. The pooled difference in percentage change from baseline was 2.05% [95% confidence interval (CI) 0.24-3.86] for total body bone density, 1.66% (95% CI 0.92-2.39) for the lumbar spine, 1.64% (95% CI 0.70-2.57) for the hip, and 1.91% (95% CI 0.33-3.50) for the distal radius. The relative risk (RR) of fractures of the vertebrae was 0.77, with a wide CI (95% CI 0.54-1.09); the RR for nonvertebral fractures was 0.86 (95% CI 0.43-1.72). CONCLUSIONS: Calcium supplementation alone has a small positive effect on bone density. The data show a trend toward reduction in vertebral fractures, but do not meaningfully address the possible effect of calcium on reducing the incidence of nonvertebral fractures.