Deciding to Attend the Emergency Department: Experiences of Patients With Inflammatory Arthritis.

OBJECTIVE: Patients may use emergency departments (EDs) to meet their health needs when ambulatory care systems are not sufficient. We aim to describe contributing factors to the decision made by persons with inflammatory arthritis (IA) to present to the ED, as well as their experiences of ED care and postdischarge follow-up. METHODS: An embedded mixed-methods approach was taken to contextualize quantitative data with associated free-text responses from an online survey distributed to residents of Alberta with a known IA condition and an ED visit. RESULTS: Eighty-two persons (63% aged 16-55 years, 48% female, 50% urban residents) with rheumatoid arthritis (48%), psoriatic arthritis (12%), spondyloarthritis (6%), or gout (34%) completed the survey. Presenting concerns were arthritis flare (37%), chest pain (15%), injury (12%), and infection (11%). Of all visits, 29% proceeded directly to the ED, 35% attempted accessing ambulatory care first, and 32% arrived for a return visit. In presentations for arthritis flare, patients were aware of the rheumatology service being contacted by the ED provider for advice in just 9% of events. Challenges in healthcare system coordination and system pressures resulted in patients requiring ED attendance to assess their concern. The quality of communication and relationality developed between patients with IA and healthcare providers informed experiences of ED care. CONCLUSION: Modifying rheumatology ambulatory care models could better meet patient needs and ultimately reduce avoidable ED use by patients with IA.

Modelling population-level and targeted interventions of weight loss on chronic disease prevention in the Canadian population.

Obesity is a known risk factor for major chronic diseases. Prevention of chronic disease is a top global priority. The study aimed to model scenarios of population-level and targeted weight loss interventions on 10-year projected risk of chronic disease in Canada using a population-level risk prediction algorithm. The validated Chronic Disease Population Risk Tool (CDPoRT) forecasts 10-year risk of chronic disease in the adult population. We applied CDPoRT to the 2013/14 Canadian Community Health Survey to generate prospective chronic disease estimates for adults 20 years and older in Canada (n = 83,220). CDPoRT was used to model the following scenarios: British Columbia's (BC) and Quebec's (QC) provincial population-level weight reduction targets, a population-level intervention that could achieve weight loss, targeted weight loss interventions for overweight and obese groups, and the combination of a population-level and targeted weight loss intervention. We estimated chronic disease risk reductions and number of cases prevented in each scenario compared with the baseline. At baseline, we predicted an 18.4% risk and 4,151,929 new cases of chronic disease in Canada over the 10-year period. Provincial weight loss targets applied to the Canadian population estimated chronic disease reductions of 0.6% (BC) and 0.1% (QC). The population-level intervention estimated a greater reduction in risk (0.2%), compared to the targeted interventions (0.1%). The combined approach estimated a 0.3% reduction in chronic disease risk. Our modelling predicted that population-level approaches that achieve weight loss in combination with targeted weight loss interventions can substantially decrease the chronic disease burden in Canada.

Examining the role of Indigenous primary healthcare across the globe in supporting populations during public health crises.

When health systems are overwhelmed during a public health crisis regular care is often delayed and deaths result from lapses in routine care. Indigenous primary healthcare (PHC) can include a range of programmes that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health (SDoH) and a focus on redressing health inequities. We examined how Indigenous PHC mobilises and innovates during a public health crisis to address patient needs and the broader SDoH. A rapid review methodology conducted from January 2021 - March 2021 was purposefully chosen given the urgency with COVID-19, to understand the role of Indigenous PHC during a public health crisis. Our review identified five main themes that highlight the role of Indigenous PHC during a public health crisis: (1) development of culturally appropriate communication and education materials about vaccinations, infection prevention, and safety; (2) Indigenous-led approaches for the prevention of infection and promotion of health; (3) strengthening intergovernmental and interagency collaboration; (4) maintaining care continuity; and (5) addressing the SDoH. The findings highlight important considerations for mobilising Indigenous PHC services to meet the needs of Indigenous patients during a public health crisis such as the COVID-19 pandemic.

Associations between the self-reported happy home lives and health of Canadian school-aged children: An exploratory analysis with stratification by level of relative family wealth.

BACKGROUND: Connections between home life, level of family wealth, happiness and health are strong, yet these relationships are complex and for Canadian adolescents not well studied. The objective of this investigation was to explore associations between aspects of health and self-reported happy home life among Canadian adolescents aged 10-16 years and to determine if level of self-reported relative family wealth modified associations. MATERIAL AND METHODS: This was a secondary analysis of Canadian data from the 2018 Health Behaviour in School-aged Children (HBSC) study (n=21,745). Theory drove the selection of 26 health-related HBSC variables. Bivariate analyses and calculation of adjusted odds ratios, considering level of self-reported relative family wealth in a stratified analysis, were undertaken. RESULTS: Overall, proximal, micro-level factors were most strongly associated with reports of a happy home life, with distal, macro-level factors less strongly associated. Differences existed between the health and home-life associations for adolescents of different levels of self-reported relative family wealth indicating effect modification. Family support and levels of adolescent self-reported overall health and mental health were common factors that were strongly associated with reporting a happy home life. CONCLUSION: We believe happy home lives are central and critical for thriving youth and families. This was an exploratory analysis. Many of the factors and relationships in this study are potentially modifiable and represent important possible areas of future focus for adolescent and family health improvement.

Global Rural and Remote Patients With Rheumatoid Arthritis: A Systematic Review.

OBJECTIVE: Rural and remote patients with rheumatoid arthritis (RA) are at risk for inequities in health outcomes based on differences in physical environments and health care access potential compared to urban populations. The aim of this systematic review was to synthesize epidemiology, clinical outcomes, and health service use reported for global populations with RA residing in rural and remote locations. METHODS: Medline, Embase, HealthStar, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library were searched from inception to June 2019 using librarian-developed search terms for RA and rural and remote populations. Peer-reviewed published manuscripts were included if they reported on epidemiologic, clinical, or health service use outcomes. RESULTS: Fifty-four articles were included for data synthesis, representing studies from all continents. In 11 studies in which there was an appropriate urban population comparator, rural and remote populations were not at increased risk for RA; 1 study reported increased prevalence, and 5 studies reported decreased prevalence in rural and remote populations. Clinical characteristics of rural and remote populations in studies with an appropriate urban comparator showed no significant differences in disease activity measures or disability, but 1 study reported worse physical function and health-related quality of life in rural and remote populations. Studies reporting on health service use provided evidence that rural and remote residence adversely impacts diagnostic time, ongoing follow-up, access to RA-care-related practitioners and services, and variation in medication access and use, with prominent heterogeneity noted between countries. CONCLUSION: RA epidemiology and clinical outcomes are not necessarily different between rural/remote and urban populations within countries. Rural and remote patients face greater barriers to care, which increases the risk for inequities in outcomes.

Human factors applications in the design of decision support systems for population health: a scoping review.

INTRODUCTION: Public health professionals engage in complex cognitive tasks, often using evidence-based decision support tools to bolster their decision-making. Human factors methods take a user-centred approach to improve the design of systems, processes, and interfaces to better support planning and decision-making. While human factors methods have been applied to the design of clinical health tools, these methods are limited in the design of tools for population health. The objective of this scoping review is to develop a comprehensive understanding of how human factors techniques have been applied in the design of population health decision support tools. METHODS AND ANALYSIS: The scoping review will follow the methodology and framework proposed by Arksey and O'Malley. We include English-language documents between January 1990 and August 2021 describing the development, validation or application of human factors principles to decision support tools in population health. The search will include Ovid MEDLINE: Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE 1946-present; EMBASE, Scopus, PsycINFO, Compendex, IEEE Xplore and Inspec. The results will be integrated into Covidence. First, the abstract of all identified articles will be screened independently by two reviewers with disagreements being resolved by a third reviewer. Next, the full text for articles identified as include or inconclusive will be reviewed by two independent reviewers, leading to a final decision regarding inclusion. Reference lists of included articles will be manually screened to identify additional studies. Data will be extracted by one reviewer, verified by a second, and presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. ETHICS AND DISSEMINATION: Ethics approval is not required for this work as human participants are not involved. The completed review will be published in a peer-reviewed, interdisciplinary journal.

Informing the GRADE evidence to decision process with health equity considerations: demonstration from the Canadian rheumatoid arthritis care context.

OBJECTIVES: Health equity is a priority for clinical and public health practice and promoted in GRADE's Evidence to Decision (EtD) Framework, yet there is still limited integration of specific equity considerations in chronic disease guideline development and implementation. Our objective was to embed equity considerations for upcoming Canadian Rheumatoid Arthritis treatment guidelines. STUDY DESIGN AND SETTING: In parallel with the Guidelines Committee process, considerations for six population groups (rural and remote residents, Indigenous Peoples, elderly persons with frailty, minority populations of first-generation immigrants and refugees, persons with low socioeconomic status or who are vulnerably housed, and sex and gender populations) based on literature reviews and key informant interviews were identified and contextualized to each step in the GRADE EtD framework. RESULTS: The EtD Framework domains relevant to rheumatoid arthritis treatment and management were analyzed through patient-centric, social determinant and economic lenses, while considering implementation feasibility. This determined tailored considerations relevant to recommendations for the priority populations to mitigate potential intervention-generated inequities. CONCLUSION: This approach provides a demonstration of the process of incorporating equity in the evidence to decision process and can be applied in future rheumatic disease guidelines while also informing a research agenda for equity in rheumatology outcomes.

Supporting Equity in Rheumatoid Arthritis Outcomes in Canada: Population-specific Factors in Patient-centered Care.

OBJECTIVE: Health equity considerations have not been incorporated into prior Canadian Rheumatology Association guidelines. Our objective was to identify the challenges and possible solutions to mitigate threats to health equity in rheumatoid arthritis (RA) care in Canada. METHODS: A consultation process informed selection of priority populations, determined to be rural and remote, Indigenous, elderly with frailty, first-generation immigrant and refugee, low income and vulnerably housed, and diverse gender and sex populations. Semistructured interviews were completed with patients with lived experience, healthcare providers, and equity-oriented researchers. These interviews probed on population factors, initial and ongoing healthcare access issues, and therapeutic considerations influencing RA care. Known or proposed solutions to mitigate inequities during implementation of service models for the population group were requested. The research team used a phenomenological thematic analysis model and mapped the data into a logic model. Solutions applicable to several population groups were proposed. RESULTS: Thirty-five interviews were completed to identify realities for each population in accessing RA care. Five themes emerged as primary solutions to population-based inequities, including actively improving the patient-practitioner relationship, increasing accessibility and coordination of care through alternative models of care, upholding autonomy in treatment selection while actively addressing logistical barriers and individualized therapy needs, collaborating with health supports valued by the patient, and being advocates for policy change and health system restructuring to ensure appropriate resource redistribution. CONCLUSION: The challenges for populations facing inequities in rheumatology care and promising solutions should inform guideline development and implementation, policy change, and health system restructuring.