Self-care interventions to assist family physicians with mental health care of older patients during the COVID-19 pandemic: Feasibility, acceptability, and outcomes of a pilot randomized controlled trial.

BACKGROUND: The COVID-19 pandemic has required family physicians to rapidly address increasing mental health problems with limited resources. Vulnerable home-based seniors with chronic physical conditions and commonly undermanaged symptoms of anxiety and depression were recruited in this pilot study to compare two brief self-care intervention strategies for the management of symptoms of depression and/or anxiety. METHODS: We conducted a pilot RCT to compare two tele-health strategies to address mental health symptoms either with 1) validated CBT self-care tools plus up to three telephone calls from a trained lay coach vs. 2) the CBT self-guided tools alone. The interventions were abbreviated from those previously trialed by our team, to enable their completion in 2 months. Objectives were to assess the feasibility of delivering the interventions during a pandemic (recruitment and retention); and assess the comparative acceptability of the interventions across the two groups (satisfaction and tool use); and estimate preliminary comparative effectiveness of the interventions on severity of depression and anxiety symptoms. Because we were interested in whether the interventions were acceptable to a wide range of older adults, no mental health screening for eligibility was performed. RESULTS: 90 eligible patients were randomized. 93% of study completers consulted the self-care tools and 84% of those in the coached arm received at least some coaching support. Satisfaction scores were high among participants in both groups. No difference in depression and anxiety outcomes between the coached and non-coached participants was observed, but coaching was found to have a significant effect on participants' use and perceived helpfulness of the tools. CONCLUSION: Both interventions were feasible and acceptable to patients. Trained lay coaching increased patients' engagement with the tools. Self-care tools offer a low cost and acceptable remote activity that can be targeted to those with immediate needs. While effectiveness results were inconclusive, this may be due to the lack of eligibility screening for mental health symptoms, abbreviated toolkit, and fewer coaching sessions than those used in our previous effective interventions. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT0460937.

Adaptation and outcomes of a lay-guided mental health self-care model: Results of six trials.

OBJECTIVE: To synthesize results of six controlled trials of self-care interventions for depression and/or anxiety, focusing on five trials in which lay guidance was compared to self-directed use of the same self-care tools. METHODS: The trials were conducted in Canada in different target populations. Self-care tools were adapted to each population. Guidance was provided in 3-15 calls over a period of 6-26 weeks. Depression and/or anxiety were assessed at follow-up (6-26 weeks). Pooled analyses used a meta-analytic approach. Engagement with the self-care tools was compared using the standardized difference or Cohen's d effect size. RESULTS: In studies with homogeneous outcomes (three for depression, four for anxiety), the pooled effect sizes of guidance vs. self-directed use of the self-care tools were 0.36 (95% CI 0.10, 0.62, N = 235) for depression and 0.21 (95% CI -0.03, 0.44, N = 285) for anxiety. Guidance consistently led to greater engagement with the tools. CONCLUSIONS: The intervention model is a potentially sustainable and accessible alternative to professionally guided self-care for people with mild-moderate depression. Factors which may have limited implementation success include: co-interventions, reduced number of guide calls (3 vs 6 or more), and delivery to dyads (patient-caregiver).

Development of an individual index of social vulnerability that predicts negative healthcare events: a proposed tool to address healthcare equity in primary care research and practice.

PURPOSE: Socially disadvantaged patients may lack self-efficacy to navigate a complex health system making them vulnerable to healthcare inequity. We aimed to develop an Index of social vulnerability that predicts increased risk of negative healthcare events (e.g. emergency hospitalization), independent of chronic disease burden. The analysis illustrates the conceptual and practical steps leading to the development of a pragmatic Index of social vulnerability to limited healthcare self-efficacy. METHODS: Using data from a 3-year cohort of 2507 adult primary care patients in Québec (Canada), we applied two complementary structural equation modelling approaches-Partial Least Squares Path Modelling (PLS-PM) and Multiple indicators and Multiple Causes (MIMIC) modelling-to identify a minimal set of social characteristics that could be summed into an Index related to limited healthcare self-efficacy. We then used logistic regression to determine if the Index predicted: hospital emergency department use; hospital admissions; unmet need for care, and others. We privileged parsimony over explanatory capacity in our analytic decisions to make the Index pragmatic for epidemiologic and clinical use. RESULTS: The Individual Social Vulnerability Index is the weighted sum of five indicators: two indicators of social support; educational achievement; financial status; limited language proficiency. The Index predicts increased likelihood of all negative healthcare outcomes except unmet need, with a clear threshold at Index ≥ 2. The effect is independent of chronic disease burden. CONCLUSION: When social deficits outweigh social assets by two or more (Index ≥ 2), there is an increased risk of negative healthcare events beyond the risk attributable to poor health. The Index is a pragmatic tool to identify a minority of patients who will require additional support to receive equitable healthcare.

Effectiveness of a Multi-component Delirium Prevention Program Implemented on General Medicine Hospital Units: an Interrupted Time Series Analysis.

BACKGROUND: Delirium is among the most prevalent harmful events in hospitals that is associated with an elevated risk for severe outcomes such as functional decline, falls, longer length of stay, and increased mortality. OBJECTIVE: To evaluate the impact of the implementation of a multi-component delirium program on the prevalence of delirium and the incidence of falls among patients staying on general medicine inpatient hospital units. DESIGN: A pre-post intervention study using retrospective chart abstraction and interrupted time series analysis. COHORT: Patients were selected from adult patients that stayed at least 1 day on one of the five general medicine units in a large community hospital in Ontario, Canada. A total of 16 random samples of 50 patients per month for 8 consecutive months pre-intervention (October 2017 to May 2018) and 8 months post intervention (January 2019 to August 2019) were selected for a total of 800 patients. There were no exclusion criteria. INTERVENTION: The delirium program included multiple components: education of staff and hospital leadership, twice per day bed-side screen for delirium, non-pharmacological and pharmacological prevention, and intervention strategies and a delirium consultation team. MEASUREMENT: Delirium prevalence was assessed using the evidence-based delirium chart abstraction method, CHART-del. Demographic data as well as fall incidence were also collected. RESULT: Our evaluation showed that the implementation of a multicomponent delirium program led to a reduction in delirium prevalence and fall incidences. The reduction in both delirium and falls was the largest for patients in the ages between 72 and 83 years old and varied across inpatient units. CONCLUSION: A multi-component delirium program to improve the prevention, recognition, and management of delirium reduces the prevalence of delirium and fall incidence among patients in general medicine units.

Multi-center validation of Catquest-9SF visual function questionnaire in Ontario, Canada.

PURPOSE: To investigate the psychometric performance and responsiveness of Catquest-9SF, a patient-reported questionnaire developed to evaluate visual function as related to daily tasks, in patients referred for cataract surgery in Ontario, Canada. METHODS: This is a pooled analysis on prospective data collected for previous projects. Subjects were recruited from three tertiary care centers in Peel region, Hamilton, and Toronto, Ontario, Canada. Catquest-9SF was administered pre-operative and post-operatively to patients with cataract. Psychometric properties, including category threshold order, infit/outfit, precision, unidimensionality, targeting, and differential item functioning were tested using Rasch analysis with Winsteps software (v.4.4.4) for Catquest-9SF. Responsiveness of questionnaire scores to cataract surgery was assessed. RESULTS: 934 patients (mean age = 71.6, 492[52.7%] female) completed the pre- and post-operative Catquest-9SF questionnaire. Catquest-9SF had ordered response thresholds, adequate precision (person separation index = 2.01, person reliability = 0.80), and confirmed unidimensionality. The infit range was 0.75-1.29 and the outfit range was 0.74-1.51, with one item ('satisfaction with vision') misfitting (outfit value = 1.51). There was mistargeting of -1.07 in pre-operative scores and mistargeting of -2.43 in both pre- and post-operative scores, meaning that tasks were relatively easy for respondent ability. There was no adverse differential item functioning. There was a mean 1.47 logit improvement in Catquest-9SF scores after cataract surgery (p<0.001). CONCLUSION: Catquest-9SF is a psychometrically robust questionnaire for assessment of visual function in patients with cataract in Ontario, Canada. It is also responsive to clinical improvement after cataract surgery.

Validation of a novel patient satisfaction questionnaire for preoperative fasting in cataract surgery: a discrimination analysis.

OBJECTIVE: Preoperative fasting is routinely performed to prevent anaesthesia-related pulmonary aspiration. To capture patients' experiences with preoperative fasting, a 13-item questionnaire was developed and validated using Rasch analysis and shortened to 6 items. This extension study aims to assess this questionnaire's ability to discriminate between participants with a short versus long duration of fasting and early versus late day surgery. DESIGN: Single-centred cross-sectional study. PARTICIPANTS: Subjects were recruited via consecutive sampling of cataract patients on surgery day at Kensington Eye Institute in Toronto from February to December 2019. METHODS: A validated preoperative fasting questionnaire was administered. Discriminative ability was assessed by comparing responses in patients scheduled for surgery in the morning (8:00 am-12:00 pm) versus afternoon (12:00 pm-3:30 pm) and fasting for short (≤8 hours) versus long (>8 hours) duration. Diagnostic ability of the 6-item questionnaire relative to the 13-item questionnaire was assessed with receiver operating characteristics curve analysis. RESULTS: A total of 164 patients (mean age 70.8 ± 10.0 years; 57% female) were included. Total scores of patients having surgery in the morning were greater (i.e., less fasting-related burden) than in the afternoon (p = 0.04). There was no significant difference in scores between patients fasting for a short versus long duration (p > 0.05). Receiver operating characteristics curve analysis showed excellent diagnostic ability of the 6-item questionnaire relative to the 13-item version (area under the curve = 0.964). CONCLUSION: The 6-item questionnaire for fasting-related burden has excellent discriminative ability between early versus late surgery patients. The time fasting while awake may be a more relevant predictor of fasting-related burden relative to the total duration of fasting.

An Integrated Care Model to Support Adolescents With Diabetes-related Quality-of-life Concerns: An Intervention Study.

BACKGROUND: Our aim in this study was to determine whether participating in an integrated stepped care model for adolescents with type 1 diabetes (T1D) would lead to improvements in overall quality of life (QoL), diabetes-related quality of life (DRQoL) and glycated hemoglobin (A1C) levels compared with usual care. METHODS: A nonrandomized, 2-group, pre/post, delayed-intervention design was used for this study. The Mind Youth Questionnaire (MY-Q) was used to assess QoL and DRQoL. Adolescents attending the diabetes clinic using the stepped care model formed the intervention group (n=77). These adolescents completed the MY-Q, and the identified concerns were discussed and addressed with them by their care team as part of the care model. Adolescents attending a pediatric diabetes clinic on another site completed the MY-Q as a comparison group (n=39), results were not shared with their care team, and they received the standard care. RESULTS: There were 116 adolescents between 13 to 17 years of age, who completed the MY-Q on 2 occasions. Baseline data were obtained on the first occasion, and, on the second occasion, an average of 12 months later, there was a follow-up assessment. At follow-up, adolescents in the intervention group had a significantly higher overall QoL and reported significantly fewer concerns on DRQoL domains than those in the comparison group. Participation in the intervention group, however, did not lead to improvements in A1C. CONCLUSION: This study shows that implementing an integrated stepped care model within an interprofessional pediatric diabetes clinic can lead to the improvement of adolescents' overall QoL and DRQoL.

An observational study evaluating the impact on prostate patient outcomes and experiences when radiation therapists use a standard grading system tool to assess and document treatment-related toxicities and interventions.

BACKGROUND/PURPOSE: Men undergoing radiation therapy (RT) treatment for prostate cancer (PC) often experience acute urinary, bowel, sexual, and hormonal toxicities. Timely screening, management, and documentation of these toxicities is an integral part of clinician practice, ensuring patients receive the care they require. Various screening tools, completed by either the patient or the clinician, are available, which allow clinicians to collect and respond to these toxicity outcomes; however there is a paucity of literature regarding the effective use and timing of these tools during RT treatment. This study aims to evaluate the feasibility of conducting comprehensive toxicity screening and symptom management using a toxicity screening tool in one of the busiest RT departments in Canada. Specifically, the use of a toxicity screening tool and its effect on the quality of toxicity documentation, operational impact, and patient reported outcomes (PRO). METHODS: 90 consented patients were allocated to either the structured or non-structured arm. Patients in the structured arm were assessed weekly by radiation therapists for 13 toxicities across four domains (bladder, bowel, hormonal, and sexual), using an in-house developed structured questionnaire, known as the Grid, to complete the National Cancer Institute's Common Toxicity Criteria for Adverse Events v3 (CTCAEv3). Patients in the non-structured arm were assessed and had free text clinical documentation charted according to current department policy. The Expanded Prostate Cancer Index Composite (EPIC), a PRO tool to evaluate patient function and bother after prostate cancer treatment, was completed by all study patients on a weekly basis. Statistical analysis compared documentation completeness, EPIC scores, patient satisfaction, and operational impact between study arms, as well as evaluated optimal timing of toxicity assessments. RESULTS: Assessment of the non-structured arm for completeness revealed an inconsistent and insufficient amount of documentation for the bladder and bowel domains. As for both the sexual and hormonal domains, documentation was largely absent. There was no difference in EPIC scores and patient satisfaction scores between the structured arm and the non-structured arm. Evaluation of the timing of PROs showed significant week to week change for the bladder and bowel toxicities, but not the sexual and hormonal toxicities. Finally, the use of the Grid revealed no significant impact on daily operations, only increasing average treatment times by seven seconds, and did not create any additional workload for the oncologists. CONCLUSIONS: Use of the Grid increased documentation completeness without negatively impacting clinical flow or operations, despite the fact that PROs were not improved. Based on EPIC PRO scores, bladder and bowel toxicities should be evaluated on a weekly basis during RT treatment, while sexual and hormonal toxicities need only be evaluated monthly.

All together: Integrated care for youth with type 1 diabetes.

OBJECTIVE: We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression. RESEARCH DESIGN AND METHODS: The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods. RESULTS: There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team. CONCLUSION: The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

Predicting changes in cataract surgery health outcomes using a cataract surgery appropriateness and prioritization instrument.

OBJECTIVE: Determine whether items in a cataract surgery appropriateness and prioritization questionnaire can predict change in best corrected visual acuity (BCVA) and health related quality of life (HRQOL) following cataract surgery. METHODS: 313 patients with a cataract in Ontario, Canada were recruited to participate. BCVA was measured using the Snellen chart. HRQOL was measured using a generic instrument (EQ5D), a visual functioning instrument (Catquest-9SF), and an appropriateness and prioritization instrument (17 items). Outcomes were measured preoperatively and 3-6 months postoperatively. Descriptive statistics were used to describe demographics and outcomes. For each appropriateness and prioritization questionnaire item, a one-way ANOVA was used to compare group means of the change in BCVA, EQ5D, and Catquest-9SF. RESULTS: Participants had a mean age of 69 years and were 56% female. BCVA improved in 81%, EQ5D in 49.6%, and Catquest-9SF score in 84% of patients. Improvement in both BCVA and Catquest-9SF scores were found in 68.5% of patients. The ANOVA showed a statistically significant association between a change in BCVA and the ability to participate in social life, and a statistically significant association between a change in Catquest-9SF and glare, extent of impairment in visual function, safety and injury concerns, ability to work and care for dependents, ability to take care of local errands, ability to assist others and ability to participate in social life. CONCLUSIONS: Almost all patients had improved BCVA and/or visual functioning after surgery. Seven variables from the cataract appropriateness and prioritization instrument were found to be predictors of improvement in Catquest-9SF measuring visual functioning.

Development and Validation of a Questionnaire Assessing Patient Distress from Preoperative Fasting in Cataract Surgery.

Purpose: To develop and psychometrically validate a questionnaire to measure patient distress with preoperative fasting related to cataract surgery.Methods: In this single-centered cross-sectional study, consecutive sampling of cataract patients was undertaken immediately preoperatively from February to December 2019. A questionnaire evaluating patient distress with fasting was designed and administered. Questionnaire development occurred in an iterative process and was conducted with consultation from expert investigators and patients. Validation and psychometric evaluation of the questionnaire were performed with Rasch analysis.Results: A preliminary version of the questionnaire was developed by 10 study investigators. Across five iterations of development, the questionnaire was administered to 186 cataract patients. Psychometric evaluation of the 13-item questionnaire demonstrated ordered thresholds, acceptable item calibration and fit, adequate internal consistency, ability to discriminate between three levels of distress from preoperative fasting and no notable differential item functioning. However, issues with mistargeting, clustering of items on the person-item map and multidimensionality remained. Given these concerns, 13 separate re-analyses were conducted via removal of certain items. A 6-item subset was determined to be well targeted, unidimensional, did not display item clustering and was able to discriminate between patients with high and low distress from preoperative fasting.Conclusion: A 6-item questionnaire is a valid, psychometrically robust and reliable measure for the assessment of patient distress with preoperative fasting in cataract surgery. Items include hunger, thirst, hoarseness, weakness, anxiety and nausea. Future studies should seek to validate this questionnaire across a variety of sociodemographic contexts, languages and specialties.

Catquest-9SF questionnaire and eCAPS: Validation in a Canadian population.

BACKGROUND: Visual acuity alone has limitations in assessing a patient's appropriateness and prioritization for cataract surgery. Several tools, including the Catquest-9SF questionnaire and the electronic cataract appropriateness and priority system (eCAPS) have been developed to evaluate patients-reported visual function as related to day-to-day tasks. The aim of this study was to validate Catquest-9SF and eCAPS in a Canadian population and propose a shorter version of each, in an attempt to extend their applicability in clinical practice. METHODS: The English translation of the Swedish Catquest-9SF and eCAPS were self-administered separately in pre-operative patients in tertiary care in Peel region, Ontario. Rasch analysis was used to validate both scales and assess their psychometric properties, such as category threshold order, item fit, unidimensionality, precision, targeting, and differential item functioning. RESULTS: A total of 313 cataract patients (mean age = 69.1, 56.5% female) completed the Catquest-9SF and eCAPS. Catquest-9SF had ordered response thresholds, adequate precision (person separation index = 2.09, person reliability = 0.81), unidimensionality and no misfits (infit range 0.75-1.35, outfit range 0.83-1.36). There mean for patients was equal to -1.43 (lower than the mean for items which is set automatically at zero), meaning that tasks were relatively easy for respondent ability. eCAPS had 3 items that misfit the Rasch model and were excluded (infit range 0.82-1.30, outfit range 0.75-1.36). Precision was inadequate (person separation index = 0.19, person reliability = 0.04). 78.8% of subjects scored≤9 (answered that they had no issues for most questions). CONCLUSIONS: Catquest-9SF demonstrated good psychometric properties and is suitable for assessing visual function of care-seeking patients referred for cataract surgery in Ontario, Canada. There was some mistargeting, suggesting that the tasks were relatively easy to perform, which is consistent with previous research. On the contrary, eCAPS is not sensitive in differentiating patients who had impaired visual functioning.