Interventions that have potential to help older adults living with social frailty: a systematic scoping review.

BACKGROUND: The impact of social frailty on older adults is profound including mortality risk, functional decline, falls, and disability. However, effective strategies that respond to the needs of socially frail older adults are lacking and few studies have unpacked how social determinants operate or how interventions can be adapted during periods requiring social distancing and isolation such as the COVID-19 pandemic. To address these gaps, we conducted a scoping review using JBI methodology to identify interventions that have the best potential to help socially frail older adults (age ≥65 years). METHODS: We searched MEDLINE, CINAHL (EPSCO), EMBASE and COVID-19 databases and the grey literature. Eligibility criteria were developed using the PICOS framework. Our results were summarized descriptively according to study, patient, intervention and outcome characteristics. Data synthesis involved charting and categorizing identified interventions using a social frailty framework.  RESULTS: Of 263 included studies, we identified 495 interventions involving ~124,498 older adults who were mostly female. The largest proportion of older adults (40.5%) had a mean age range of 70-79 years. The 495 interventions were spread across four social frailty domains: social resource (40%), self-management (32%), social behavioural activity (28%), and general resource (0.4%). Of these, 189 interventions were effective for improving loneliness, social and health and wellbeing outcomes across psychological self-management, self-management education, leisure activity, physical activity, Information Communication Technology and socially assistive robot interventions. Sixty-three interventions were identified as feasible to be adapted during infectious disease outbreaks (e.g., COVID-19, flu) to help socially frail older adults. CONCLUSIONS: Our scoping review identified promising interventions with the best potential to help older adults living with social frailty.

Evaluation of an online arts-based platform to support the health and well-being of older adults during the COVID-19 pandemic: a cross-sectional survey.

OBJECTIVES: The objective of this study was to conduct a formative evaluation of the Art Your Service (AYS) arts-based program to determine the program's potential for improving the social and physical well-being of older adults during the COVID-19 pandemic. DESIGN, SETTINGS AND PARTICIPANTS: An online questionnaire was administered to the AYS members who consented to be invited to participate in the study. Questionnaire items consisted of a Likert scale and open-ended questions delivered using an online platform (SurveyMonkey). Participants provided feedback on their perceptions and experiences of the AYS program, such as its impact on their health and well-being during the COVID-19 pandemic, the benefits and challenges of participating, and any suggestions for program improvement. OUTCOME MEASURES AND ANALYSIS: Quantitative data were analyzed using descriptive statistics (frequencies, means with standard deviations), and open-ended questions (qualitative data) were analyzed using content analysis. Outcomes included participant demographics, perceptions about the program, usability (System Usability Scale [SUS]), eHealth literacy (eHealth Literacy Scale), and social isolation (Lubben Social Network Scale; LSNS-6). RESULTS: Program participants revealed consistent patterns of their perceptions and experiences about the program, including a high satisfaction rate (95%) and a perceived positive impact on participants' health and well-being. The program sessions were perceived to be a well-organized, convenient, and safe way to engage with one another socially during the COVID-19 pandemic. The program usability was also perceived to be high (SUS mean score 86.2). Participants felt a sense of connectedness and had reduced feelings of social isolation. Most participants (75%) reported that the program improved their physical health. CONCLUSIONS: Findings from this formative evaluation study identified key strengths and opportunities to improve the Art Your Service arts-based program, which can be used to help enhance the program's functioning and long-term sustainability potential.

Guidelines and recommendations about virtual mental health services from high-income countries: a rapid review.

OBJECTIVES: This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services. DESIGN: We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings. METHODS: Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes. RESULTS: The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients' access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients. CONCLUSIONS: This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.

Recommendations for supporting healthcare workers' psychological well-being: Lessons learned during the COVID-19 pandemic.

Healthcare workers are at risk of adverse mental health outcomes due to occupational stress. Many organizations introduced initiatives to proactively support staff's psychological well-being in the face of the COVID-19 pandemic. One example is the STEADY wellness program, which was implemented in a large trauma centre in Toronto, Canada. Program implementors engaged teams in peer support sessions, psychoeducation workshops, critical incident stress debriefing, and community-building initiatives. As part of a project designed to illuminate the experiences of STEADY program implementors, this article describes recommendations for future hospital wellness programs. Participants described the importance of having the hospital and its leaders engage in supporting staff's psychological well-being. They recommended ways of doing so (e.g., incorporating conversations about wellness in staff onboarding and routine meetings), along with ways to increase program uptake and sustainability (e.g., using technology to increase accessibility). Results may be useful in future efforts to bolster hospital wellness programming.

A scoping review reveals candidate quality indicators of knowledge translation and implementation science practice tools.

OBJECTIVES: To identify candidate quality indicators from existing tools that provide guidance on how to practice knowledge translation and implemenation science (KT practice tools) across KT domains (dissemination, implementation, sustainability, and scalability). STUDY DESIGN AND SETTING: We conducted a scoping review using the Joanna Briggs Institute Manual for Evidence Synthesis. We systematically searched multiple electronic databases and the gray literature. Documents were independently screened, selected, and extracted by pairs of reviewers. Data about the included articles, KT practice tools, and candidate quality indicators were analyzed, categorized, and summarized descriptively. RESULTS: Of 43,060 titles and abstracts that were screened from electronic databases and gray literature, 850 potentially relevant full-text articles were identified, and 253 articles were included in the scoping review. Of these, we identified 232 unique KT practice tools from which 27 unique candidate quality indicators were generated. The identified candidate quality indicators were categorized according to the development (n = 17), evaluation (n = 5) and adaptation (n = 3) of the tools, and engagement of knowledge users (n = 2). No tools were identified that appraised the quality of KT practice tools. CONCLUSIONS: The development of a quality appraisal instrument of KT practice tools is needed. The results will be further refined and finalized in order to develop a quality appraisal instrument for KT practice tools.

Development of the Preferred Components for Co-Design in Research Guideline and Checklist: Protocol for a Scoping Review and a Modified Delphi Process.

BACKGROUND: There is increasing evidence that co-design can lead to more engaging, acceptable, relevant, feasible, and even effective interventions. However, no guidance is provided on the specific designs and associated methods or methodologies involved in the process. We propose the development of the Preferred Components for Co-design in Research (PRECISE) guideline to enhance the consistency, transparency, and quality of reporting co-design studies used to develop complex health interventions. OBJECTIVE: The aim is to develop the first iteration of the PRECISE guideline. The purpose of the PRECISE guideline is to improve the consistency, transparency, and quality of reporting on studies that use co-design to develop complex health interventions. METHODS: The aim will be achieved by addressing the following objectives: to review and synthesize the literature on the models, theories, and frameworks used in the co-design of complex health interventions to identify their common elements (components, values or principles, associated methods and methodologies, and outcomes); and by using the results of the scoping review, prioritize the co-design components, values or principles, associated methods and methodologies, and outcomes to be included in the PRECISE guideline. RESULTS: The project has been funded by the Canadian Institutes of Health Research. CONCLUSIONS: The collective results of this project will lead to a ready-to-implement PRECISE guideline that outlines a minimum set of items to include when reporting the co-design of complex health interventions. The PRECISE guideline will improve the consistency, transparency, and quality of reports of studies. Additionally, it will include guidance on how to enact or enable the values or principles of co-design for meaningful and collaborative solutions (interventions). PRECISE might also be used by peer reviewers and editors to improve the review of manuscripts involving co-design. Ultimately, the PRECISE guideline will facilitate more efficient use of new results about complex health intervention development and bring better returns on research investments. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50463.

Psychological interventions for individuals with Ehlers-Danlos syndrome and hypermobility spectrum disorder: a scoping review.

PURPOSE: To identify the nature and extent of the evidence on psychological interventions among individuals with Ehlers-Danlos Syndrome (EDS) and Hypermobility Spectrum Disorder (HSD). MATERIALS AND METHODS: Eligible studies reported on psychological interventions for individuals of all ages with EDS and/or HSD. All studies published in English were included, with no restrictions to publication year or status. MEDLINE, CINAHL, EMBASE, and PsycINFO were searched. Two reviewers independently screened studies and abstracted data. RESULTS: This scoping review included 10 studies reporting on EDS, HSD, or both. Only cohort studies and case studies were identified. Four studies investigated Cognitive Behavioural Therapy (CBT), one investigated Dialectical Behavioural Therapy (DBT), two investigated psychoeducation, two investigated Intensive Interdisciplinary Pain Treatment (IIPT), and one investigated Acceptance Commitment Therapy (ACT). Interventions targeted pain management, self-destructive behaviours, and related psychological issues (e.g., depression/anxiety). Sample sizes were small (n < 50) for most studies and interventions were generally poorly described. CONCLUSIONS: There is a critical need for high-quality research surrounding psychological interventions for individuals with EDS/HSD. Psychological interventions for these individuals are understudied and existing studies lack validity. Researchers should investigate psychological interventions for individuals with all types of EDS/HSD with high-quality studies to validate findings from the existing studies.

Assessing the sustainability and scalability of a diabetes eHealth innovation: a mixed-methods study.

BACKGROUND: To date, little is known about the sustainability and scalability of MyDiabetesPlan, an eHealth innovation designed to facilitate shared decision-making within diabetes care. To avoid the possibility of its short-lived implementation and promote wider adoption so as to promote patient-centred diabetes care, it is critical to understand MyDiabetesPlan's sustainability and scalability in order to ensure its long-term impact at a greater scale. We sought to identify the sustainability and scalability potential of MyDiabetesPlan and its limiting factors. METHODS: Using a concurrent triangulation mixed-methods approach, data were collected from 20 individuals involved in the development and implementation of MyDiabetesPlan. The National Health Services Sustainability Model (NHSSM) and the Innovation Scalability Self-administered Questionnaire (ISSaQ) were administered using a 'think-aloud' approach and subsequently, short semi-structured interviews were conducted. Mean aggregate scores and stakeholder-specific scores were generated for the NHSSM and ISSaQ, to quantitatively determine facilitating and limiting factors to sustainability and scalability. Content analysis occurred iteratively with qualitative data, to examine commonalities and differences with the quantitative findings. RESULTS: The top facilitating factor to sustaining MyDiabetesPlan was "Staff involvement and training to sustain the process.", whereas the top limiting factors were: "Adaptability of Improved Process", "Senior Leadership Engagement" and "Infrastructure for Sustainability". The top three facilitating factors for scale-up were "Acceptability", "Development with Theory" and "Consistency with Policy Directives." Conversely, the top three limiting factors were "Financial and Human Resources", "Achievable Adoption" and "Broad Reach". Qualitative findings corroborated the limiting/facilitating factors identified. CONCLUSIONS: Addressing staff involvement throughout the dynamic care contexts, and resource constraints impacting scale-up can enhance the sustainability and scalability of MyDiabetesPlan. As such, future plans will focus on garnering organizational leadership buy-in and support, which may address the resource constraints associated with sustainability and scalability and improve the capacity for adequate staff involvement. eHealth researchers will be able to prioritize these limiting factors from the outset of their tool development to purposefully optimize its sustainability and scalability performance.

Clustering of Health Behaviors in Canadians: A Multiple Behavior Analysis of Data from the Canadian Longitudinal Study on Aging.

BACKGROUND: Health behaviors such as physical inactivity, unhealthy eating, smoking tobacco, and alcohol use are each leading risk factors for non-communicable chronic disease. Better understanding which behaviors tend to co-occur (i.e., cluster together) and co-vary (i.e., are correlated) may provide novel opportunities to develop more comprehensive interventions to promote multiple health behavior change. However, whether co-occurrence or co-variation-based approaches are better suited for this task remains relatively unknown. PURPOSE: To compare the utility of co-occurrence vs. co-variation-based approaches for understanding the interconnectedness between multiple health-impacting behaviors. METHODS: Using baseline and follow-up data (N = 40,268) from the Canadian Longitudinal Study of Aging, we examined the co-occurrence and co-variation of health behaviors. We used cluster analysis to group individuals based on their behavioral tendencies across multiple behaviors and to examine how these clusters are associated with demographic characteristics and health indicators. We compared outputs from cluster analysis to behavioral correlations and compared regression analyses of clusters and individual behaviors predicting future health outcomes. RESULTS: Seven clusters were identified, with clusters differentiated by six of the seven health behaviors included in the analysis. Sociodemographic characteristics varied across several clusters. Correlations between behaviors were generally small. In regression analyses individual behaviors accounted for more variance in health outcomes than clusters. CONCLUSIONS: Co-occurrence-based approaches may be more suitable for identifying sub-groups for intervention targeting while co-variation approaches are more suitable for building an understanding of the relationships between health behaviors.

Health behaviors such as physical inactivity, unhealthy eating, smoking tobacco, and alcohol use are each leading risk factors for non-communicable chronic disease. A better understanding of which behavioral combinations people engage in, and which behaviors are associated with each other, may provide new insights to support the development of interventions to promote multiple health behavior change. Using data with two time points (N = 40,268) from the Canadian Longitudinal Study of Aging, we grouped people into clusters based on their health behaviors and examined how these clusters are associated with demographic characteristics and health indicators. Seven clusters were identified with sociodemographic patterns evident across several clusters. Correlations between behaviors were generally small. We compared whether individual health behaviors, or groupings of people based on their health behaviors, were better predictors of future health outcomes. Individual behaviors were slightly better predictors of future health outcomes than clusters.

Identifying candidate quality indicators of tools that support the practice of knowledge translation: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify and characterize relevant knowledge translation methods tools (those that provide guidance for optimized knowledge translation practice) to uncover candidate quality indicators to inform a future quality assessment tool for knowledge translation strategies. INTRODUCTION: Knowledge translation strategies (defined as including knowledge translation interventions, tools, and products) target various knowledge users, including patients, clinicians, researchers, and policy-makers. The development and use of strategies that support knowledge translation practice have been rapidly increasing, making it difficult for knowledge users to decide which to use. There is limited evidence-based guidance or measures to help assess the overall quality of knowledge translation strategies. INCLUSION CRITERIA: Empirical and non-empirical documents will be considered if they explicitly describe a knowledge translation methods tool and its development, evaluation or validation, methodological strengths or limitations, and/or use over time. The review will consider a knowledge translation methods tool if it falls within at least one knowledge translation domain (ie, implementation, dissemination, sustainability, scalability, integrated knowledge translation) in the health field. METHODS: We will conduct a systematic search of relevant electronic databases and gray literature. The search strategy will be developed iteratively by an experienced medical information specialist and peer-reviewed with the PRESS checklist. The search will be limited to English-only documents published from 2005 onward. Documents will be independently screened, selected, and extracted by 2 researchers. Data will be analyzed and summarized descriptively, including the characteristics of the included documents, knowledge translation methods tools, and candidate quality indicators. SCOPING REVIEW REGISTRATION: Open Science Framework ( https://osf.io/chxvq ).

Occupational Therapist Led Cognitive Stimulation Therapy: Feasibility of Implementation.

Background. Despite local training opportunities for Cognitive Stimulation Therapy (CST) for occupational therapists, there has been limited evaluation of the feasibility of implementation in Canada. Purpose. This study explored the feasibility of CST delivery by an occupational therapist in an Ontario health care setting and the impact it may have on self-efficacy and hope measures of individuals with dementia. Methods. A mixed-methods experimental pre/post design was used. Survey measures included hope, self-efficacy, feasibility, satisfaction, and individual session evaluation. Semistructured focus groups were held for participants and facilitators. Findings. Quantitative findings are summarized descriptively for the 10 participants. Qualitative findings were grouped into themes: social connectedness, knowledge gained and shared, tailored implementation adjustments, and need for long-term programing. Implications. Occupational therapists are well-positioned to implement CST and should be a part of further research to test the intervention rigorously for applicability within a range of Canadian health care settings.

Research Partnerships with Patients Living with Type 2 Diabetes: Practices and Challenges in Quebec Among People New to Canada.

Patients are increasingly encouraged to participate in health research programs as partners, with the aim to ensure that studies address their priorities. In response, the Strategy for Patient-Oriented Research (SPOR) has been created in Canada to transform the patient's role in research from a passive beneficiary to a more proactive partner of change within the healthcare system. This research investigates what people new to Canada living with type 2 diabetes think about participating in research partnerships. Using an ethnographic approach, 31 people new to Canada with a diagnosis of type 2 diabetes were interviewed. Findings indicated that few people new to Canada were represented among the Diabetes Action Canada (DAC) Network's Circles of Patient Partners in Quebec. Barriers to engagement in research were: lack of information; competing priorities; language barrier and privacy concerns; preconceptions about being a patient partner; prejudices on research engagement as something demanding and binding; and the matter of religious and gender differences. Some participants questioned the extent to which involvement in research can really meet their expectations considering institutional control over research, funding requirements that often dictate priorities and the biomedical approach which still, in many respects, dominates health research. Implications for achieving equity, diversity, and inclusion of patient partners in research are discussed.

Les patients sont de plus en plus encouragés à devenir des partenaires de recherche en santé afin que leurs besoins soient mieux pris en compte. C'est dans cette optique que la Stratégie de Recherche Axée sur le Patient a été créée au Canada, pour que le patient soit plus qu'un bénéficiaire passif des soins et devienne un acteur proactif du changement au sein du système de santé. Grâce à une approche ethnographique, cette recherche examine comment 31 personnes vivant avec le diabète de type 2, qui résident au Québec et qui sont nouvellement arrivées au Canada apprécient l'engagement dans des partenariats de recherche. Les résultats font constater que les personnes nouvellement arrivées au Canada sont sous-représentées dans les Cercles de patients partenaires du réseau Action Diabète Canada (ADC). Les barrières identifiées sont liées : au manque d'information, aux conflits d'horaire, aux barrières linguistiques qui soulèvent aussi les problèmes de confidentialité, aux idées préconçues sur le rôle du patient partenaire, aux perceptions suspicieuses de la recherche ainsi qu'aux différences religieuses et de genre. Par ailleurs, les personnes interrogées se demandent à quel point leurs points de vue peuvent vraiment changer quelque chose, étant donné que les recherches font l'objet d'un contrôle institutionnel, que les opportunités de financement dictent les priorités de recherché et que l'approche biomédicale est omniprésente dans les sciences de la santé. Pour conclure, l'article souligne que l'implication de patients partenaires dans la recherche soulève des enjeux d'équité, de diversité et d'inclusion.

Training the Next Generation of Diabetes Researchers: Evaluation of the Diabetes Action Canada Training and Mentoring Program.

BACKGROUND: The Diabetes Action Canada Training and Mentoring (DAC-TM) Program launched in June 2017, with the goal of building capacity in the next generation of diabetes researchers in Canada in patient-oriented research (POR). METHODS: We conducted a program evaluation of the DAC-TM program using a sequential, mixed-methods research design. RESULTS: Our analysis of 82 surveys and 22 in-depth interviews from a wide range of DAC-TM Program stakeholders revealed consistent patterns in experience with the program. The training sessions were perceived to be well-organized, convenient educational opportunities to gain new knowledge about POR and become integrated into a community of practice of POR researchers who study diabetes and its complications in Canada. The content of the training was perceived to be useful and relevant to participants, although improvements could be made to help address the training needs of the broader DAC community. There is broad support for and appreciation of the mentorship awards, which were perceived to be appropriately targeted to early-career investigators. The mentor-mentee relationships were perceived to be positive, productive and career-advancing overall, but could benefit from a more strategic design and promote better connectivity to foster mentor-mentee relationships. In addition, feedback about opportunities to network and forge new connections was mixed and represents another opportunity for improvement to strengthen capacity building. CONCLUSIONS: Findings from this formative evaluation study show key strengths and opportunities to improve the DAC-TM Program, which can be used to help enhance its function and promote its long-term sustainability.

The Guideline Language and Format Instrument (GLAFI): development process and international needs assessment survey.

BACKGROUND: Successful guideline implementation depends both on factors extrinsic to guidelines and their intrinsic features. In the Guideline Implementability for Decision Excellence Model (GUIDE-M), "communicating" content (language and format) is one of three core determinants of intrinsic implementability, but is seldom addressed. Our aims were to develop a tool that could be used by guideline developers to optimize language and format during development; identify gaps in this type of guidance in existing resources; and evaluate the perceived need for and usefulness of such a tool among guideline developers. METHODS: Our mixed-methods design consisted of (1) content development (selection and organization of evidence-based constructs from the GUIDE-M into a prototype Guideline Language and Format Instrument (GLAFI), followed by face validation with guideline developers); (2) document analysis (duplicate) of seven existing guideline tools to measure coverage of GLAFI items and identify new items; and (3) an international survey of guideline developers (corresponding authors of recent Canadian Medical Association or Guidelines International Network database guidelines) to measure perceived importance of language and format, quality of existing resources, and usefulness of a language and format tool. RESULTS: GLAFI items were organized into 4 language and 4 format subdomains. In face validation with guideline developers (17 clinicians, 1 methodologist), all agreed that the tool would improve guideline implementability and 93% indicated a desire for regular use. In the existing guideline tool document analysis, only 14/44 (31.8%) GLAFI items were operationalized in at least one tool. We received survey responses from 148/674 (22.0%) contacted guideline authors representing 45 organizations (9 countries). Language was rated as "extremely important" or "important" in determining uptake by 94% of respondents, and format by 84%. Correspondingly, 72% and 70% indicated that their organization would likely use such a tool. CONCLUSIONS: Optimal language and format are fundamental to guideline implementability but often overlooked. The GLAFI tool operationalizes evidence-based constructs, most of which are absent in existing guideline tools. Guideline developers perceive these concepts to be important and express a willingness to use such a tool. The GLAFI should be further tested and refined with guideline developers and its impact on end-users measured.

Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals.

BACKGROUND: Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations. METHODS: Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis. FINDINGS: Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not 'patient facing'; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions. CONCLUSIONS: This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review.

BACKGROUND: There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care. METHODS: We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review. RESULTS: Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently. CONCLUSIONS: This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Choosing Wisely: An idea worth sustaining.

OBJECTIVES: To evaluate the sustainability potential of Choosing Wisely (CW) to address unnecessary medical care at Ontario community hospitals. DATA SOURCES/STUDY SETTING: Ontario community hospitals and their affiliated family health teams (FHTs). STUDY DESIGN: A mixed-methods study involving the administration of a validated sustainability survey to CW implementation teams followed by their participation in focus groups. DATA COLLECTION/EXTRACTION METHODS: Survey data were collected using an Excel file with an embedded, automated scoring system. We collated individual survey scores and generated aggregate team scores. We also performed descriptive statistics for quantitative data (frequencies, means). Qualitative data were triangulated with quantitative assessments to support data interpretations using the meta-matrix method. PRINCIPAL FINDINGS: Fifteen CW implementation teams across four Ontario community hospitals and six affiliated primary care FHTs participated. CW priority areas investigated were de-prescribing of proton pump inhibitors (PPIs) and reducing Pre-Op testing and BUN/Urea lab testing. Survey results showed steady improvements in sustainability scores from baseline to final follow-up among most implementation teams: 10% increase for PPI de-prescribing (six FHTs) and 2% increase (three hospital teams); 18% increase in BUN/Urea lab testing (three hospital teams). Regardless of site or CW priority area, common facilitators were fit with existing processes and workflows, leadership support, and optimized team communication; common challenges were lack of awareness and buy-in, leadership engagement or a champion, and lack of fit with existing workflow and culture. All teams identified at least one challenge for which they co-designed and implemented a plan to maximize the sustainability potential of their CW initiative. CONCLUSIONS: Evaluating the sustainability potential of an innovation such as Choosing Wisely is critical to ensuring that they have the best potential for impact. Our work highlights that implementation teams can be empowered to influence implementation efforts and to realize positive outcomes for their health care services and patients.

Prioritizing a Research Agenda of Transitional Care Interventions for Childhood-Onset Disabilities.

Transitional care interventions have the potential to optimize continuity of care, improve health outcomes and enhance quality of life for adolescents and young adults living with chronic childhood-onset disabilities, including neurodevelopmental disorders, as they transition to adult health and social care services. The paucity of research in this area poses challenges in identifying and implementing interventions for research, evaluation and implementation. The purpose of this project was to advance this research agenda by identifying the transitional care interventions from the scientific literature and prioritize interventions for study. A modified-Delphi approach involving two rounds of online surveys followed by a face-to-face consensus meeting with knowledge users, researchers and clinician experts in transitional care (n = 19) was used. A subsequent virtual meeting concluded the formulation of next steps. Experts rated 16 categories of interventions, derived from a systematic review, on importance, impact, and feasibility. Seven of the 16 interventions categories received a mean score rating of ≥7 (out of 10) on all three rating categories. Participants then rank ordered the reduced list of seven interventions in order of priority and the top four ranked interventions advanced for further discussion at a consensus meeting. Using the Template for Intervention Description and Replication (TIDieR) checklist as a guide, the participants identified that a study of a peer system navigator was worthy of future evaluation. This study highlighted that transitional care interventions are complex and multifaceted. However, the presence of a peer to support system navigation, advocacy and individual and family education was considered the most ideal intervention addressing the current gap in care. Future research, which aims to engage patients and families in a co-design approach, is recommended to further develop this intervention.

Using an integrated knowledge translation approach to inform a pilot feasibility randomized controlled trial on peer support for individuals with traumatic brain injury: A qualitative descriptive study.

INTRODUCTION: Traumatic brain injury (TBI) is estimated to affect 10 million people annually, making it a leading cause of morbidity and mortality worldwide. One cost-effective intervention that has been shown to minimize some of the negative sequelae after TBI is peer support. However, the evidence supporting the benefits of peer support for individuals with TBI is sparse and of low quality. Integrated knowledge translation (iKT) may be one approach to optimizing the evaluation of peer support programs among individuals with TBI. Therefore, the objectives are: (1) To understand key informants' perspectives of the barriers and facilitators of participating in peer support research and programs among individuals with TBI; (2) to understand key informants' perspectives on the perceived impacts of peer support programs on individuals with TBI; and, (3) to demonstrate how an iKT approach can inform the development and implementation of a pilot feasibility randomized controlled trial (RCT). METHODS: A qualitative descriptive approach using one-on-one semi-structured interviews was used. Purposive sampling of 22 key informants included 8 peer support mentors, 4 individuals with TBI who received peer support, 3 caregivers of individuals with TBI, 4 peer support program staff, and 3 academics in peer support and/or TBI. RESULTS: There were five main themes related to the barriers and facilitators to participating in peer support research and programs: knowledge, awareness, and communication; logistics of participating; readiness and motivation to participate; need for clear expectations; and matching. There were three main themes related to the perceived impact of peer support: acceptance, community, social experiences; vicarious experience/learning through others: shared experiences, role-modelling, encouragement; and "I feel better." Discussions with our Research Partner led to several significant adaptations to our trial protocol, including removing the twice/week intervention arm, shortening of the length of trial, and changing the measure for the community integration outcome. DISCUSSION/CONCLUSION: This is the first study to use an iKT approach to inform a trial protocol and the first to assess the barriers and facilitators to participating in peer support research.

A Pilot Feasibility Randomized Controlled Trial on the Ontario Brain Injury Association Peer Support Program.

BACKGROUND: The long-term consequences of traumatic brain injury can create major barriers to community integration. Peer support represents a sustainable model of support across this transition. The objective of the current study was to determine the feasibility of conducting a randomized controlled trial on the Ontario Brain Injury Association Peer Support Program and the preliminary effectiveness of the program on community integration, mood, health-related quality of life, and self-efficacy; Methods: A pilot feasibility randomized controlled trial with an embedded qualitative component was conducted. Mentees with moderate-to-severe traumatic brain injury (n = 13) were randomized to a weekly intervention or waitlist control group. Interviews were conducted with a subset of mentees and peer mentors (n = 10). Integration of the quantitative and qualitative data was completed using a joint display approach; Results: No statistically significant results were found for community integration, mood, or self-efficacy; however, changes in these outcomes were accompanied by moderate-to-large effect sizes. Within health-related quality of life, the mean pain score of the intervention group was significantly lower than that of the control group at the two-month timepoint but not at completion. Interviews revealed proximal improvements in knowledge, skills, and goals, and identified two domains related to trial acceptability: (1) environmental context and resources, and (2) reinforcement; Conclusions: Given the conceivable importance of proximal improvements in domains such as knowledge, skills, and/or goals for the attainment of more distal outcomes, modifications to the existing Peer Support Program may be warranted. The introduction of program recommendations which promote discussion around particular domains may help facilitate long-term improvements in health outcomes.