Individual and Geospatial Determinants of Health Associated With School-Based Human Papillomavirus Immunization in Alberta: Population-Based Cohort Study.

BACKGROUND: Human papillomavirus (HPV) infection causes nearly all cervical cancer cases and is a cause of anogenital and oropharyngeal cancers. The incidence of HPV-associated cancers is inequitable, with an increased burden on marginalized groups in high-income countries. Understanding how immunization status varies by material and social deprivation, health system, and geospatial factors is valuable for prioritizing and planning HPV immunization interventions. OBJECTIVE: The objective of this study was to describe school-based HPV immunization rates by individual and geospatial determinants of health in Alberta, Canada. METHODS: Health administrative data for male and female individuals born in 2004 in Alberta were used to determine HPV immunization status based on age and the number of doses administered in schools during the 2014/2015-2018/2019 school years. Immunization status and its relationship with material and social deprivation and health system factors were assessed by a logistic regression model. Geospatial clustering was assessed using Getis-Ord Gi* hot spot analysis. Mean scores of material and social deprivation and health system factors were compared between hot and cold spots without full HPV immunization using independent samples t tests. A multidisciplinary team comprising researchers and knowledge users formed a co-design team to design the study protocol and review the study results. RESULTS: The cohort consisted of 45,207 youths. In the adjusted model, the odds of those who did not see their general practitioner (GP) within 3 years before turning 10 years old and not being fully immunized were 1.965 times higher (95% CI 1.855-2.080) than those who did see their GP. The odds of health system users with health conditions and health system nonusers not being fully immunized were 1.092 (95% CI 1.006-1.185) and 1.831 (95% CI 1.678-1.998) times higher, respectively, than health system users without health conditions. The odds of those who lived in areas with the most material and social deprivation not being fully immunized were 1.287 (95% CI 1.200-1.381) and 1.099 (95% CI 1.029-1.174) times higher, respectively, than those who lived in areas with the least deprivation. The odds of those who lived in rural areas not being fully immunized were 1.428 times higher (95% CI 1.359-1.501) than those who lived in urban areas. Significant hot spot clusters of individuals without full HPV immunization exist in rural locations on the northern and eastern regions of Alberta. Hot spots had significantly worse mean material deprivation scores (P=.008) and fewer GP visits (P=.001) than cold spots. CONCLUSIONS: Findings suggest that material and social deprivation, health system access, and rural residency impact HPV immunization. Such factors should be considered by public health professionals in other jurisdictions and will be used by the Alberta co-design team when tailoring programs to increase HPV vaccine uptake in priority populations and regions.

Facilitators and barriers for implementing screening brief intervention and referral for health promotion in a rural hospital in Alberta: using consolidated framework for implementation research.

BACKGROUND: Screening, brief intervention, and referral (SBIR) is an evidence-based, comprehensive health promotion approach commonly implemented to reduce alcohol and substance use. Implementation research on SBIR demonstrate that patients find it acceptable, reduces hospital costs, and it is effective. However, SBIR implementation in hospital settings for multiple risk factors (fruit and vegetable consumption, physical activity, alcohol and tobacco use) is still emergent. More evidence is needed to guide SBIR implementation for multiple risk factors in hospital settings. OBJECTIVE: To explore the facilitators and barriers of SBIR implementation in a rural hospital using the Consolidated Framework for Implementation Research (CFIR). METHODS: We conducted a descriptive qualitative investigation consisting of both inductive and deductive analyses. We conducted virtual, semi-structured interviews, guided by the CFIR framework. All interviews were audio-recorded, and transcribed verbatim. NVivo 12 Pro was used to organize and code the raw data. RESULTS: A total of six key informant semi-structured interviews, ranging from 45 to 60 min, were carried out with members of the implementation support team and clinical implementers. Implementation support members reported that collaborating with health departments facilitated SBIR implementation by helping (a) align health promotion risk factors with existing guidelines; (b) develop training and educational resources for clinicians and patients; and (c) foster leadership buy-in. Conversely, clinical implementers reported several barriers to SBIR implementation including, increased and disrupted workflow due to SBIR-related documentation, a lack of knowledge on patients' readiness and motivation to change, as well as perceived patient stigma in relation to SBIR risk factors. CONCLUSION: The CFIR provided a comprehensive framework to gauge facilitators and barriers relating to SBIR implementation. Our pilot investigation revealed that future SBIR implementation must address organizational, clinical implementer, and patient readiness to implement SBIR at all phases of the implementation process in a hospital.

Effective strategies for Fecal Immunochemical Tests (FIT) programs to improve colorectal cancer screening uptake among populations with limited access to the healthcare system: a rapid review.

BACKGROUND: Colorectal cancer (CRC) is one of the leading causes of cancer death globally. CRC screening can reduce the incidence and mortality of CRC. However, socially disadvantaged groups may disproportionately benefit less from screening programs due to their limited access to healthcare. This poor access to healthcare services is further aggravated by intersecting, cumulative social factors associated with their sociocultural background and living conditions. This rapid review systematically reviewed and synthesized evidence on the effectiveness of Fecal Immunochemical Test (FIT) programs in increasing CRC screening in populations who do not have a regular healthcare provider or who have limited healthcare system access. METHODS: We used three databases: Ovid MEDLINE, Embase, and EBSCOhost CINAHL. We searched for systematic reviews, meta-analysis, and quantitative and mixed-methods studies focusing on effectiveness of FIT programs (request or receipt of FIT kit, completion rates of FIT screening, and participation rates in follow-up colonoscopy after FIT positive results). For evidence synthesis, deductive and inductive thematic analysis was conducted. The findings were also classified using the Cochrane Methods Equity PROGRESS-PLUS framework. The quality of the included studies was assessed. RESULTS: Findings from the 25 included primary studies were organized into three intervention design-focused themes. Delivery of culturally-tailored programs (e.g., use of language and interpretive services) were effective in increasing CRC screening. Regarding the method of delivery for FIT, specific strategies combined with mail-out programs (e.g., motivational screening letter) or in-person delivery (e.g., demonstration of FIT specimen collection procedure) enhanced the success of FIT programs. The follow-up reminder theme (e.g., spaced out and live reminders) were generally effective. Additionally, we found evidence of the social determinants of health affecting FIT uptake (e.g., place of residence, race/ethnicity/culture/language, gender and/or sex). CONCLUSIONS: Findings from this rapid review suggest multicomponent interventions combined with tailored strategies addressing the diverse, unique needs and priorities of the population with no regular healthcare provider or limited access to the healthcare system may be more effective in increasing FIT screening. Decision-makers and practitioners should consider equity and social factors when developing resources and coordinating efforts in the delivery and implementation of FIT screening strategies.

Geospatial analysis and participant characteristics associated with colorectal cancer screening participation in Alberta, Canada: a population-based cross-sectional study.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of death in Canada and early detection can prevent deaths through screening. However, CRC screening in Alberta, Canada remains suboptimal and varies by sociodemographic and health system characteristics, as well as geographic location. This study aimed to further the understanding of these participant and health system characteristics associated with CRC screening in Alberta and identify clusters of regions with higher rates of overdue or unscreened individuals. METHODS: We included Albertans aged 52 to 74 as of December 31, 2019 (index date) and we used data from administrative health data sources and linked to the Alberta Colorectal Cancer Screening Program database to determine colorectal cancer screening rates. We used multivariable multinomial logistic regression analysis to investigate the relationship between sociodemographic, health system characteristics and participation in CRC screening. We used optimized Getis-Ord Gi* hot-spot analysis to identify hot and cold-spots in overdue for and no record of CRC screening. RESULTS: We included 919,939 Albertans, of which 65% were currently up to date on their CRC screening, 21% were overdue, and 14% had no record of CRC screening. Compared to Albertans who were currently up to date, those who were in older age groups, those without a usual provider of care, those who were health system non-users, and those living in more deprived areas were more likely to have no record of screening. Areas with high number of Albertans with no record of screening were concentrated in the North and Central zones. CONCLUSIONS: Our study showed important variation in colorectal cancer screening participation across sociodemographic, health system and geographical characteristics and identified areas with higher proportions of individuals who have no record of screening or are under-screened in Alberta, Canada.

Indigenous identity identification in administrative health care data globally: A scoping review.

OBJECTIVE: Both Indigenous and non-Indigenous governments and organizations have increasingly called for improved Indigenous health data in order to improve health equity among Indigenous peoples. This scoping review identifies best practices, potential consequences and barriers for advancing Indigenous health data and Indigenous data sovereignty globally. METHODS: A scoping review was conducted to capture the breadth and nature of the academic and grey literature. We searched academic databases for academic records published between 2000 and 2021. We used Google to conduct a review of the grey literature. We applied Harfield's Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) to all original research articles included in the review to assess the quality of health information from an Indigenous perspective. RESULTS: In total, 77 academic articles and 49 grey literature records were included. Much of the academic literature was published in the last 12 years, demonstrating a more recent interest in Indigenous health data. Overall, we identified two ways for Indigenous health data to be retrieved. The first approach is health care organizations asking clients to voluntarily self-identify as Indigenous. The other approach is through data linkage. Both approaches to improving Indigenous health data require awareness of the intergenerational consequences of settler colonialism along with a general mistrust in health care systems among Indigenous peoples. This context also presents special considerations for health care systems that wish to engage with Indigenous communities around the intention, purpose, and uses of the identification of Indigenous status in administrative databases and in health care settings. Partnerships with local Indigenous nations should be developed prior to the systematic collection of Indigenous identifiers in health administrative data. The QAT revealed that many research articles do not include adequate information to describe how Indigenous communities and stakeholders have been involved in this research. CONCLUSION: There is consensus within the academic literature that improving Indigenous health should be of high priority for health care systems globally. To address data disparities, governments and health organizations are encouraged to work in collaboration with local Indigenous nations and stakeholders at every step from conceptualization, data collection, analysis, to ownership. This finding highlights the need for future research to provide transparent explanation of how meaningful Indigenous collaboration is achieved in their research.

Implementing Screening, Brief Intervention and Referral Intervention for Health Promotion and Disease Prevention in Hospital Settings in Alberta: A Pilot Study.

Objective: This study assessed the feasibility of implementing screening, brief intervention and referral (SBIR) intervention in hospital settings. Methods: This cross-sectional study evaluated the implementation of the SBIR intervention in a hospital in Alberta for tobacco use, alcohol intake, physical inactivity, and insufficient vegetable and fruit consumption. Patients were interviewed approximately 4-month later to collect data on the acceptability and effectiveness of the intervention received (n = 108). The data were primarily analyzed using descriptive statistics. Results: Of 108 patients, >80% agreed that "they were ok with being screened" for the risk factors during their hospital visit. Up to 68% of patients recalled the provider's brief education. At the follow-up, 20% of patients quit tobacco, 50% reduced alcohol use, 30% increased physical activity, and 25% increased vegetable and fruit intake. Conclusion: Risk factor screening was acceptable for patients. Patients recalled the brief education they received from healthcare providers. Patients reported risk-reducing changes in their risk factors. Our future work will integrate the SBIR approach within the Electronic Clinical Information System and use robust research methods to investigate the impact of SBIR on patients' behavior change.

Physician influence on medication adherence, evidence from a population-based cohort.

BACKGROUND: The overall impact of physician prescribers on population-level adherence rates are unknown. We aimed to quantify the influence of general practitioner (GP) physician prescribers on the outcome of optimal statin medication adherence. METHODS: We conducted a retrospective cohort study using health administrative databases from Saskatchewan, Canada. Participants included physician prescribers and their patients beginning a new statin medication between January 1, 2012 and December 31, 2017. We grouped prescribers based on the prevalence of optimal adherence (i.e., proportion of days covered ≥ 80%) within their patient group. Also, we constructed multivariable logistic regression analyses on optimal statin adherence using two-level non-linear mixed-effects models containing patient and prescriber-level characteristics. An intraclass correlation coefficient was used to estimate the physician effect. RESULTS: We identified 1,562 GPs prescribing to 51,874 new statin users. The median percentage of optimal statin adherence across GPs was 52.4% (inter-quartile range: 35.7% to 65.5%). GP prescribers with the highest patient adherence (versus the lowest) had patients who were older (median age 61.0 vs 55.0, p<0.0001) and sicker (prior hospitalization 39.4% vs 16.4%, p<0.001). After accounting for patient-level factors, only 6.4% of the observed variance in optimal adherence between patients could be attributed to GP prescribers (p<0.001). The majority of GP prescriber influence (5.2% out of 6.4%) was attributed to the variance unexplained by patient and prescriber variables. INTERPRETATION: The overall impact of GP prescribers on statin adherence appears to be very limited. Even "high-performing" physicians face significant levels of sub-optimal adherence among their patients.

Factors influencing human papillomavirus school-based immunization in Alberta: A mixed-methods study protocol.

More than 1,300 Canadians are diagnosed with cervical cancer annually, which is nearly preventable through human papillomavirus (HPV) immunization. Across Canada, coverage rates remain below the 90% target set out by the Action Plan for the Elimination of Cervical Cancer in Canada (2020-2030). To support this Plan, the Canadian Partnership Against Cancer has commissioned the Urban Public Health Network (UPHN) to coordinate a quality improvement project with Canada's school-based HPV immunization programs. In Alberta, the UPHN partnered with Alberta Health Services (AHS) for this work. This study has one overarching research question: what are parent/guardian and program stakeholder perceived barriers, enablers and opportunities to immunization for youth as part of the school-based HPV immunization program in Alberta? This study uses a mixed-methods sequential explanatory design. A survey will be emailed to a sample of Albertans with children aged 11-17 years. Questions will be based on a Conceptual Framework of Access to Health Care. Subsequent qualitative work will explore the survey's findings. Parents/guardians identifying as vaccine hesitant in the survey will be invited to participate in virtual, semi-structured, in-depth interviews. Stakeholders of the school-based immunization program will be purposively sampled from AHS' five health zones for virtual focus groups. Quantitative data will be analyzed using SAS Studio 3.6 to carry out descriptive statistics and, using logistic regression, investigate if Framework constructs are associated with parents'/guardians' decision to immunize their children. Qualitative data will be analyzed using NVivo 12 to conduct template thematic analysis guided by the Framework. Study results will provide insights for Alberta's public health practitioners to make evidence-informed decisions when tailoring the school-based HPV immunization program to increase uptake in vaccine hesitant populations. Findings will contribute to the national study, which will culminate in recommendations to increase HPV immunization uptake nationally and progress towards the 90% coverage target.

Interventions to Increase Colorectal Cancer Screening Uptake in Primary Care: A Systematic Review.

OBJECTIVE: We systematically reviewed and summarized previous studies that examined facilitators and barriers to implementing interventions to increase CRCS uptake in primary care practice. METHODS: We searched PubMed, Medline (EBSCO), and CINAHL databases, from the inception of these databases to April 2020. The search strategy combined a set of terms related to facilitators/barriers, intervention implementation, CRCS, and uptake/participation. A priori set inclusion and exclusion criteria were used during both title/abstract screening and full-text screening phases to identify the eligible studies. Quality of the included studies was appraised using quality assessment tools, and data were extracted using a predetermined data extraction tool. We classified facilitators and barriers according to the Consolidated Framework for Implementation Research domains and constructs and identified the common facilitators and barriers looking at how common they were across studies. RESULTS: A total of 12 studies were included in the review. Engagement of the clinic team, leadership team, and partners, clinics' motivation to improve CRCS rates, use of the EMR system, continuous monitoring and feedback system, and having a supportive environment for implementation were the most commonly reported implementation facilitators. Limited time for the clinic team to devote to a new project, challenges in getting accurate, timely data related to CRCS, limited capacity/support to use the EMR system, and disconnect between clinic team members were the most commonly reported implementation barriers. CONCLUSIONS: The synthesized findings improve our understanding of facilitators of and barriers to the implementation of interventions to increase CRCS participation in primary care practice, and inform the customized implementation strategies. Many of the included studies had limited use of rigorous implementation science frameworks to guide their implementation and evaluation, which precludes a comprehensive understanding of the implementation factors specific to CRCS interventions in primary care. Future studies assessing the CRCS intervention implementation factors would benefit from the use of implementation science frameworks.

Patterns of up-to-date status for colorectal cancer screening in Alberta: a cross-sectional study using survey data.

BACKGROUND: Regular screening for colorectal cancer (CRC) reduces its mortality. We explored patterns of use of different CRC screening modalities and quantified the association between having a regular primary care provider and being up to date for CRC screening in a community-based population in Alberta, Canada. METHODS: We conducted a cross-sectional study of adults between 50 and 74 years of age in Alberta, using Canadian Community Health Survey data (2015-2016). We defined being up to date for CRC screening as having completed a fecal occult blood test (FOBT) or fecal immunochemical test (FIT) within the previous 2 years, or having a colonoscopy or sigmoidoscopy in the previous 5 years before the survey. We analyzed data using multivariable logistic regression models. RESULTS: Of 4600 surveyed adults, 62.6% were up to date for CRC screening, with 45.1% having completed a FIT or FOBT (45.1%), and 34.1% having undergone a colonoscopy or sigmoidoscopy. The adjusted odds ratio of being up to date for CRC screening was 0.25 (95% confidence interval 0.17-0.38) and the absolute probability of being up to date for CRC screening was 34.4% lower for adults who had no regular primary care provider, compared with those who had. This pattern was observed in both male and female subgroups. INTERPRETATION: Our findings suggest a suboptimal uptake of CRC screening overall in Alberta, with high disparity between adults with and without a regular primary care provider. The use of customized, multicomponent intervention strategies that are shown to be effective in increasing participation in CRC screening may address this issue.

An integrated continuity of care measure improves performance in models predicting medication adherence using population-based administrative data.

OBJECTIVES: Continuity of care (COC) is considered an important determinant of medication adherence based on measures such as the usual provider continuity index (UPCI) that are derived exclusively from physician visit claims. This study aimed to: a) determine if high UPCI values predict physicians who deliver different clinical services; and b) compare UPCI with an integrated COC measure capturing physician visits, prescribing, and a complete medical examination in a multivariable model of patients receiving statin medications. METHODS: This was a retrospective cohort study of new statin users between 2012 and 2017 in Saskatchewan, Canada. We calculated sensitivity/specificity of a high UPCI value for predicting physicians who were prescribers of statins and/or providers of complete medical examinations. Next, we used logistic regression models to test two measures of COC (high UPCI value or an integrated COC measure) on the outcome of optimal statin adherence (proportion of days covered ≥80%). The DeLong test was used to compare predictive performance of the two models. RESULTS: Among 55,144 new statin users, a high UPCI was neither a sensitive or specific marker of physicians who prescribed statins or performed a complete medical examination. The integrated COC measure had a stronger association with optimal adherence [adjusted odds ratio (OR) = 1.56, 95% confidence interval (CI) 1.50 to 1.63] than UPCI (adjusted OR = 1.23, 95% CI 1.19 to 1.28), and improved predictive performance of the adherence model. CONCLUSION: The number of physician visits alone appears to be insufficient to represent COC. An integrated measure improves predictive performance for optimal medication adherence in patients initiating statins.

Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

The Impact of Age and Sex Concordance Between Patients and Physicians on Medication Adherence: A Population-Based Study.

PURPOSE: Age or sex concordance (same sex or same age range) may also be associated with medication adherence but was not fully investigated. We aim to quantify the impact of age and sex concordance on optimal adherence to statin medications. PATIENTS AND METHODS: A retrospective cohort study was conducted using population-based health administrative data from Saskatchewan, Canada. Participants were individuals newly initiated on statin medications between January 1, 2012, and December 31, 2017. The outcome was optimal adherence (proportion of days covered ≥ 80%) measured at one year after the first statin claim. The independent variables were sex and age concordance (age within five years) between patients and prescribers. The association between adherence outcome and sex/age concordance was analyzed by multivariable logistic regression models using generalized estimating equations controlled by a package of potential confounding factors. RESULTS: Among 51,874 new statin users, 20.6% (n = 10,710) were age concordant with prescriber. The vast majority of age concordance occurred in patients younger than 66 years (88.6%, 9,486/10,710). Sex concordance was observed in 62.8% (n = 32,551) of patients and age-sex combined concordance in 13.2% (n = 6,856). Among patients younger than 66 years (n = 36,641/51,874, 70.6%), age concordance did not have a significant impact on optimal adherence [adjusted OR (aOR) = 1.02, 95% CI 0.97 to 1.07]. Weak association between sex concordance (aOR = 1.05, 95% CI 1.00 to 1.11), and age-sex combined concordance (aOR = 1.05, 95% CI 0.99 to 1.12) was observed. CONCLUSION: Age and sex concordance were not statistically significant predictors of optimal statin adherence. However, a weak association was detected for sex concordance. Future studies should examine this factor in different health care settings.

How Does the Facilitation Effort of Clinical Educators Interact With Aspects of Organizational Context to Affect Research Use in Long-term Care? Evidence From CHAID Analysis.

PURPOSE: Organizational context influences the effect of facilitation efforts on research use in care settings. The interactions of these factors are complex. Therefore, the use of traditional statistical methods to examine their interrelationships is often impractical. Big Data analytics can automatically detect patterns within the data. We applied the chi-squared automatic interaction detection (CHAID) algorithm and classification tree technique to explore the dynamic and interdependent relationships between the implementation science concepts-context, facilitation, and research use. DESIGN: Observational, cross-sectional study based on survey data collected from a representative sample of nursing homes in western Canada. METHODS: We assessed three major constructs: (a) Conceptual research utilization (CRU) using the CRU scale; (b) facilitation of research use measured by the frequency of contacts between the frontline staff and a clinical educator, or person who brings new ideas to the care unit; and (c) organizational context at the unit level using the Alberta Context Tool (ACT). CHAID analysis was performed to detect the interactions between facilitation and context variables. Results were illustrated in a classification tree to provide a straightforward visualization. FINDINGS: Data from 312 care units in three provinces were included in the final analysis. Results indicate significant multiway interactions between facilitation and various aspects of the organizational context, including leadership, culture, evaluation, structural resources, and organizational slack (staffing). Findings suggested the preconditions of the care settings where research use can be maximized. CONCLUSIONS: CHAID analysis helped transform data into usable knowledge. Our findings provide insight into the dynamic relationships of facilitators' efforts and organizational context, and how these factors' interplay and their interdependence together may influence research use. CLINICAL RELEVANCE: Knowledge of the combined effects of facilitators' efforts and various aspects of organizational context on research use can contribute to effective strategies to narrow the evidence-practice gap in care settings.

Self-Monitoring of Blood Glucose and Hypoglycemia-Related Hospitalization in a Population-Based Cohort of Canadian Patients With Type 1 or Type 2 Diabetes.

OBJECTIVES: The aim of this work was to determine whether: 1) blood glucose test strip use in the population is associated with hypoglycemia hospitalization rates, and 2) blood glucose test strip use among individuals is associated with a reduced risk of hypoglycemia hospitalization. METHODS: Administrative databases from Saskatchewan, Canada, were used to ascertain population-level hypoglycemia hospitalizations and test strip utilization over the period from 1996 to 2014. For objective 1, a generalized linear model with generalized estimating equations was fit to provincial data stratified by age group, sex and year. For objective 2, a nested case-control study was conducted for a cohort of insulin users with diagnosed diabetes. Multivariable conditional logistic regression was used to test the association of test strip use with hospitalization, after adjusting for clinical and demographic factors and health services use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) are reported. RESULTS: A total of 5,166 hospitalizations for hypoglycemia were identified in the observation period. Annual glucose test strip use increased by over 350%; however, no association was found with provincial hypoglycemia hospitalization rate during the same period, even after controlling for all-cause hospitalizations and population demographics. In the case-control analysis, test strip use was not associated with hospitalization for hypoglycemia among insulin users (n=10,617; adjusted OR, 1.08; 95% CI, 0.88 to 1.31). A sensitivity analysis in an independent cohort of noninsulin users produced a similar finding (n=47,501; adjusted OR, 1.04; 95% CI, 0.55 to 1.94). CONCLUSION: Our findings add to the body of evidence against a protective effect of blood glucose test strip use for serious hypoglycemia.

Inappropriateness of health care in Canada: a systematic review protocol.

BACKGROUND: There is increasing recognition in Canada and globally that a substantial proportion of health care delivered is inappropriate as evidenced by (1) harmful and/or ineffective practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused. Inappropriate health care leads to negative patient experiences, poor health outcomes, and inefficient use of scarce health care resources. The purpose of this study is to conduct a systematic review of inappropriate health care in Canada. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada; (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions. METHODS: We will include all quantitative study designs reporting objective or subjective measurements of inappropriate health care in Canada over the last 10 years. We will search the following online databases: MEDLINE, Cochrane Central Register of Controlled Trials, EconLit, and ISI-Web of Knowledge, which contains Web of Science Core Collection-Citation Indexes, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science & Humanities. We will also search grey literature sources to identify provincial and national audits of inappropriate health care. Two authors will independently screen, assess data quality, and extract data for synthesis. Study findings will be synthesized narratively. We will organize our data into three care categorizations: preventive care, acute care, and chronic care. We will provide a compendium of inappropriate health care for each care category for Canada and each Canadian province and territory, where sufficient data exists, by calculating (1) overall medians of underuse, overuse, and misuse of clinical practices and (2) the range of medians of underuse, overuse, and misuse for each clinical practice investigated. DISCUSSION: This review will result in the first-ever evidence-based compendium of inappropriate health care in Canada. We will also develop detailed reports of inappropriate health care for each Canadian province and territory. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018093495.

Bringing Together Research and Quality Improvement: The Saskatchewan Approach.

Improving health and health services requires both better knowledge (a key function of research) and better action to adapt and use what is already known (quality improvement). However, organizational and cultural divides between academic research institutions and health system organizations too often result in missed opportunities to integrate research and improvement. The Saskatchewan Health Quality Council's experience and relationships, from linking research, quality improvement and patient engagement in its leadership of the province's healthcare quality improvement journey, provided core support and leadership in the development of Saskatchewan's Strategy for Patient-Oriented Research SUPPORT Unit. The vision is for the SUPPORT Unit to integrate research and quality improvement into a continuous learning health system.

Variation in the health outcomes associated with frailty among home care clients: relevance of caregiver distress and client sex.

BACKGROUND: The identification of contextual factors that modify associations between client frailty and their health and service use outcomes is essential for informed home health care and policy planning. Our objective was to examine variation in the associations between frailty and select 1-year health outcomes by caregiver distress and client sex among community-residing older care recipients. METHODS: We conducted a retrospective cohort study using linked population-based clinical and health administrative databases for all long-stay home care clients (n = 234,552) aged 66+ years assessed during April 2010-2013 in Ontario, Canada. Frailty was assessed using a previously validated 72-item frailty index (FI). Presence of caregiver distress was derived from clinical assessment items administered by trained home care assessors. Multivariable log-binomial regression models were used to examine variations in the associations between frailty and outcomes of interest (mortality, nursing home [NH] placement, all-cause and prolonged hospitalization) by caregiver distress, with further model stratification by client sex. RESULTS: Frailty prevalence varied little by sex (19.3% women, 19.9% men) despite significant sex-differences in clients' sociodemographic and health characteristics. In both sexes, frailty was significantly associated with all outcomes, particularly NH placement (RR = 3.84, 95%CI 3.75-3.93) and death (RR = 2.32, 95%CI 2.27-2.37), though risk ratios were greater for women. Caregiver distress was more common with increasing frailty and for male clients, and a significant independent predictor of NH placement and prolonged hospitalization in both sexes. The association between frailty and NH placement (but not other outcomes) varied by caregiver distress for both men and women (p < 0.001 interaction terms), showing a greater magnitude of association among clients without (vs. with) a distressed caregiver. CONCLUSIONS: As caregiver distress varies by client sex, represents a key driver of NH placement (even among relatively robust clients), and modifies the impact of other risk factors such as frailty, it should be routinely assessed. Further, sex-differences should be considered when developing and evaluating community-based services for older adults and their caregivers.

Importance of clinical educators to research use and suggestions for better efficiency and effectiveness: results of a cross-sectional survey of care aides in Canadian long-term care facilities.

OBJECTIVE: This study explored the effect of clinical educators as facilitators of research use and how it may be modified by organisational context in the settings. DESIGN: Cross-sectional observational study. SETTING: A representative sample of 91 residential long-term care (LTC) facilities across Western Canada. PARTICIPANTS: We used surveys to collect data from the frontline care aides and information about the organisational context of the care units. OUTCOME MEASURE AND EXPLANATORY VARIABLES: We assessed research use (the outcome) with the Conceptual Research Utilization (CRU) scale. Explanatory variables in the multiple regression analysis were facilitation, organisational context and the interaction terms. Facilitation was measured by the frequency of contacts between care aides and clinical educator or person who brings new ideas about resident care. Three core organisational context variables were measured using the Alberta Context Tool. RESULTS: We included data of 3873 care aides from 294 care units in the LTC facilities. We found significant associations between CRU and facilitation, leadership, culture and evaluation. Interactions of facilitation x leadership and facilitation x culture were negative. The coefficient of the facilitation x evaluation term in the regression model was positive (0.019, 95% CI 0.012 to 0.026), suggesting synergistic effects between facilitation and a well-developed process to evaluate care quality using relevant data. CONCLUSIONS: Findings indicate clinical educators are effective facilitators of research use among the care aides, but the effect is modified by organisational context. For greatest impact, managers can direct efforts of the clinical educators to care units where leadership and culture ratings are lowest, but a proficient feedback and evaluation process is in place. This understanding enables managers to deploy clinical educators (a scarce resource in LTC settings) most efficiently.