Thinking and Enacting the Patient Medical Home Under Pandemic Conditions: A Qualitative Study From Primary Care in Alberta, Canada.

BACKGROUND: The COVID-19 (C19) pandemic shocked primary care systems around the world. Those systems responded by supporting patients in the community, and acute care facilities in crisis. In Canada, the Patient Medical Home (PMH) is a widely adopted care model that aims to operationalize the tenets and principles of Primary Health Care (PHC) as developed since the Alma-Ata Declaration. This paper describes how personnel working in and with Primary Care Networks (PCNs) in Alberta, Canada deployed the PMH model and its underlying PHC principles to frame and respond to the C19 shock. METHODS: Using purposive and snowball sampling techniques, we interviewed 57 participants who worked in public health and primary care, including community-based family physicians. We used interpretive description to analyze the interviews. RESULTS: PCN staff and physicians described how the PMH model was foundational to normal operations, and how C19 responses were framed by the patient-centric, team-delivered, and continuous care principles the model shares with PHC. Specifically, participants described ensuring access to care, addressing the social determinants of health, being patient centered, and redeploying and expanding PHC teams to accomplish these goals. DISCUSSION: Delivering PHC through the PMH allowed physicians and allied health staff to deliver patient-centered, team-based, holistic bio-medical services to Albertans. In tailoring services to meet the specific social and health needs of the populations served by each PCN, healthcare providers were able to ensure relevant support remained available and accessible.

An exploration of COVID-19 vaccination models for newcomer refugees and immigrants in Calgary, Canada.

BACKGROUND: The World Health Organization stresses the need for tailored COVID-19 models of vaccination to meet the needs of diverse populations and ultimately reach high rates of vaccination. However, little evidence exists on how COVID-19 models of vaccination operated in the novel context of the pandemic, how vulnerable populations, such as refugees, experience COVID-19 vaccination systems in high-income countries, and what lessons may be learned from vaccination efforts with vulnerable populations. To address this gap, this study explored COVID-19 vaccine delivery models available to newcomer refugees and immigrants, and refugee experiences across different COVID-19 vaccine delivery models in Calgary, Canada, and surrounding area in 2021 and 2022, to understand the barriers, strengths, and strategies of models to support access to COVID-19 vaccination for newcomer refugees and immigrants. METHODS: Researchers conducted structured interviews with Government Assisted Refugees (n = 39), and semi-structured interviews with Privately Sponsored Refugees (n = 6), private refugee sponsors (n = 3), and stakeholders involved in vaccination systems (n = 13) in 2022. Thematic analysis was conducted to draw out themes related to barriers, strengths, and strategies of vaccine delivery models and the intersections with patient experiences. RESULTS: Newcomer refugee and immigrant focused vaccination models and strategies were explored. They demonstrated how partnerships between organizations, multi-pronged approaches, and culturally responsive services were crucial to navigate ongoing and emergent factors, such as vaccine hesitancy, mandates, and other determinants of under-vaccination. Many vaccination models presented through interviews were not specific to refugees and included immigrants, temporary residents, ethnocultural community members, and other vulnerable populations in their design. CONCLUSIONS: Increasing COVID-19 vaccine uptake for newcomer refugees and immigrants, is complex and requires trust, ongoing information provision, and local partnerships to address ongoing and emerging factors. Three key policy implications were drawn. First, findings demonstrated the need for flexible funding to offer outreach, translation, cultural interpretation, and to meet the basic needs of patients prior to engaging in vaccinations. Second, the research showed that embedding culturally responsive strategies within services ensures community needs are met. Finally, collaborating with partners that reflect the diverse needs of communities is crucial for the success of any health efforts serving newcomers.

COVID-19 Vaccinations, Trust, and Vaccination Decisions within the Refugee Community of Calgary, Canada.

Refugee decisions to vaccinate for COVID-19 are a complex interplay of factors which include individual perceptions, access barriers, trust, and COVID-19 specific factors, which contribute to lower vaccine uptake. To address this, the WHO calls for localized solutions to increase COVID-19 vaccine uptake for refugees and evidence to inform future vaccination efforts. However, limited evidence engages directly with refugees about their experiences with COVID-19 vaccinations. To address this gap, researchers conducted qualitative interviews (N = 61) with refugees (n = 45), sponsors of refugees (n = 3), and key informants (n = 13) connected to local COVID-19 vaccination efforts for refugees in Calgary. Thematic analysis was conducted to synthesize themes related to vaccine perspectives, vaccination experiences, and patient intersections with policies and systems. Findings reveal that refugees benefit from ample services that are delivered at various stages, that are not solely related to vaccinations, and which create multiple positive touch points with health and immigration systems. This builds trust and vaccine confidence and promotes COVID-19 vaccine uptake. Despite multiple factors affecting vaccination decisions, a key reason for vaccination was timely and credible information delivered through trusted intermediaries and in an environment that addressed refugee needs and concerns. As refugees placed trust and relationships at the core of decision-making and vaccination, it is recommended that healthcare systems work through trust and relationships to reach refugees. This can be targeted through culturally responsive healthcare delivery that meets patients where they are, including barrier reduction measures such as translation and on-site vaccinations, and educational and outreach partnerships with private groups, community organizations and leaders.

Prioritizing Patient Reported Outcome Measures (PROMs) to use in the clinical care of youth living with mental health concerns: a nominal group technique study.

BACKGROUND: In the past few decades, particularly in the mental health setting, there has been growing interest in using Patient Reported Outcome Measures (PROMs) to assess the efficacy of the treatments in healthcare systems. Despite recent initiatives for global harmonization, there remains a lack of consensus on which PROMs are best practice and appropriate. Engagement of the service users, such as patients and family members/caregivers, is vital at this stage to ensure the selected PROMs are feasible, relevant, and acceptable to them. This study aimed to prioritize PROMs by youth and family/caregiver based on feasibility, relevance, and overall importance to be used in the clinical care of youth living with anxiety and/or depression. METHODS: Ten validated and widely used PROMs were presented to the patients and family/caregivers. Nominal group techniques were employed to prioritize the PROMs based on feasibility, relevance, and overall importance. RESULTS: For patients and families/caregivers, the PROMs, Revised Child Anxiety and Depression Scale (RCAD 25), and The Young Person's Core (YP-CORE) were the highest priorities. Both felt that RCAD 25 was comprehensive, short, easy, and quick to complete, whereas regarding YP-CORE, patients and family/caregivers thought it was also short and relevant. Due to some specific concerns, the Strength and Difficulties Questionnaire and Child Health Questionnaire were the lowest prioritized by patients and family/caregivers. CONCLUSION: It is of utmost importance that patient's and family/caregivers' voices or opinions are considered while selecting and implementing PROMs in mental health settings. Our study provides practical recommendations around measures best suited to achieve this.

Maternal Iron and Vitamin D Status during the Second Trimester Is Associated with Third Trimester Depression Symptoms among Pregnant Participants in the APrON Cohort.

BACKGROUND: The maternal status of multiple micronutrients during pregnancy and postpartum and their potential associations with maternal health outcomes are largely undescribed. OBJECTIVES: This study aimed to examine associations between maternal iron and vitamin D status, individually and in combination, on depression symptoms in pregnant individuals. METHODS: The Alberta Pregnancy Outcomes and Nutrition cohort study included pregnant participants and their children from Calgary and Edmonton, Canada. Iron biomarkers (serum ferritin [SF], soluble transferrin receptor, and hepcidin) were measured via immunoassays and vitamin D [25-hydroxyvitamin D3 (25(OH)D3) and 3-epi-25-hydoxyvitamin D3 (3-epi-25(OH)D3)] metabolites were quantifed using liquid chromatography with tandem mass spectroscopy. Four categories of maternal iron and vitamin D status during the second trimester were conceptualized using concentrations of SF and total 25-hydoxyvitamin D [25(OH)D], respectively. Maternal Edinburgh Postnatal Depression Scale (EPDS) scores during the third trimester (n = 1920) and 3 mo postpartum (n = 1822) were obtained. RESULTS: Concentrations of maternal 25(OH)D3, 3-epi-25(OH)D3, and the ratio of both metabolites were significantly higher during the second trimester compared with their status at 3 mo postpartum. Higher second trimester maternal concentrations of SF (ß: -0.8; 95% confidence interval [CI]: -1.5, -0.01), hepcidin (ß: -0.5; 95% CI: -0.9, -0.2), and 25(OH)D3 (ß: -0.01; 95% CI: -0.02, -0.004) predicted lower maternal EPDS scores during the third trimester. Pregnant individuals with a low iron (SF <15 µg/L) and replete vitamin D (25(OH)D ≥75 nmol/L) (ß: 1.1; 95% CI: 0.03, 2.1) or low iron (SF <15 µg/L) and vitamin D (25(OH)D <75 nmol/L) (ß: 2.2; 95% CI: 0.3, 4.2) status during midpregnancy had higher third trimester EPDS scores compared with those that were replete in both micronutrients. CONCLUSIONS: A higher midpregnancy maternal iron and vitamin D status, independently or in combination, predicted fewer maternal depression symptoms in the third trimester. Concentrations of maternal 25(OH)D3 and 3-epi-25(OH)D3 may be lower in the postpartum period compared with midpregnancy.

What are effective vaccine distribution approaches for equity-deserving and high-risk populations during COVID-19? Exploring best practices and recommendations in Canada: protocol for a mixed-methods multiple case codesign study.

INTRODUCTION: The WHO has stated that vaccine hesitancy is a serious threat to overcoming COVID-19. Vaccine hesitancy among underserved and at-risk communities is an ongoing challenge in Canada. Public confidence in vaccine safety and effectiveness and the principles of equity need to be considered in vaccine distribution. In Canada, governments of each province or territory manage their own healthcare system, providing an opportunity to compare and contrast distribution strategies. The overarching objective of this study is to identify effective vaccine distribution approaches and advance knowledge on how to design and implement various strategies to meet the different needs of underserved communities. METHODS AND ANALYSIS: Multiple case studies in seven Canadian provinces will be conducted using a mixed-methods design. The study will be informed by Experience-Based CoDesign techniques and theoretically guided by the Socio-Ecological Model and the Vaccine Hesitancy Matrix frameworks. Phase 1 will involve a policy document review to systematically explore the vaccine distribution strategy over time in each jurisdiction. This will inform the second phase, which will involve (2a) semistructured, in-depth interviews with policymakers, public health officials, researchers, providers, groups representing patients, researchers and stakeholders and (2b) an analysis of population-based administrative health data of vaccine administration. Integration of qualitative and quantitative data will inform the identification of effective vaccine distribution approaches for various populations. Informed by this evidence, phase 3 of the study will involve conducting focus groups with multiple stakeholders to codesign recommendations for the design and implementation of effective vaccine delivery strategies for equity-deserving and at-risk populations. ETHICS AND DISSEMINATION: This study is approved by the University of Toronto's Health Sciences Research Ethics Board (#42643), University of British Columbia Behavioural Research Ethics Board (#H22-01750-A002), Research Ethics Board of the Nova Scotia Health Authority (#48272), Newfoundland and Labrador Health Research Ethics Board (#2022.126), Conjoint Health Research Ethics Board, University of Calgary (REB22-0207), and University of Manitoba Health Research Board (H2022-239). The outcome of this study will be to produce a series of recommendations for implementing future vaccine distribution approaches from the perspective of various stakeholders, including equity-deserving and at-risk populations.

Bisphosphonates Preserve Bone Mineral Density and Suppress Bone Turnover Markers in Early Menopausal Women: A Systematic Review and Meta-Analysis of Randomized Trials.

Most women do not qualify for pharmacologic osteoporosis treatment until more than a decade after menopause, by which time they will have lost up to 30% of their bone mass and may have already sustained fractures. Short or intermittent courses of bisphosphonate therapy, initiated around the time of menopause, might prevent excessive bone loss and lower long-term fracture risk. We undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the effects of nitrogen-containing bisphosphonates on fracture incidence, bone mineral density (BMD), and bone turnover markers in early menopausal women (ie, perimenopausal or <5 years postmenopausal) over ≥12 months. Medline, Embase, CENTRAL, and CINAHL were searched in July 2022. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool. Random effect meta-analysis was undertaken using RevMan v5.3. In total, 12 trials were included (n = 1722 women); five evaluated alendronate, three risedronate, three ibandronate, and one zoledronate. Four were at low risk of bias; eight raised some concerns. Fractures were infrequent in the three studies that reported them. Compared with placebo, bisphosphonates improved BMD over 12 months (mean percentage difference, 95% confidence interval [CI]) at the spine (4.32%, 95% CI, 3.10%-5.54%, p < 0.0001, n = 8 studies), the femoral neck (2.56%, 95% CI, 1.85%-3.27%, p = 0.001, n = 6 studies), and the total hip (1.22%, 95% CI 0.16%-2.28%, p = 0.002, n = 4 studies). Over treatment durations of 24 to 72 months, bisphosphonates improved BMD at the spine (5.81%, 95% CI 4.71%-6.91%, p < 0.0001, n = 8 studies), femoral neck (3.89%, 95% CI 2.73%-5.05%, p = 0.0001, n = 5 studies) and total hip (4.09%, 95% CI 2.81%-5.37%, p < 0.0001, n = 4 studies). Bisphosphonates reduced urinary N-telopeptide (-52.2%, 95% CI -60.3% to -44.2%, p < 0.00001, n = 3 studies) and bone-specific alkaline phosphatase (-34.2%, 95% CI -42.6% to -25.8%, p < 0.00001, n = 4 studies) more than placebo at 12 months. This systematic review and meta-analysis shows that bisphosphonates improve BMD and lower bone turnover markers in early menopause, warranting further investigation of these agents for osteoporosis prevention. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Patient-reported outcome measures used to improve youth mental health services: a systematic review.

BACKGROUND: Patient-reported outcome measures (PROMs) are standardized and validated self-administered questionnaires that assess whether healthcare interventions and practices improve patients' health and quality of life. PROMs are commonly implemented in children and youth mental health services, as they increasingly emphasize patient-centered care. The objective of this study was to identify and describe the PROMs that are currently in use with children and youth living with mental health conditions (MHCs). METHODS: Three databases (MEDLINE, EMBASE, and PsycINFO) were systematically searched that used PROMs with children and youth < 18 years of age living with at least one diagnosed MHC. All methods were noted according to Preferred Reporting Items for Systematic reviews and Meta-Analysis. Four independent reviewers extracted data, which included study characteristics (country, year), setting, the type of MHC under investigation, how the PROMs were used, type of respondent, number of items, domain descriptors, and the psychometric properties. RESULTS: Of the 5004 articles returned by the electronic search, 34 full-texts were included in this review. This review identified both generic and disease-specific PROMs, and of the 28 measures identified, 13 were generic, two were generic preference-based, and 13 were disease-specific. CONCLUSION: This review shows there is a diverse array of PROMs used in children and youth living with MHCs. Integrating PROMs into the routine clinical care of youth living with MHCs could improve the mental health of youth. Further research on how relevant these PROMs are children and youth with mental health conditions will help establish more uniformity in the use of PROMs for this population.

Building a Data Bridge: Policies, Structures, and Governance Integrating Primary Care Into the Public Health Response to COVID-19.

PURPOSE: The effective integration of primary care into public health responses to the COVID-19 pandemic, particularly through data sharing, has received some attention in the literature. However, the specific policies and structures that facilitate this integration are understudied. This paper describes the experiences of clinicians and administrators in Alberta, Canada as they built a data bridge between primary care and public health to improve the province's community-based response to the pandemic. METHODS: Fifty-seven semistructured qualitative interviews were conducted with a range of primary care and public health stakeholders working inside the Calgary Health Zone. Interpretive description was used to analyze the interviews. RESULTS: SARS-CoV-2 test results produced by the local public laboratory were, initially, only available to central public health clinicians and not independent primary care physicians. This enabled centrally managed contact tracing but meant primary care physicians were unaware of their patients' COVID-19 status and unable to offer in-community follow-up care. Stakeholders from both central public health and independent primary care were able to leverage a policy commitment to the Patient Medical Home (PMH) care model, and a range of existing organizational structures, and governance arrangements to create a data bridge that would span the gap. CONCLUSIONS: Primary care systems looking to draw lessons from the data bridge's construction may consider ways to: leverage care model commitments to integration and adjust or create organization and governance structures which actively draw together primary care and non-primary care stakeholders to work on common projects. Such policies and structures develop trusting relationships, open the possibility for champions to emerge, and create the spaces in which integrative improvisation can take place.

The primary care COVID-19 integrated pathway: a rapid response to health and social impacts of COVID-19.

BACKGROUND: The first wave of COVID-19 in Calgary, Alberta accelerated the integration of primary care with the province's centrally managed health system. This integration aimed to deliver wraparound in-community patient care through two interventions that combined to create the COVID-19 Integrated Pathway (CIP). The CIP's interventions were: 1) a data sharing platform that ensured COVID-19 test results were directly available to family physicians (FPs), and 2) a clinical algorithm that supported FPs in delivering in-community follow up to improve patient outcomes. We describe the CIP function and its capacity to facilitate FP follow-up with COVID-19 patients and evaluate its impact on Emergency Department (ED) visits and hospitalization. METHOD: We generated descriptive statistics by analyzing data from a Calgary Zone hub clinic called the Calgary COVID-19 Care Clinic (C4), provincially maintained records of hospitalization, ED visits, and physician claims. RESULTS: Between Apr. 16 and Sep. 27, 2020, 7289 patients were referred by the Calgary Public Health team to the C4 clinic. Of those, 48.6% were female, the median age was 37.4 y. 97% of patients had at least one visit with a healthcare professional, where follow-up was conducted using the CIP's algorithm. 5.1% of patients visited an ED and 1.9% were hospitalized within 30 days of diagnosis. 75% of patients had a median of 4 visits with their FP. DISCUSSION: Our data suggest that information exchange between Primary Care (PC) and central systems facilitates primary care-based management of patients with COVID-19 in the community and has potential to reduce acute care visits.

Co-designing person-centred quality indicator implementation for primary care in Alberta: a consensus study.

BACKGROUND: We aimed to contribute to developing practical guidance for implementing person-centred quality indicators (PC-QIs) for primary care in Alberta, Canada. As a first step in this process, we conducted stakeholder-guided prioritization of PC-QIs and implementation strategies. Stakeholder engagement is necessary to ensure PC-QI implementation is adapted to the context and local needs. METHODS: We used an adapted nominal group technique (NGT) consensus process. Panelists were presented with 26 PC-QIs, and implementation strategies. Both PC-QIs and strategies were identified from our extensive previous engagement of patients, caregivers, healthcare providers, and quality improvement leaders. The NGT objectives were to: 1. Prioritize PC-QIs and implementation strategies; and 2. Facilitate the participation of diverse primary care stakeholders in Alberta, including patients, healthcare providers, and quality improvement staff. Panelists participated in three rounds of activities. In the first, panelists individually ranked and commented on the PC-QIs and strategies. The summarized results were discussed in the second-round face-to-face group meeting. For the last round, panelists provided their final individual rankings, informed by the group discussion. Finally, we conducted an evaluation of the consensus process from the panelists' perspectives. RESULTS: Eleven primary care providers, patient partners, and quality improvement staff from across Alberta participated. The panelists prioritized the following PC-QIs: 'Patient and caregiver involvement in decisions about their care and treatment'; 'Trusting relationship with healthcare provider'; 'Health information technology to support person-centred care'; 'Co-designing care in partnership with communities'; and 'Overall experience'. Implementation strategies prioritized included: 'Develop partnerships'; 'Obtain quality improvement resources'; 'Needs assessment (stakeholders are engaged about their needs/priorities for person-centred measurement)'; 'Align measurement efforts'; and 'Engage champions'. Our evaluation suggests that panelists felt that the process was valuable for planning the implementation and obtaining feedback, that their input was valued, and that most would continue to collaborate with other stakeholders to implement the PC-QIs. CONCLUSIONS: Our study demonstrates the value of co-design and participatory approaches for engaging stakeholders in adapting PC-QI implementation for the primary care context in Alberta, Canada. Collaboration with stakeholders can promote buy-in for ongoing engagement and ensure implementation will lead to meaningful improvements that matter to patients and providers.

Person-centred care (PCC) is a model of care where patient needs and preferences are included in decisions about care and treatment. To improve PCC in primary care in Alberta, Canada, we plan to use person-centred quality indicators (PC-QIs). Using PC-QIs involves surveying patients about their care experiences and using this information to make improvements. For example, if 20% of patients do not feel they are getting enough information, the clinic may create a checklist for the providers so information is not missed. We engaged a panel of 11 people, including patients, family doctors, and staff who support quality improvement in clinics across the province to decide together which PC-QIs primary care clinics in Alberta should use. We also asked the panel to decide the most important strategies that would make using the PC-QIs more successful. The panel chose PC-QIs related to: patient and caregiver involvement in decisions about care and treatment, a trusting relationship with the healthcare provider, having health information technology to support PCC, partnering with communities in healthcare, and the patient's overall experience. The most important strategies were: developing partnerships among people working in primary care in Alberta, discussing their needs and common efforts for improving PCC, engaging "champions," and securing funding that would be needed. Finally, we asked the panelists to share their experiences with participating in this process. Panelists found the process useful and that their input was valued. Most panelists would also like to continue to work together to put the PC-QIs into practice.

Immigrant Healthcare Experiences and Impacts During COVID-19: A Cross-Sectional Study in Alberta, Canada.

Primary Health Care is a gateway of healthcare services. The COVID-19 pandemic has modified the process of delivering care. We aimed to assess Albertan's healthcare experiences during the pandemic and compared experiences between Albertans that were born in and outside Canada. A cross-sectional online survey (experiences and impacts of COVID-19) was conducted in October 2020, 16 years, and older Albertans. Descriptive statistics and multivariable logistic regression were performed using STATA. Of 10 175 study participants, 10% were born outside Canada. Demographics were significantly different between the 2 groups (P < .05). Results revealed that Canadian-born were more likely to report worse mental and physical health status (AOR = 1.36; 95% CI: 1.17-1.56), and higher stress, anxiety, and depression during the pandemic (AOR = 1.37; 95% CI: 1.16-1.60) than those born outside Canada. However, Canadian-born reported a trend toward better virtual care experiences (AOR = 1.16; 95% CI: 0.94-1.44). Albertans reported negative health impacts due to delay in care during the pandemic and vaccine hesitancy for COVID-19, which was not significantly difference among the cohorts (P > .05). The study findings can inform primary healthcare providers and policymakers that could be used to develop quality improvement strategies.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study.

PURPOSE: Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs. METHODS: We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression. RESULTS: Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin. CONCLUSIONS: Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

The Alberta Pregnancy Outcomes and Nutrition (APrON) longitudinal study: cohort profile and key findings from the first three years.

PURPOSE: The objectives of the ongoing Canadian longitudinal cohort called the Alberta Pregnancy Outcomes and Nutrition (APrON) study are to: (1) determine the relationship between maternal nutrient intake and status before, during, after pregnancy, and (a) maternal mental health, (b) pregnancy and birth outcomes, and (c) infant/child neurodevelopment and behavior; (2) identify maternal mental health and nutrient predictors of child behaviour; and (3) establish a DNA biobank to explore genomic predictors of children's neurodevelopment and behavior. The purpose of this paper is to describe the participants, measures, and key findings on maternal and paternal mental health, maternal nutrition, and child outcomes to when children are 3 years of age. PARTICIPANTS: Participants included mothers and their children (n=2189) and mothers' partners (usually fathers; n=1325) from whom data were collected during the period from pregnancy to when children were 3 years of age, in Alberta, Canada. More than 88% of families have been retained to take part in completed data collection at 8 years of age. FINDINGS TO DATE: Data comprise: questionnaires completed by pregnant women/mothers and their partners on mothers', fathers' and children's health; dietary interviews; clinical assessments; linkage to hospital obstetrical records; and biological samples such as DNA. Key findings on mental health, nutrition and child outcomes are presented. APrON women who consumed more selenium and omega-3 were less likely to develop symptoms of perinatal depression. Higher prenatal consumption of choline rich foods such as eggs and milk were recommended as was vitamin D supplementation for both mothers and children to meet guidelines. Couples in which both mothers and fathers were affected by perinatal depression reported lower incomes and higher maternal prenatal depressive symptoms and lower support from fathers postnatally and their children presented with the most behavioural problems. Maternal experiences of early adversity predicted increased likelihood of perinatal depression and anxiety and children's behavioural problems. FUTURE PLANS: The APrON cohort offers a unique opportunity to advance understanding of the developmental origins of health and disease. There is a planned follow-up to collect data at 12 years of age.

Prenatal Folate and Choline Levels and Brain and Cognitive Development in Children: A Critical Narrative Review.

Women's nutritional status during pregnancy can have long-term effects on children's brains and cognitive development. Folate and choline are methyl-donor nutrients and are important for closure of the neural tube during fetal development. They have also been associated with brain and cognitive development in children. Animal studies have observed that prenatal folate and choline supplementation is associated with better cognitive outcomes in offspring and that these nutrients may have interactive effects on brain development. Although some human studies have reported associations between maternal folate and choline levels and child cognitive outcomes, results are not consistent, and no human studies have investigated the potential interactive effects of folate and choline. This lack of consistency could be due to differences in the methods used to assess folate and choline levels, the gestational trimester at which they were measured, and lack of consideration of potential confounding variables. This narrative review discusses and critically reviews current research examining the associations between maternal levels of folate and choline during pregnancy and brain and cognitive development in children. Directions for future research that will increase our understanding of the effects of these nutrients on children's neurodevelopment are discussed.

The primary care COVID-19 integrated pathway: a quantitative study of rapid response to health and social impacts of COVID-19.

Context: The first wave of COVID-19 in Calgary, Alberta health zone accelerated Primary Care (PC) integration. Specifically, it connected Family Physicians (FPs) with their counterparts in the broader health system to deliver wraparound patient care through a COVID-19 Integrated Pathway (CIP). A key element of the CIP included a data sharing platform that facilitated the provision of test results directly to the FP identified by patients. Public Health provided test results for all patients to the primary care system so they could be followed up by primary care to improve their outcomes. Objectives: To evaluate the CIP by describing its function and capacity to facilitate FP follow-up with COVID positive patients; and to inform refinement of the CIP for future use. Study Design: This abstract reports on the quantitative arm of a mixed methods study. Setting/Dataset: The Calgary Health Zone. Primary data were drawn from the Calgary COVID-19 Care Clinic (C4), a designated hub clinic for COVID-19 patients. Secondary data were drawn from provincially maintained records of hospitalization, emergency department visits, and FP claims. Participants: FPs and COVID-19 patients. Intervention: The data platform and PC attachment elements of the CIP. Outcome Measures: The characteristics of patients cared for via the CIP (age, sex, ethnicity, and risk-level); the proportion of patients without a FP who were attached to an FP; the number of patients followed by their FP in the community, and the number of specialist consultations made by FPs to support care, time from diagnosis to follow-up with PC/FP; ED and acute care utilization. Results: Between Apr. 16 and Sep. 27, 2020, 7706 patients were referred by the Public Health team to the C4 clinic. Of those, 51.4% were male, the median age was 36 y., and 86 deaths were reported. The majority of patients were referred to local PC networks where follow-up was conducted using the CIP: 3223 (43%) already had their own FP, 2448 (32%) were successfully attached to an FP, and 1899 (25%) of these patients were monitored by C4 physicians - these patients either did not have FP or their FP was not available to follow the patient. 8.6% of these patients visited ED and 3.1% were hospitalized. More than 80% of these patients had at least of 5 visits with their FP. Conclusion: Data suggest that the CIP facilitated primary care based management of patients with COVID-19.

Comparison of 2 fracture risk estimation processes in Alberta: a cross-sectional chart review.

BACKGROUND: In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences. METHODS: We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%-19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories. RESULTS: Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%-25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%-43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients. INTERPRETATION: Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.

Patient-Reported Experiences in Accessing Primary Healthcare among Immigrant Population in Canada: A Rapid Literature Review.

(1) Background: Immigrants represent around 21.9% of the total population in Canada and encounter multifaceted obstacles in accessing and receiving primary healthcare. This literature review explores patient experiences in primary care from the perspective of immigrants and identifies areas for further research and improvement. (2) Methods: A comprehensive search was performed on PubMed, MEDLINE, Embase, SCOPUS, and Google scholar to identify studies published from 2010 to July 2020. Relevant articles were peer-reviewed, in English language, and reported patient experiences in primary healthcare in Canada. (3) Results: Of the 1566 searched articles, 19 articles were included in this review. Overall, the finding from articles were summarized into four major themes: cultural and linguistic differences; socioeconomic challenges; health system factors; patient-provider relationship. (4) Conclusion: Understanding the gaps to accessing and receiving appropriate healthcare is important to shape policies, enhance the quality of services, and deliver more equitable healthcare services. It is therefore pertinent that primary healthcare providers play an active role in bridging these gaps with strong support from policymakers. Understanding and respecting diversity in culture, language, experiences, and systems is crucial in reducing health inequalities and improving access to quality care in a respectful and responsive manner.

Optimizing emergency department care transitions to outpatient settings: A systematic review and meta-analysis.

INTRODUCTION: Suboptimal transitions from the emergency department (ED) to outpatient settings can result in poor care continuity, and subsequently higher costs to the healthcare system. We aimed to systematically review care transition interventions (CTIs) for adult patients to understand how effective ED-based CTIs are in reducing return visits to the ED and increasing follow-up visits with primary care physicians. METHODS: We searched multiple databases and identified eligible published RCTs of ED-based CTIs affecting outpatient follow-up rates, ED readmission and hospital admission. Two independent authors reviewed titles and abstracts for potential inclusion and selected studies for full review. Study quality was assessed using the Cochrane risk-of-bias tool. ED-based CTIs were classified using a care continuity framework. RESULTS: Our search generated 28,807 articles; 112 were selected for full-text review. Data were abstracted from 42 articles that met inclusion criteria. Pooling data from 20 studies (n = 8178 patients) found a relative increase in outpatient follow-up with ED-based CTIs compared to routine care (odds ratio 1.79, 95% confidence interval [CI] 1.43, 2.24). However, ED-based CTIs (20 studies, n = 8048 patients) had no significant effect on ED readmissions (odds ratio 1.02, 95% CI 0.87, 1.20]) or hospital admission after ED discharge (13 studies, n = 5742 patients) (odds ratio 0.99, 95% CI 0.86, 1.14) when compared to routine care. Twenty-two studies encompassed CTIs supporting all three functions of care continuity (information, communication and coordination). CONCLUSIONS: ED-based CTIs do not appear to reduce ED revisit or hospital admission after ED discharge but are effective in increasing follow-up.

Academic Achievement and Psychosocial Adjustment in Child Refugees: A Systematic Review.

Child refugees are at high risk for problems with academic achievement and psychosocial well-being. We aimed to review the literature concerning these outcomes in primary school-aged child refugees. This study was a systematic review and included studies that reported on outcomes of interest in child refugees between 5 and 12 years of age. Our search generated 3,172 articles; we selected 313 for review and included 45. Child refugees are diverse in their educational performance, and early deficits often resolve with time spent in the host country. These children are at an increased risk of emotional and behavioral difficulties, and multiple factors are associated with these outcomes. Although educational difficulties of primary school-aged child refugees in high-income countries tend to resolve, the risks for psychosocial problems persist. This review provides a deepened understanding of the diverse educational and psychosocial experiences of these children and highlights the need for developing health and educational programs to support this population.