Drivers of COVID-19 Outcomes in Long-Term Care Facilities Using Multi-Level Analysis: A Systematic Review.

This study aimed to identify the individual, organizational, and environmental factors which contributed to COVID-19-related outcomes in long-term care facilities (LTCFs). A systematic review was conducted to summarize and synthesize empirical studies using a multi-level analysis approach to address the identified influential factors. Five databases were searched on 23 May 2023. To be included in the review, studies had to be published in peer-reviewed journals or as grey literature containing relevant statistical data. The Joanna Briggs Institute critical appraisal tool was employed to assess the methodological quality of each article included in this study. Of 2137 citations identified after exclusions, 99 records met the inclusion criteria. The predominant individual, organizational, and environmental factors that were most frequently found associated with the COVID-19 outbreak comprised older age, higher dependency level; lower staffing levels and lower star and subset domain ratings for the facility; and occupancy metrics and co-occurrences of outbreaks in counties and communities where the LTCFs were located, respectively. The primary individual, organizational, and environmental factors frequently linked to COVID-19-related deaths comprised age, and male sex; higher percentages of racial and ethnic minorities in LTCFs, as well as ownership types (including private, for-profit, and chain membership); and higher occupancy metrics and LTCF's size and bed capacity, respectively. Unfolding the risk factors collectively may mitigate the risk of outbreaks and pandemic-related mortality in LTCFs during future endemic and pandemics through developing and improving interventions that address those significant factors.

"We could have used a lot more of this before ": A qualitative study understanding barriers and facilitators to implementing a provincial PPE safety coach program during the COVID-19 pandemic.

BACKGROUND: A Provincial PPE Safety Coach Program was introduced to support appropriate use of personal protective equipment by health care workers. The objective was to understand barriers and facilitators to implementation. METHODS: A qualitative study was conducted mid-2021. Participants were recruited using a purposive sampling strategy. Interviews were conducted using a guide informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research. Analysis was conducted using the Theoretical Domains Framework. RESULTS: Prominent domains identified by staff were "social influences and skills", "environmental context and resources", "social/professional role and identity", "emotion", and "belief of consequences". Prominent domains identified by safety coaches were "knowledge", "social/professional role and identity", "environmental context and resources", and "memory". Only "environmental context and resources" and "social/professional role and identity" were similar. The main facilitators were fear of COVID-19 and leadership commitment, while the main barriers were lack of clarity and balancing the role. DISCUSSION: Understanding the local context of a health care environment influenced the success of safety coaches. The role allowed individuals to develop leadership skills and help staff improve their perceived competence in using personal protective equipment. CONCLUSIONS: Safety coaches were well received. Influencing factors provide a basis for strategies to embed this approach throughout a health care system.

Artificial intelligence predictive analytics in heart failure: results of the pilot phase of a pragmatic randomized clinical trial.

OBJECTIVES: We conducted an implementation planning process during the pilot phase of a pragmatic trial, which tests an intervention guided by artificial intelligence (AI) analytics sourced from noninvasive monitoring data in heart failure patients (LINK-HF2). MATERIALS AND METHODS: A mixed-method analysis was conducted at 2 pilot sites. Interviews were conducted with 12 of 27 enrolled patients and with 13 participating clinicians. iPARIHS constructs were used for interview construction to identify workflow, communication patterns, and clinician's beliefs. Interviews were transcribed and analyzed using inductive coding protocols to identify key themes. Behavioral response data from the AI-generated notifications were collected. RESULTS: Clinicians responded to notifications within 24 hours in 95% of instances, with 26.7% resulting in clinical action. Four implementation themes emerged: (1) High anticipatory expectations for reliable patient communications, reduced patient burden, and less proactive provider monitoring. (2) The AI notifications required a differential and tailored balance of trust and action advice related to role. (3) Clinic experience with other home-based programs influenced utilization. (4) Responding to notifications involved significant effort, including electronic health record (EHR) review, patient contact, and consultation with other clinicians. DISCUSSION: Clinician's use of AI data is a function of beliefs regarding the trustworthiness and usefulness of the data, the degree of autonomy in professional roles, and the cognitive effort involved. CONCLUSION: The implementation planning analysis guided development of strategies that addressed communication technology, patient education, and EHR integration to reduce clinician and patient burden in the subsequent main randomized phase of the trial. Our results provide important insights into the unique implications of implementing AI analytics into clinical workflow.

Social participation of older people in urban and rural areas: Canadian Longitudinal Study on Aging.

BACKGROUND AND OBJECTIVES: Although the positive influence of social activity on health is now well-established, a complex relationship exists among social participation, personal, social and the environment. Social participation of older adults was examined in rural and urban settings to identify features of the built-environment and perception of neighborhood specific to the locale. RESEARCH DESIGN AND METHODS: Using cross-sectional data from the Canadian Longitudinal Study on Aging (CLSA), we examined social participation and health of older people (65 + yrs) in relation to the built environment and sociocultural contexts for urban and rural areas. A social participation index was derived from responses on the frequency of participating in 8 social activities over the past 12 months. Personal, household and neighborhood indicators were examined to develop multivariable regression models for social participation in urban and rural cohorts. RESULTS: No meaningful differences were seen with the frequency of social participation between rural and urban settings; however, the type of community-related activities differed in that a greater proportion of urban participants reported sports and educational/cultural events than rural participants. Service club activities were greater for rural than urban participants. Different neighborhood features were statistically significant factors in explaining social participation in rural than in urban locales, although transportation was a significant factor regardless of locale. Trustworthiness, belonging and safety were perceived factors of the neighborhood associated with higher social participation for rural participants. DISCUSSION AND IMPLICATIONS: The relationship between home and health becomes stronger as one ages. Social and physical features of built environment specific to urban and rural settings need to be considered when implementing appropriate social activities for older people.

Lessons learned from implementing a surge capacity support program for COVID-19 contact management in Ontario.

SETTING: In Ontario, local public health units (PHUs) are responsible for leading case investigations, contact tracing, and follow-up. The workforce capacity and operational requirements needed to maintain this public health strategy during the COVID-19 pandemic were unprecedented. INTERVENTION: Public Health Ontario's Contact Tracing Initiative (CTI) was established to provide a centralized workforce. This program was unique in leveraging existing human resources from federal and provincial government agencies and its targeted focus on initial and follow-up phone calls to high-risk close contacts of COVID-19 cases. By setting criteria for submissions to the program, standardizing scripts, and simplifying the data management process, the CTI was able to support a high volume of calls. OUTCOMES: During its 23 months of operation, the CTI was used by 33 of the 34 PHUs and supported over a million calls to high-risk close contacts. This initiative was able to meet its objectives while adapting to the changing dynamics of the pandemic and the implementation of a new COVID-19 provincial information system. Core strengths of the CTI were timeliness, volume, and efficient use of resources. The CTI was found to be useful for school exposures, providing support when public health measures were lifted, and in supporting PHU's reallocation of resources during the vaccine roll-out. IMPLICATIONS: When considering future use of this model, it is important to take note of the program strengths and limitations to ensure alignment with future needs for surge capacity support. Lessons learned from this initiative could provide practice-relevant knowledge for surge capacity planning.

RéSUMé: CONTEXTE: En Ontario, ce sont les bureaux de santé publique qui s'occupent des enquêtes de cas, de la recherche des contacts et des suivis. Pendant la pandémie de COVID-19, les besoins opérationnels et de capacité de la main-d'œuvre à combler pour conserver cette stratégie de santé publique ont atteint une ampleur jamais vue. INTERVENTION: L'Initiative de recherche des contacts dans le cadre de la lutte contre la COVID-19 de Santé publique Ontario a été mise sur pied dans l'objectif de centraliser l'effectif. Mobilisant des ressources humaines d'organisations fédérales et provinciales, ce programme a permis de faire les appels initiaux et de suivi aux contacts étroits de cas de COVID-19 exposés à un risque élevé. Grâce à des critères bien établis pour les soumissions au programme, à l'uniformisation des scripts et à la simplification du processus de gestion des données, un grand volume d'appels a pu être traité. RéSULTATS: Durant les 23 mois de l'Initiative, 33 des 34 bureaux de santé publique y ont eu recours. Ce sont ainsi plus d'un million d'appels à des contacts étroits qui ont pu être faits. L'Initiative a permis d'atteindre les objectifs en s'adaptant au contexte pandémique en constante évolution et de mettre en œuvre un nouveau système de gestion des renseignements provinciaux sur la COVID-19. Ses grandes forces sont la rapidité, le volume et l'efficacité de l'utilisation des ressources. Elle a été particulièrement utile dans les cas d'exposition en milieu scolaire, permettant d'offrir du soutien à la levée des mesures sanitaires et d'aider à la réaffectation des ressources des bureaux de santé publique pendant la campagne de vaccination. CONSéQUENCES: Si l'on envisage de réutiliser ce modèle, il importe de tenir compte des forces et des faiblesses du programme pour qu'il cadre avec les besoins futurs de soutien en matière de capacité de mobilisation. Les leçons tirées de cette initiative pourraient s'avérer pertinentes pour la planification de cette capacité.

Cultural Knowledge in Context - People Aged 50 Years and Over Make Sense of a First Fracture and Osteoporosis.

Catch a Break (CaB) is a secondary fracture prevention program that uses medical understandings of osteoporosis to assess first fractures and determine appropriateness for secondary fracture prevention. In this study, we interviewed CaB program participants to identify the understandings that patients themselves used to make sense of first fractures and the osteoporosis suggestion as cause. Semi-structured interviews were conducted with female and male participants of the CaB program in Canada. An interpretive practice approach was used to analyze the data. A random sample of 20 individuals, 12 women, and eight men all aged 50 years and over participated. First fractures were produced as meaningful in the context of osteoporosis only for seniors of very advanced age, and for people of any age with poor nutrition. The trauma events that led to a first fracture were produced as meaningful only if perceived as accidents, and having an active lifestyle was produced as beneficial only for mental health and well-being unrelated to osteoporosis. Cultural knowledge shapes, but does not determine, how individuals make sense of their health and illness experiences. Risk prevention program designers should include patients on the design team and be more aware of the presumptive knowledge used to identify individuals at risk of disease.

Supporting Rehabilitation of Rural Patients Receiving Total Knee Arthroplasty Through Physical Activity: Perceptions of Stakeholder Groups.

OBJECTIVE: To identify how patients with osteoarthritis waiting for and recovering from total knee arthroplasty (TKA) conceptualized and participated in physical activity behaviors in their rural setting and to gather perceptions of health care professionals and rehabilitation decision-makers on the feasibility of a remotely led physical activity coaching intervention. METHODS: Using a qualitative descriptive study, we collected data from three stakeholder groups: patients waiting for or recovering from TKA (interviews), health professionals delivering a physical activity intervention to patients in the recovering cohort (focus group), and rehabilitation leaders involved in decision-making at the local or provincial level (interviews). RESULTS: A total of 38 individuals provided their perspectives (25 patients, five health professionals, eight decision-makers). Patients waiting for and recovering from surgery described the attributes of their rural environment that supported and restricted their ability to participate in physical activities. Patients recovering from TKA appreciated support for goal-setting and problem-solving during their rehabilitation. Health care professionals and decision-makers commented on the benefits of the program's innovative use of relatively simple technology to support remotely delivered, personalized rehabilitation in rural settings. CONCLUSION: This study adds to the limited voice of and about patients living with osteoarthritis who reside in rural settings and identifies facilitators and barriers to TKA rehabilitation in this population. Our findings highlight that it is important to consider the local context and the resources available to patients as they navigate living well with osteoarthritis.

Human Retrovirus Genomic RNA Packaging.

Two non-covalently linked copies of the retrovirus genome are specifically recruited to the site of virus particle assembly and packaged into released particles. Retroviral RNA packaging requires RNA export of the unspliced genomic RNA from the nucleus, translocation of the genome to virus assembly sites, and specific interaction with Gag, the main viral structural protein. While some aspects of the RNA packaging process are understood, many others remain poorly understood. In this review, we provide an update on recent advancements in understanding the mechanism of RNA packaging for retroviruses that cause disease in humans, i.e., HIV-1, HIV-2, and HTLV-1, as well as advances in the understanding of the details of genomic RNA nuclear export, genome translocation to virus assembly sites, and genomic RNA dimerization.

Molecular Determinants of Human T-cell Leukemia Virus Type 1 Gag Targeting to the Plasma Membrane for Assembly.

Assembly of human T-cell leukemia virus type 1 (HTLV-1) particles is initiated by the trafficking of virally encoded Gag polyproteins to the inner leaflet of the plasma membrane (PM). Gag-PM interactions are mediated by the matrix (MA) domain, which contains a myristoyl group (myr) and a basic patch formed by lysine and arginine residues. For many retroviruses, Gag-PM interactions are mediated by phosphatidylinositol 4,5-bisphosphate [PI(4,5)P2]; however, previous studies suggested that HTLV-1 Gag-PM interactions and therefore virus assembly are less dependent on PI(4,5)P2. We have recently shown that PI(4,5)P2 binds directly to HTLV-1 unmyristoylated MA [myr(-)MA] and that myr(-)MA binding to membranes is significantly enhanced by inclusion of phosphatidylserine (PS) and PI(4,5)P2. Herein, we employed structural, biophysical, biochemical, mutagenesis, and cell-based assays to identify residues involved in MA-membrane interactions. Our data revealed that the lysine-rich motif (Lys47, Lys48, and Lys51) constitutes the primary PI(4,5)P2-binding site. Furthermore, we show that arginine residues 3, 7, 14 and 17 located in the unstructured N-terminus are essential for MA binding to membranes containing PS and/or PI(4,5)P2. Substitution of lysine and arginine residues severely attenuated virus-like particle production, but only the lysine residues could be clearly correlated with reduced PM binding. These results support a mechanism by which HTLV-1 Gag targeting to the PM is mediated by a trio engagement of the myr group, Arg-rich and Lys-rich motifs. These findings advance our understanding of a key step in retroviral particle assembly.

Accounts of health risk assessment survey administration in the Catch a Break Program: the social construction of osteoporosis risk identification and need for intervention.

Catch a Break staff conducting the organizational work of delivering secondary fracture prevention screening conversations drew on cultural and organizational resources to determine eligibility of individuals. They encountered and navigated their way through interactional troubles as they requested participation, assessed trauma risk, and provided lifestyle information. PURPOSE: We investigated delivery of a population-based type C fracture liaison service for non-hip fractures. The purpose of this study was to examine accounts of how osteoporosis health risk screening interactions were delivered. METHODS: A pre-determined sample of 5 organizational representatives (program staff) were interviewed by telephone. We analyzed the qualitative data through the lens of interpretive inquiry, informed by discourse analysis, to examine staff's "talk" about conducting the program risk screening conversations. RESULTS: A dominant finding emerging from CAB staff's accounts of program delivery was the conversational work required to include only those individuals deemed appropriate for the program while managing the survey interaction. Staff talked about specific examples of interactional troubles they experienced as barriers to the smooth and successful risk screening conversation. They drew on cultural and organizational resources as interpretive frameworks to make decisions about individuals and groups at risk and in need of further investigation. They drew on larger ideas about ageism and genderism, judging as inappropriate for participation the oldest old adults, men involved in high risk occupations, and adults aged 50 to 70. Staff also employed interactional resources useful in managing problems in the conversation during the request to participate, trauma risk assessment, and lifestyle/health information provision sequences of the risk screening call. CONCLUSION: We uncovered areas in the screening interaction that were talked about by staff as problematic to achieving the program objective of identifying and enrolling individuals in the secondary fracture prevention program. By highlighting areas for improvement in program delivery, this study may help to reduce the interactional troubles staff negotiate as they deliver this type of program.

Structural Insights into the Mechanism of Human T-cell Leukemia Virus Type 1 Gag Targeting to the Plasma Membrane for Assembly.

Retroviral Gag targeting to the plasma membrane (PM) for assembly is mediated by the N-terminal matrix (MA) domain. For many retroviruses, Gag-PM interaction is dependent on phosphatidylinositol 4,5-bisphosphate (PI(4,5)P2). However, it has been shown that for human T-cell leukemia virus type 1 (HTLV-1), Gag binding to membranes is less dependent on PI(4,5)P2 than HIV-1, suggesting that other factors may modulate Gag assembly. To elucidate the mechanism by which HTLV-1 Gag binds to the PM, we employed NMR techniques to determine the structure of unmyristoylated MA (myr(-)MA) and to characterize its interactions with lipids and liposomes. The MA structure consists of four α-helices and unstructured N- and C-termini. We show that myr(-)MA binds to PI(4,5)P2 via the polar head and that binding to inositol phosphates (IPs) is significantly enhanced by increasing the number of phosphate groups on the inositol ring, indicating that the MA-IP binding is governed by charge-charge interactions. The IP binding site was mapped to a well-defined basic patch formed by lysine and arginine residues. Using an NMR-based liposome binding assay, we show that PI(4,5)P2and phosphatidylserine enhance myr(-)MA binding in a synergistic fashion. Confocal microscopy data revealed formation of puncta on the PM of Gag expressing cells. However, G2A-Gag mutant, lacking myristoylation, is diffuse and cytoplasmic. These results suggest that although myr(-)MA binds to membranes, myristoylation appears to be key for formation of HTLV-1 Gag puncta on the PM. Altogether, these findings advance our understanding of a key mechanism in retroviral assembly.

The Brain in Motion II Study: study protocol for a randomized controlled trial of an aerobic exercise intervention for older adults at increased risk of dementia.

BACKGROUND: There remains no effective intervention capable of reversing most cases of dementia. Current research is focused on prevention by addressing risk factors that are shared between cardiovascular disease and dementia (e.g., hypertension) before the cognitive, functional, and behavioural symptoms of dementia manifest. A promising preventive treatment is exercise. This study describes the methods of a randomized controlled trial (RCT) that assesses the effects of aerobic exercise and behavioural support interventions in older adults at increased risk of dementia due to genetic and/or cardiovascular risk factors. The specific aims are to determine the effect of aerobic exercise on cognitive performance, explore the biological mechanisms that influence cognitive performance after exercise training, and determine if changes in cerebrovascular physiology and function persist 1 year after a 6-month aerobic exercise intervention followed by a 1-year behavioural support programme (at 18 months). METHODS: We will recruit 264 participants (aged 50-80 years) at elevated risk of dementia. Participants will be randomly allocated into one of four treatment arms: (1) aerobic exercise and health behaviour support, (2) aerobic exercise and no health behaviour support, (3) stretching-toning and health behaviour support, and (4) stretching-toning and no health behaviour support. The aerobic exercise intervention will consist of three supervised walking/jogging sessions per week for 6 months, whereas the stretching-toning control intervention will consist of three supervised stretching-toning sessions per week also for 6 months. Following the exercise interventions, participants will receive either 1 year of ongoing telephone behavioural support or no telephone support. The primary aim is to determine the independent effect of aerobic exercise on a cognitive composite score in participants allocated to this intervention compared to participants allocated to the stretching-toning group. The secondary aims are to examine the effects of aerobic exercise on a number of secondary outcomes and determine whether aerobic exercise-related changes persist after a 1-year behavioural support programme (at 18 months). DISCUSSION: This study will address knowledge gaps regarding the underlying mechanisms of the pro-cognitive effects of exercise by examining the potential mediating factors, including cerebrovascular/physiological, neuroimaging, sleep, and genetic factors that will provide novel biologic evidence on how aerobic exercise can prevent declines in cognition with ageing. TRIAL REGISTRATION: ClinicalTrials.gov NCT03035851 . Registered on 30 January 2017.

Identification of knowledge translation theories, models or frameworks suitable for health technology reassessment: a survey of international experts.

OBJECTIVE: Health technology reassessment (HTR) is a field focused on managing a technology throughout its life cycle for optimal use. The process results in one of four possible recommendations: increase use, decrease use, no change or complete withdrawal of the technology. However, implementation of these recommendations has been challenging. This paper explores knowledge translation (KT) theories, models and frameworks (TMFs) and their suitability for implementation of HTR recommendations. DESIGN: Cross-sectional survey. PARTICIPANTS: Purposeful sampling of international KT and HTR experts was administered between January and March 2019. METHODS: Sixteen full-spectrum KT TMFs were rated by the experts as 'yes', 'partially yes' or 'no' on six criteria: familiarity, logical consistency/plausibility, degree of specificity, accessibility, ease of use and HTR suitability. Consensus was determined as a rating of ≥70% responding 'yes'. Descriptive statistics and manifest content analysis were conducted on open-ended comments. RESULTS: Eleven HTR and 11 KT experts from Canada, USA, UK, Australia, Germany, Spain, Italy and Sweden participated. Of the 16 KT TMFs, none received ≥70% rating. When ratings of 'yes' and 'partially yes' were combined, the Consolidated Framework for Implementation Research was considered the most suitable KT TMF by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: Knowledge to Action framework. HTR experts selected two additional KT TMFs: Co-KT framework and Plan-Do-Study-Act cycle. Experts identified three key characteristics of a KT TMF that may be important to consider: practicality, guidance on implementation and KT TMF adaptability. CONCLUSIONS: Despite not reaching an overall ≥70% rating on any of the KT TMFs, experts identified four KT TMFs suitable for HTR. Users may apply these KT TMFs in the implementation of HTR recommendations. In addition, KT TMF characteristics relevant to the field of HTR need to be explored further.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention.

INTRODUCTION: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches. METHODS AND ANALYSIS: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation. ETHICS AND DISSEMINATION: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners. TRIAL REGISTRATION NUMBER: NCT03442426;Pre-results.

Identifying what matters most for the health of older adults in Alberta: results from a James Lind Alliance Research Priority Setting Partnership.

BACKGROUND: As the number of older adults continues to increase, addressing their health becomes increasingly important for both the population and the health care system. The aim of this priority setting partnership was to use direct engagement with older adults, caregivers and health care providers to identify and prioritize the most important topics on the health of older adults that should be addressed by future research. METHODS: We followed the James Lind Alliance method. We conducted an initial online and paper survey from Jan. 22 to May 2, 2018, with older adults in Alberta aged 65 years and older to identify what respondents saw as being most important for the health of older adults. We formed responses into summary questions and checked them against existing evidence. We administered a second survey (July 3 to Aug. 2, 2018) to shortlist summary questions and held an in-person workshop (Aug. 30, 2018) to rank the list through discussion and shared decision-making. RESULTS: We recruited 670 participants (32.7% older adults, 19.7% caregivers, 46.9% health and social care workers) in the initial survey to tell us what topics on the health of older adults mattered most to them. Over 3000 responses generated 101 summary questions, of which only 4 were completely answered by existing evidence. The second prioritization survey was completed by 232 participants (28.4% older adults, 24.6% care partners, 47.0% health and social care workers) to produce a shortlist of 22 high priority questions. Twenty-two attendees participated in the summary workshop to create a prioritized list of 10 questions for future research that address aspects of the health system, provision of care and living well in older adulthood. INTERPRETATION: Older adults, caregivers and clinicians collectively produced a prioritized list of questions that matter most to older adults' health in Alberta. Provincial researchers and research funders should consider these unmet knowledge needs of end-users in future endeavours.

Characteristics of knowledge translation theories, models and frameworks for health technology reassessment: expert perspectives through a qualitative exploration.

BACKGROUND: Health Technology Reassessment (HTR) is a process that systematically assesses technologies that are currently used in the health care system. The process results in four outputs: increase use or decrease use, no change, or de-adoption of a technology. Implementation of these outputs remains a challenge. The Knowledge Translation (KT) field enables to transfer/translate knowledge into practice. KT could help with implementation of HTR outputs. This study sought to identify which characteristics of KT theories, models, and frameworks could be useful, specifically for decreased use or de-adoption of a technology. METHODS: A qualitative descriptive approach was used to ascertain the perspectives of international KT and HTR experts on the characteristics of KT theories, models, and frameworks for decreased use or de-adoption of a technology. One-to-one semi-structured interviews were conducted from September to December 2019. Interviews were audio recorded and transcribed verbatim. Themes and sub-themes were deduced from the data through framework analysis using five distinctive steps: familiarization, identifying an analytic framework, indexing, charting, mapping and interpretation. Themes and sub-themes were also mapped to existing KT theories, models, and frameworks. RESULTS: Thirteen experts from Canada, United States, United Kingdom, Australia, Germany, Spain, and Sweden participated in the study. Three themes emerged that illustrated the ideal traits: principles that were foundational for HTR, levers of change, and steps for knowledge to action. Principles included evidence-based, high usability, patient-centered, and ability to apply to the micro, meso, macro levels. Levers of change were characterized as positive, neutral, or negative influences for changing behaviour for HTR. Steps for knowledge to action included: build the case for HTR, adapt research knowledge, assess context, select interventions, and assess impact. Of the KT theories, models, and frameworks that were mapped, the Consolidated Framework for Implementation Research had most of the characteristics, except ability to apply to micro, meso, macro levels. CONCLUSIONS: Characteristics that need to be considered within a KT theory, model, and framework for implementing HTR outputs have been identified. Consideration of these characteristics may guide users to select relevant KT theories, models, and frameworks to apply to HTR projects.

Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care.

BACKGROUND: Antipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted to address inappropriate antipsychotic medication use in long-term care (LTC) in the province of Alberta. METHODS: We conducted a multimethod evaluation of the provincial implementation of the project in 170 LTC sites over a 3-year project period incorporating a quasi-experimental before-after design. Using a three-component intervention of education and audit and feedback delivered in a learning workshop innovation collaborative format, local LTC teams were supported to reduce the number of residents receiving antipsychotic medications in the absence of a documented indication. Project resources were preferentially allocated to supporting sites with the highest baseline antipsychotic medication use. Changes in antipsychotic medication use, associated clinical and economic outcomes, and the effects of the project on LTC staff, physicians, leaders and administrators, and family members of LTC residents were assessed at the conclusion of the implementation phase. RESULTS: The province-wide initiative was delivered with a 75% implementation fidelity. Inappropriate antipsychotic medication use declined from 26.8% to 21.1%. The decrease was achieved without unintended consequences in other outcomes including physical restraint use or aggressive behaviours. The project was more expensive but resulted in less inappropriate use of antipsychotics than the pre-project period (incremental cost per inappropriate antipsychotic avoided of $5 678.71). Accounts from family, organisational leaders, and LTC staff were supportive of the project activities and outcomes. CONCLUSION: This quality improvement initiative was successfully delivered across an entire delivery arm of the continuing care sector. Quality of care in LTC was improved.

Return on Investment of the Primary Health Care Integrated Geriatric Services Initiative Implementation.

BACKGROUND: Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities. AIM OF THE STUDY: We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread. METHODS: We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 \sim = USD 0.75) using the Canadian Consumer Price Index. RESULTS: The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The PHC IGSI is cost-effective in Alberta. IMPLICATIONS FOR HEALTH POLICY: The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted. IMPLICATIONS FOR FURTHER RESEARCH: Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.

Successful implementation of a Fracture Liaison Service through effective change management: a qualitative study.

We assessed the context in which a hip Fracture Liaison Service was implemented. We conducted semi-structured interviews with 21 key informants at two time points to understand organizational readiness, facilitators, and barriers to change. We identified strategies important to successful implementation, particularly in the context of change fatigue. PURPOSE: Fracture Liaison Service (FLS) is effective for secondary fracture prevention. Two hospital sites implemented FLS for hip fracture patients, 50 + years, in Alberta, Canada. We assessed organizational readiness, facilitators, and barriers to change to better understand the context in which the FLS was implemented to inform its potential spread provincially. METHODS: We recruited individuals involved in FLS implementation at provincial and site levels to participate in telephone interviews at baseline and 16 months post-implementation. Interviews were transcribed and analyzed using thematic content analysis. In addition, site-level participants were invited to complete the Organizational Readiness to Implement Change tool at baseline. RESULTS: We conducted 33 semi-structured interviews (20 at baseline; 13 at post-implementation) with 21 key informants. Participants included managers (24%), FLS physicians/clinical nurses (19%), operational/leadership roles (19%), physicians/surgeons (14%), pharmacists (10%), nurse practitioners (10%), and social work (5%). Seventeen site-level participants completed the ORIC tool at baseline; all participants scored high (71%) or neutral (29%). We found that the use of several strategies, including demonstrating value, providing resources, and selecting appropriate sites, were important to implementation, particularly in the context of change fatigue. Participants perceived the FLS as acceptable and there was evidence of facilitated learning rather than simply monitoring implementation as intended. CONCLUSIONS: An effective change management approach neutralized change fatigue. This approach, if maintained, bodes well for the potential spread of the FLS provincially if proven effective and cost effective. Change readiness assessment tools could be used strategically to inform the spread of the FLS to early adopter sites.