What features of drug treatment programs help, or not, with access? a qualitative study of the perspectives of family members and community-based organization staff in Atlantic Canada.

BACKGROUND: Withdrawal management and opioid agonist treatment (OAT) programs help to reduce some of the harms experienced by people who use substances (PWUS). There is literature on how features of drug treatment programs (e.g., policies and practices) are helpful, or not helpful, to PWUS when seeking access to, or in, treatment. There is, however, relatively little literature based on the perspectives of family members/family of choice of PWUS and community-based organization staff within the context of Atlantic Canada. This paper explored the perspectives of these two groups on what was helpful, or not, about drug treatment programs in Atlantic Canada in terms of supporting access to, and retention in, treatment. METHODS: One-on-one qualitative telephone interviews were conducted in 2020 with the two groups. Interviews focused on government-funded withdrawal management and OAT programs. Data were coded using a qualitative data management program (ATLAS.ti) and analyzed inductively for key themes/subthemes using grounded theory techniques. RESULTS: Fifteen family members/family of choice and 16 community-based organization staff members participated (n = 31). Participants spoke about features of drug treatment programs in various places, and noted features that were perceived as helpful (e.g., quick access), as well as not helpful (e.g., wait times, programs located far from where PWUS live). Some participants provided their perceptions of how PWUS felt when seeking or accessing treatment. A number of participants reported taking various actions to help support access to treatment, including providing transportation to programs. A few participants also provided suggestions for change to help support access and retention such as better alignment of mental health and addiction systems. CONCLUSIONS: Participants highlighted several helpful and not helpful features of drug treatment programs in terms of supporting treatment access and retention. Previous studies with PWUS and in other places have reported similar features, some of which (e.g., wait times) have been reported for many years. Changes are needed to reduce barriers to access and retention including the changes recommended by study participants. It is critical that the voices of key groups, (including PWUS) are heard to ensure treatment programs in all places support access and retention.

Programs and practices that support pregnant people who use drugs' access to sexual and reproductive health care in Canada: a scoping review.

BACKGROUND: Pregnant people who use unregulated drugs (PPWUD) are at high risk of health complications yet experience a range of barriers to sexual and reproductive health care. Given that improving maternal health and access to reproductive health care are key targets underpinning the Sustainable Development Goals (SDG), there is an urgent need to improve access to appropriate supports and services for this population. Little is known about what programs and practices exist to support PPWUD's access to sexual and reproductive health care. This scoping review aimed to identify the available literature on these programs and practices in Canada. METHODS: A scoping review was conducted using JBI methodology and reported using PRISMA guidelines. Scholarly databases and grey literature sources were searched to identify literature published between 2016-2023 in English or French that discussed, defined, conceptualised, or evaluated programs and practices that support PPWUD's access to sexual and reproductive health care in Canada. Identified literature was screened using Covidence. Data were extracted from included texts, then analysed descriptively. Frequencies and key concepts were reported. RESULTS: A total of 71 articles were included, most of which were grey literature. Of the total, 46 unique programs were identified, as well as several useful practices. Most programs were in urban centres in Western Canada, and most programs offered holistic 'wrap-around services.' Several programs delivered these services on-site or as 'drop-in' programs with the support of staff with lived/living experience of substance use. Most frequent program outcomes included keeping parents and children together, improving connection to other services, and reducing substance use harms. Noted helpful practices included non-judgmental care and the use of harm-reduction strategies. CONCLUSIONS: Several programs and practices that support PPWUD exist in Canada, though few focus exclusively on sexual and reproductive health. There remain opportunities to improve access to programs, including expanding geographic availability and range of services. The review has clinical application by providing an overview of available programs that may support clinicians in identifying services for PPWUD. Future research should consider client perspectives and experiences of these programs. REVIEW REGISTRATION NUMBER: Open Science Framework https://osf.io/5y64j .

Time for a Gut Check: A Qualitative Study of Proposed Interventions to Address Gender Inequality in Gastroenterology.

Background: Gender inequalities persist in medicine, particularly in some speciality fields where fewer women are employed. Although previous research has suggested potential interventions to broadly address gender inequality in medicine, no research has focused on interventions in the field of gastroenterology. The purpose of this research was to engage women in the field of gastroenterology in Canada, to identify interventions with potential to be effective in addressing gender inequality. Methods: A World Café was hosted in 2019 to discuss gender inequality and interventions in gastroenterology. Twelve women employed in the field of gastroenterology (i.e. physicians, nurses, research staff, and trainees) were purposively recruited and participated in the event. The discussion rounds were audio-recorded, transcribed, and thematic analyses was conducted using Braun and Clarke's principles. Results: Three key themes identifying potential interventions to address gender inequality in gastroenterology were generated: (1) Education; (2) Addressing institutional structures and polices; and 3) Role modelling and mentorship. Participants indicated that interventions should target various stakeholders, including both women and men in gastroenterology, young girls, patients, and administrators. Conclusion: Many of the interventions identified by participants correspond with existing research on interventions in general medicine, suggesting that institutional changes can be made for maximum effectiveness. Some novel interventions were also identified, including publicizing instances of gender parity and supporting interventions across the educational and professional lifecourse. Moving forward, institutions must assess their readiness for change and evaluate existing policies, programs, and practices for areas of improvement.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care.

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.

Stakeholder Perspectives on Access to IBD Care: Proceedings From a National IBD Access Summit.

Background: Canada has among the highest incidence and prevalence rates of inflammatory bowel disease (IBD) in the world. While access to IBD specialty care can have a direct impact on health-related outcomes, the complexity of accessing IBD specialty care within Canada is not well understood and presents a barrier to implementation and evaluation of IBD specialty care. Aim: The IBD Summit was held in partnership with Crohn's & Colitis Canada to identify barriers and facilitators of IBD specialty care by exploring the perceptions and experiences of key stakeholders of IBD care across Canada. Results: A total of 20 key stakeholders attended, including gastroenterologists, patients, researchers and policymakers. Perceptions and experiences of stakeholders were transcribed, coded and thematically analyzed. Three key categories relating to access to IBD care arose: (1) inadequate system structure, (2) process inefficiencies and (3) using outcomes to guide system change. The IBD Summit identified similar perceptions and experiences among stakeholders and across provinces, highlighting common barriers and facilitators that transcended provincial and health care system boundaries. Conclusions: Key suggestions identify the clinical importance of comprehensive integrated multidisciplinary care approaches with enhanced communication between patient and health care providers, greater information sharing among team members, streamlined referral and triage processes, and improved incorporation of best practice into clinical care. Stakeholders across Canada and in other countries may benefit from the suggestions presented herein, as well as the successful use of collaborative and inclusive methods of gathering the perceptions and experiences of key stakeholders from diverse backgrounds.

Safety and danger: Perceptions of the implementation of harm reduction programs in two communities in Nova Scotia, Canada.

People who use substances (PWUS), and specifically individuals who use injection drugs and/or smoke crack cocaine, experience risks which harm reduction programmes can help reduce. Prior to implementing harm reduction programmes, however, it is critical to understand how programme users and others in the community perceive the programmes as their perceptions may influence implementation. A mixed-methods study asked PWUS and key informants about their perceptions of implementing five harm reduction programmes in their communities, including perceptions of the advantages of the programmes, where best to locate them, and community support. Questionnaires were administered to 160 PWUS, and qualitative interviews were conducted with 11 purposefully sampled key informants. Data were collected in one medium-size and one small-size community/municipality in Nova Scotia, Canada, during 2017-2018. SPSS was used to generate descriptive statistics and means from the quantitative data, and the qualitative data were analysed for key themes using thematic analysis. Both PWUS and key informants perceived numerous advantages of the harm reduction programmes, but some key informants suggested that there might be potential opposition to the implementation of additional needle distribution and disposal programmes in some locations and potential opposition to safer consumption sites. Further research is needed to understand why these programmes were viewed as potentially generating opposition, but findings suggest that a key factor is the association of the programmes with 'danger' because the programmes are directly linked with criminalized drug use. In contrast, the three other programmes are linked to 'safety' because naloxone saves lives, peer navigation programmes support access to existing programmes and detoxification programmes are associated with safety through the reduction/elimination of drug use. Legalization/decriminalization of drugs might help to change the association of some programmes with 'danger' and therefore help support the implementation of harm reduction programmes that appear to be perceived by some as linked to danger.

Models of Care for Inflammatory Bowel Disease: A National Cross-sectional Survey to Characterize the Landscape of Inflammatory Bowel Disease Care in Canada.

Background: Collaborative care models improve inflammatory bowel disease (IBD) patient outcomes, yet little is known about the capacity or available resources to deliver such model of care in Canada. We aimed to describe the structure and process characteristics of clinical care delivery models for IBD across Canada, including the number of collaborative care centers. Methods: A cross-sectional study was conducted between November 2017 and October 2018 through an online survey. This survey was distributed to gastroenterologists at community and academic centers across Canada who provide care for IBD patients. Comparisons between collaborative and non-collaborative centers were analyzed using chi-squares or t-tests. Descriptive statistics of respondent demographics were also generated. Results: Seventy-two gastroenterologists from 62 unique IBD centers completed the survey. A total of 7 unique collaborative centers and 55 unique non-collaborative centers were identified. There were significant differences between collaborative and non-collaborative centers in some aspects of access to IBD care, patient assessment and referral process, and patent education and empowerment. Notably, very few centers had processes for implementing and evaluating evidence-based clinical pathways, and auditing quality indicators. Conclusions: Our findings identify areas for improving the quality of IBD care in Canada. Expanding the number of and access to collaborative care centers in Canada is needed, in addition to increased focus on patient education, communication, and implementation of evidence-based care pathways.

Access to inflammatory bowel disease speciality care: the primary healthcare physician perspective.

BACKGROUND: There is little literature related to access to inflammatory bowel disease (IBD) care that incorporates the perspective of key system stakeholders, such as primary healthcare providers (PHCP), despite their clear and integral role in facilitating access. OBJECTIVE: This study aimed to identify barriers to referring patients to speciality IBD care as perceived by referring PHCP. In particular, we sought to understand PHCP satisfaction with the current IBD specialist referral system, as well as indicators of geographic variance to access. METHODS: A population-based survey was mailed out to currently practising PHCPs who have referred or who are currently referring patients to IBD speciality care in Nova Scotia (Canada). Descriptive statistics and multivariate analyses were performed. Qualitative comments were themed using framework analysis to identify key barriers. RESULTS: The majority of PHCP (57%) were dissatisfied with the current referral process due to long patient wait times and perceived system inefficiency. Key areas of geographic variance in access included access to speciality care in the community and patient wait times. PHCPs suggested ideas to improve access including increased gastroenterologist supply, particularly in rural areas, and the creation of a provincial centralized referral and triage process. CONCLUSIONS: PHCPs play an important role in identifying and managing patients with IBD in partnership with gastroenterologists. This study identifies key PHCP perceived barriers that may prevent patients from accessing speciality IBD care. Understanding and addressing barriers to access from multiple stakeholder perspectives, including PHCPs, has the potential to support informed system redesign and overcome access inequities.

Primary healthcare providers (e.g. family doctors and nurse practitioners) play an important role in connecting patients with speciality health care. Patients with digestive diseases, such as inflammatory bowel diseases (e.g. Crohn's and colitis), may rely on primary healthcare providers to connect them with inflammatory bowel disease specialists (e.g. gastroenterologists). Past research on access to inflammatory bowel disease care has focused on the patient perspective; however, almost no research has focused on how primary healthcare providers perceive access to inflammatory bowel disease speciality care, despite their important role in facilitating access. This paper focuses on what 155 primary healthcare providers in Nova Scotia (Canada) perceive as key barriers for their patients when accessing speciality Inflammatory bowel disease care. This paper also presents potential improvements to the referral process and healthcare system, as suggested by primary healthcare providers, which may improve global access to inflammatory bowel disease care.

Examining the Association Between Referral Quality, Wait Time and Patient Outcomes for Patients Referred to an IBD Specialty Program.

BACKGROUND: Most speciality inflammatory bowel disease (IBD) care can only be accessed through a referral. Timely access to specialty care has been associated with improved disease-related outcomes. To receive appropriate care, the referral needs to include high-quality information. To date, no research has explored the association between referral quality and IBD patient outcomes. The study objectives were to determine if the quality of referrals to a collaborative IBD program influenced triage accuracy, wait times and patient outcomes. METHODS: Two hundred referrals to a collaborative IBD program in Canada for patients with confirmed or suspected IBD were reviewed. Referral quality was evaluated using an evidence- and consensus-based metric. The association between referral quality and patient outcomes (wait time, hospitalizations, disease flares and additional referrals) for semi-urgent referrals was assessed through multivariate analysis. RESULTS: The majority of referrals for IBD speciality care were categorized as being low quality. Referral quality was not significantly associated with any of the patient outcomes; however, longer wait times significantly increased the occurrence of disease flares, hospitalizations and additional referrals while waiting for an IBD specialist appointment. CONCLUSION: Prolonged wait times for IBD patients are significantly associated with poor patient outcomes and increased costs for the health care system. Although there is literature that suggests that referral quality may be associated with wait time, it is still unclear how it relates to wait time and patient outcomes. Moving forward, the current referral process needs to be critically addressed in order to improve wait times and patient outcomes.

Micronutrient Absorption and Related Outcomes in People with Inflammatory Bowel Disease: A Review.

Inflammatory Bowel Disease (IBD) is a chronic disorder associated with immune dysregulation and chronic inflammation of the digestive tract. While it is poorly understood, the role of nutrition and nutrient status in the etiology of IBD and its associated outcomes has led to increased research relating to micronutrient deficiency. This review offers an overview of recent literature related to micronutrient absorption and outcomes in adults with IBD. Although the absorption and IBD-related outcomes of some micronutrients (e.g., vitamin D and iron) are well understood, other micronutrients (e.g., vitamin A) require further research. Increased research and clinician knowledge of the relationship between micronutrients and IBD may manifest in improved nutrient screening, monitoring, treatment, and outcomes for people living with IBD.

Patient-ly Waiting: A Review of Patient-Centered Access to Inflammatory Bowel Disease Care in Canada.

Canada has one of the highest prevalence estimates of inflammatory bowel disease (IBD) in the world. Like other chronic illnesses, access to specialist care is required for disease management. Traditionally, access to care is evaluated through wait times (actual access); however, new patient-oriented definitions of access (perceived access) highlight other equally important facets of access to care (e.g., appropriateness). Aim: How does access to gastroenterology speciality care influence disease-related outcomes for IBD patients in Canada? A comprehensive literature review was undertaken. Cochrane, PubMed and CINHAL databases were searched for peer-reviewed English language articles published between 2006 and 2016. Inclusion/exclusion criteria focussed on access to IBD care in Canada. Included articles were classified using Levesque et al.'s patient-centered access framework (e.g., affordability, accessibility, appropriateness, acceptability, availability and accommodation). Eight articles were found, including six which addressed patient-centered access. Most of the articles addressed issues of availability (e.g., wait times), appropriateness and affordability. Only one article addressed approachability and acceptability of IBD care. All articles emphasized a need for greater patient-centered measures (e.g., multidisciplinary clinics) with a goal to improve patient access and, ultimately, patient outcomes. Understanding patient-centered access to IBD care is important for managing IBD and improving patient outcomes. Literature examining access to gastroenterology services is limited. Increased investment in patient-oriented research should be made to better understand the relationship between access to specialist care and patient outcomes.