An economic evaluation of chronic obstructive pulmonary disease clinical pathway in Saskatchewan, Canada: Data-driven techniques to identify cost-effectiveness among patient subgroups.

BACKGROUND: Saskatchewan has implemented care pathways for several common health conditions. To date, there has not been any cost-effectiveness evaluation of care pathways in the province. The objective of this study was to evaluate the real-world cost-effectiveness of a chronic obstructive pulmonary disease (COPD) care pathway program in Saskatchewan. METHODS: Using patient-level administrative health data, we identified adults (35+ years) with COPD diagnosis recruited into the care pathway program in Regina between April 1, 2018, and March 31, 2019 (N = 759). The control group comprised adults (35+ years) with COPD who lived in Saskatoon during the same period (N = 759). The control group was matched to the intervention group using propensity scores. Costs were calculated at the patient level. The outcome measure was the number of days patients remained without experiencing COPD exacerbation within 1-year follow-up. Both manual and data-driven policy learning approaches were used to assess heterogeneity in the cost-effectiveness by patient demographic and disease characteristics. Bootstrapping was used to quantify uncertainty in the results. RESULTS: In the overall sample, the estimates indicate that the COPD care pathway was not cost-effective using the willingness to pay (WTP) threshold values in the range of $1,000 and $5,000/exacerbation day averted. The manual subgroup analyses show the COPD care pathway was dominant among patients with comorbidities and among patients aged 65 years or younger at the WTP threshold of $2000/exacerbation day averted. Although similar profiles as those identified in the manual subgroup analyses were confirmed, the data-driven policy learning approach suggests more nuanced demographic and disease profiles that the care pathway would be most appropriate for. CONCLUSIONS: Both manual subgroup analysis and data-driven policy learning approach showed that the COPD care pathway consistently produced cost savings and better health outcomes among patients with comorbidities or among those relatively younger. The care pathway was not cost-effective in the entire sample.

Text analysis of billboards and infographic graphics advertising COVID-19 on promoting preventive behaviors and taking vaccination against the coronavirus pandemic and investigating the opinions of the Iranian adult population.

BACKGROUND: Advertising is one of the most important solutions that health centers and medical services around the world use to try to encourage public opinion to create a positive attitude towards preventive measures and vaccination. This study has been done with the aim of text analysis of billboards and infographics related to promoting preventive behaviors and vaccination against the coronavirus pandemic and providing solutions and models for preventive information and advertising in the field of health. METHODS: The study method in this research is a combination of qualitative and content analysis. Data collection was done in a targeted manner. The sample size includes 33 advertising billboards and infographics. Data collection has been done through searching the sites and websites of health networks and medical education centers in Iran, taking pictures of infographics and billboards in public places, and also receiving archive files of pictures from the public relations of health networks and medical services. The data was collected from February 19, 2020 to December 30, 2022 (the time frame of the pandemic and public vaccination program in Iran). The data was analyzed based on the three-dimensional discourse analysis theory of Fairclough. Then, an online survey about promoting preventive behaviors and vaccination against the coronavirus pandemic in the format of billboards and infographics was designed in SurveyMonkey and its link was provided to the audience through virtual networks and other platforms. The age group of people was selected from 18 to 70 years. Considering that the number of participants should be representative of the entire community under investigation, therefore, based on Cochran's formula, the sample size was equal to 350 people. Finally, users' opinions were analyzed using descriptive statistics. The assessment of validity involved experts in infection control and linguistics. The reliability of the measurement, determined through the Cronbach's alpha internal consistency coefficient, yielded a coefficient of 0.968. RESULTS: The results show that among the four linguistic components of words, syntax, coherence and text structure; "live metaphors", "pronoun "we", "collocation and reference", and "attitude markers" have the most impact on the audience. The frequency percentage of the data shows that these language elements have tremendous power in attracting the audience to perform preventive behaviors. The results show that the language reflects the culture, opinions and needs of people in the society. Also, the results show that encouraging people to perform preventive behaviors should be through the integration of medical information with motivational linguistic factors in order to attract the audience more. CONCLUSIONS: It can be concluded that the use of the appropriate pattern of medical advertising discourse and correct communication strategies, will help public participation in the field of epidemic control. The language of effective health education and health communication during an epidemic must be related to the ways of thinking and speaking of ordinary people. Also, words with metaphorical and ironic meanings have a high potential to influence the health performance of people in society and increase public awareness of health communication. Therefore, using them to create a new value system with the aim of controlling and overcoming the consequences of the epidemic is very effective.

"Somebody That can Meet you on Your Level:" Cancer Survivors' Perspectives on the Role of Indigenous Patient Navigators in Cancer Care.

BACKGROUND: Cancer incidence has increased for First Nations and Métis Peoples in Canada over recent years. Despite a growing cancer burden, there remain challenges to accessing culturally appropriate and quality care in Saskatchewan. OBJECTIVE: The study aimed to explore, from cancer survivors' perspectives, the potential of Indigenous patient navigators to enhance the healthcare experiences of First Nations and Métis cancer survivors in Saskatchewan. METHODS: We conducted semi-structured interviews with 19 First Nations and Métis cancer survivors. Participants were interviewed by phone between May 2022 to March 2023. Thematic analysis was conducted to generate themes, categories, and codes reflecting participants' experiences with patient navigators. RESULTS: Participants reported several supports to help patients with cancer through their cancer journey, including family, community, traditional ways, and First Nations and Métis health support services. Challenges to accessing care included language and communication barriers, logistical challenges, cultural differences, financial challenges, and gaps in care. Indigenous patient navigators may play a critical role in overcoming barriers by providing communication, translation, coordination, education, advocacy, and guidance to Indigenous cancer survivors. In participants' view, the tasks of Indigenous patient navigators could vary, ranging from helping schedule appointments to advocating for the patient's treatment preferences. In addition, Indigenous patient navigators could be helpful bridging Western medicine with traditional medicine when supporting patients seeking cancer care. CONCLUSION: According to study participants, Indigenous patient navigators could be beneficial to Indigenous cancer survivors in Saskatchewan.

Real-World Cost-Consequence Analysis of an Integrated Chronic Disease Management Program in Saskatchewan, Canada.

An integrated disease management program otherwise called a clinical pathway was recently implemented in Saskatchewan, Canada for patients living with chronic obstructive pulmonary disease (COPD). This study compared the real-world costs and consequences of the COPD clinical pathway program with 2 control treatment programs. The study comprised adult COPD patients in Regina (clinical pathway group, N = 759) matched on propensity scores to 2 independent control groups of similar adults in (1) Regina (historical controls, N = 759) and (2) Saskatoon (contemporaneous controls, N = 759). The study measures included patient-level healthcare costs and acute COPD exacerbation outcomes, both tracked in population-based administrative health data over a one-year follow-up period. Analyses included Cox proportional hazards models and differences in means between groups. The bias-corrected and accelerated bootstrap method was used to calculate 95% confidence intervals (CI). The COPD pathway patients had lower risks of moderate (hazard ratio [HR] =0.57, 95% CI [0.40-0.83]) and severe (HR = 0.43, 95% CI [0.28-0.66]) exacerbations compared to the historical control group, but similar risks compared with the contemporaneous control group. The COPD pathway patients experienced fewer episodes of exacerbations compared with the historical control group (mean difference = -0.30, 95% CI [-0.40, -0.20]) and the contemporaneous control group (mean difference = -0.12, 95% CI [-0.20, -0.03]). Average annual healthcare costs in Canadian dollars were marginally higher among patients in the COPD clinical pathway (mean = $10 549, standard deviation [SD] =$18 149) than those in the contemporaneous control group ($8841, SD = $17 120), but comparable to the historical control group ($10 677, SD = $21 201). The COPD pathway provides better outcomes at about the same costs when compared to the historical controls, but only slightly better outcomes and at a marginally higher cost when compared to the contemporaneous controls.

Impacts of Chronic Obstructive Pulmonary Disease Care Pathway on Healthcare Utilization and Costs: A Matched Multiple Control Cohort Study in Saskatchewan, Canada.

OBJECTIVES: This study aimed to evaluate the real-world impacts of a chronic obstructive pulmonary disease (COPD) care pathway program on healthcare utilization and costs in Saskatchewan, Canada. METHODS: A difference-in-differences evaluation of a real-life deployment of a COPD care pathway, using patient-level administrative health data in Saskatchewan, was conducted. The intervention group (n = 759) included adults (35+ years) with spirometry-confirmed COPD diagnosis recruited into the care pathway program in Regina between April 1, 2018 and March 31, 2019. The 2 control groups comprised adults (35+ years) with COPD who lived in Saskatoon during the same period (n = 759) or Regina between April 1, 2015 and March 31, 2016 (n = 759) who did not participate in the care pathway. RESULTS: Compared with the individuals in the Saskatoon control groups, individuals in the COPD care pathway group had shorter inpatient hospital length of stay (average treatment effect on the treated [ATT] -0.46, 95% CI -0.88 to -0.04) but a higher number of general practitioner visits (ATT 1.46, 95% CI 1.14 to 1.79) and specialist physician visits (ATT 0.84, 95% CI 0.61 to 1.07). Regarding healthcare costs, individuals in the care pathway group had higher COPD-related specialist visit costs (ATT $81.70, 95% CI $59.45 to $103.96) but lower COPD-related outpatient drug dispensation costs (ATT -$4.81, 95% CI -$9.34 to -$0.27). CONCLUSIONS: The care pathway reduced inpatient hospital length of stay, but increased general practitioner and specialist physician visits for COPD-related services within the first year of implementation.

Outcomes of Rural Men with Breast Cancer: A Multicenter Population Based Retrospective Cohort Study.

BACKGROUND: Breast cancer is rare in men. This population-based study aimed to determine outcomes of male breast cancer in relation to residence and other variables. METHODS: In this retrospective cohort study, men diagnosed with breast cancer in Saskatchewan during 2000-2019 were evaluated. Cox proportional multivariable regression analyses were performed to determine the correlation between survival and clinicopathological and contextual factors. RESULTS: One hundred-eight eligible patients with a median age of 69 years were identified. Of them, 16% had WHO performance status ≥ 2 and 61% were rural residents. The stage at diagnosis was as follows: stage 0, 7%; I, 31%; II, 42%; III, 11%; IV, 8%. Ninety-eight percent had hormone receptor-positive breast cancer. The median disease-free survival of urban patients was 97 (95% CI: 50-143) vs. 64 (46-82) months of rural patients (p = 0.29). The median OS of urban patients was 127 (94-159) vs. 93 (32-153) months for rural patients (p = 0.27). On multivariable analysis, performance status ≥ 2, hazard ratio (HR) 2.82 (1.14-6.94), lack of adjuvant systemic therapy, HR 2.47 (1.03-5.92), and node-positive disease, HR 2.32 (1.22-4.40) were significantly correlated with inferior disease-free survival in early-stage invasive breast cancer. Whereas stage IV disease, HR 7.8 (3.1-19.5), performance status ≥ 2, HR 3.25 (1.57-6.71), and age ≥ 65 years, HR 2.37 (1.13-5.0) were correlated with inferior overall survival in all stages. CONCLUSIONS: Although residence was not significantly correlated with outcomes, rural men had numerically inferior survival. Poor performance status, node-positive disease, and lack of adjuvant systemic therapy were correlated with inferior disease-free survival.

Exploring Indigenous Traditional Healing programs in Canada, Australia, and New Zealand: A scoping review.

OBJECTIVE: To explore and catalog ways Indigenous Traditional Healing practices are supported within the mainstream healthcare system through policies and programs in Canada, Australia, and New Zealand. DATA SOURCES: A scoping review was conducted, guided by the PRISMA extension for Scoping Reviews. Databases for sources of information include CINAHL, Medline, Embase, Web of Science, Public Health ProQuest, Global Health EBSCO, iPortal, and grey literature. STUDY SELECTION: 2 reviewers screened the titles and abstracts of the studies for inclusion against the selection criteria independently. Studies that met the inclusion criteria were transferred to Covidence for further abstract and full-text review. DATA EXTRACTION: Of a total of 2,017 articles identified, 22 met the inclusion criteria for data extraction for this scoping review. Data items extracted include study title, authors, year of publication, publication type, publication source, support policy or program, health system or service, Indigenous Traditional Healing practices, and significant findings. DATA SYNTHESIS: 2 categories emerged from the analysis of the source of evidence. That is, healthcare systems and services with programs and policies supporting Indigenous Traditional Healing practices, and ways Indigenous Traditional Healing was adopted and utilized within the identified support programs. CONCLUSIONS: This study demonstrated the various ways Indigenous Traditional Healing practices are supported within the mainstream healthcare systems in Canada, Australia, and New Zealand. Indigenous Traditional Healing practices can be utilized as either the primary choice of treatment, to support Western biomedical treatment or through the adoption of Indigenous Traditional knowledge within the mainstream healthcare system.

Virtual surgical consultation during the COVID-19 pandemic: a patient-oriented, cross-sectional study using telephone interviews.

BACKGROUND: Health care delivery shifted rapidly during the COVID-19 pandemic, whereby virtual consultations replaced many face-to-face interactions. We sought to gather patient perspectives on their experiences with virtual surgical consultation, the advantages and disadvantages of this delivery method and their overall satisfaction with virtual appointments. METHODS: We conducted a patient-oriented, cross-sectional study. Adult patients (age > 18 yr) who had a virtual consultation with a participating general surgeon in Saskatoon, Saskatchewan, from April to May 2020 were eligible. We conducted telephone interviews using open- and close-ended questions. We used thematic analysis to determine themes from the qualitative data. As research team members, 2 patient partners were involved in identifying priorities, developing the research question, designing research methods, analyzing data and disseminating findings. We analyzed and presented quantitative data descriptively. RESULTS: We interviewed 45 participants from 7 general surgery practices; the average age was 62 years. Most participants lived outside Saskatoon and had virtual follow-up appointments. The 3 themes related to advantages of virtual consultations were convenience, cost savings and decreased exposure to pathogens. The 4 themes related to their disadvantages were that they were not as personal, the surgeon was not able to perform a physical examination, and there were issues with scheduling and issues with technology. Most participants were satisfied with the care they received (n = 41) and would be willing to use virtual consultation in the future (n = 31). INTERPRETATION: We found that virtual consultations are an effective and efficient way to deliver surgical care but are not appropriate for every situation and cannot completely replace face-to-face interactions. Our study identified the advantages and disadvantages of virtual surgical consultation to help better guide the delivery of virtual care in the future.

Medical Error and Under-Reporting Causes from the Viewpoints of Nursing Managers: A Qualitative Study.

Background: Patient safety as a goal can be achieved by reporting medical errors (ME); however, most errors are never reported. The aim of this study is to explore the causes of ME, and the obstacles in reporting them amongst nurses. Methods: We conducted semi-structural interviews, with 12 nursing managers in the biggest teaching hospital in southern Iran (2015-2016). The interview guide concentrated on the causes of ME and barriers in reporting them. All face-to-face interviews were recorded and transcribed verbatim and analysed using thematic analysis. Results: In this study 4 main themes were extracted for the causes of ME: personal/social characteristics, nonprofessional practice, hospital related factors/organization contextual factors, and poor management. Also, 5 main themes (such as; personal characteristics, fear from reporting, nonprofessional practices, cultural and social factors, and error surveillance system features) were obtained with regards to barriers in reporting. Conclusions: ME can be reduced by improving professional practice and better human resource management. Also, reporting errors can be increased by focusing on cultural and social factors.

Facilitators and Barriers to Clinical Pathway Uptake and Utilization Among Primary Care Providers in Saskatchewan - A Qualitative Study.

PURPOSE: Clinical Pathways (CPWs) are multidisciplinary, evidence-based, complex interventions designed to standardize patient care. In Saskatchewan, development, implementation and evaluation of the seven provincial CPWs (Hip & Knee, Spine, Pelvic Floor, Prostate Assessment, Fertility Care, Lower Extremity Wound Care and Acute Stroke) present significant challenges, leading to low utilization. This study aimed to identify facilitators and barriers to CPW utilization by Saskatchewan family physicians. METHODS: To identify the facilitators and barriers to CPWs, a qualitative interpretive approach consisted of eight one-on-one key informant interviews and five focus groups held with 30 family physicians in two larger urban and two smaller Saskatchewan cities. Inductive, thematic analysis of the interviews based on the Theoretical Domain Framework for behavioral changes was used to identify facilitators and barriers to CPW uptake and utilization. RESULTS: Fifty-one themes were mapped under 14 Theoretical Domain Framework domains. Major barriers included the following: system-level (knowledge and communication, social/professional identity, family physician engagement and education); objective clarification (goals, belief about consequences of implementing CPW); and technical and resource related (administrative, access to local specialists, enforcement and incentives). The most prominent barrier was lack of systematic CPW promotion and inconsistencies in communication between the following: organization-to-practitioner; organization-to-organization; and practitioner-to-practitioner. Facilitators who mitigated barriers were need for optimized and integrated information technology services (i.e., Electronic Medical Records) and optimism towards CPW usage and patient outcomes. CONCLUSIONS: This exploratory study identified specific improvements and recommendations required to promote uptake of CPWs based on perceived facilitators and barriers.

Moving towards the optimization of diagnosis for patients with sarcoma: A 10-year review of externally consulted sarcoma cases in a general anatomical pathology service.

INTRODUCTION: Soft tissue sarcomas (STS) are rare, diagnostically challenging, malignant tumors with diverse histomorphologic, immunohistochemical and molecular features. In our practice, STS are reported in a general anatomical pathology practice with no formal subspecialized training in reporting these complex specimens. Our study was performed to look at the rate of external consultation (EC), along with other parameters including discordance rate, associated diagnostic delay with EC and extent of secondary work-up performed by the consultant for correct diagnosis. METHODS: The reports from 880 soft tissue sarcomas cases in the province of Saskatchewan between January 1, 2010, and December 31, 2020, were analyzed descriptively. RESULTS: Of the 880 cases reviewed in our database, 51.9% (n = 457) cases were sent to 35 different North American institutions for expert opinion. The initial diagnosis and expert opinion were in full agreement for 182 cases (39.8%), while 194 cases (42.5%) had partial agreement and 66 cases (14.4%) had zero agreement. Of the cases that had zero agreement, 20 cases (4.4%) were initially diagnosed as malignant, with a benign opinion given by the expert; and 10 cases (2.2%) were initially diagnosed as benign, which were malignant upon expert review. CONCLUSION: Soft tissue sarcomas are complex tumors that frequently require expert opinion and integration of ancillary techniques with histomorphologic features for definitive classification. A multidisciplinary, subspecialized approach to STS and availability of necessary ancillary tests would improve diagnostic accuracy. In centers where the case load would not support the full-time expertise of an STS multidisciplinary team, criteria should be developed to effectively utilize EC practices.

Activation of Focal Adhesion Kinase Restores Simulated Microgravity-Induced Inhibition of Osteoblast Differentiation via Wnt/Β-Catenin Pathway.

Simulated microgravity (SMG) inhibits osteoblast differentiation (OBD) and induces bone loss via the inhibition of the Wnt/ß-catenin pathway. However, the mechanism by which SMG alters the Wnt/ß-catenin pathway is unknown. We previously demonstrated that SMG altered the focal adhesion kinase (FAK)-regulated mTORC1, AMPK and ERK1/2 pathways, leading to the inhibition of tumor cell proliferation/metastasis and promoting cell apoptosis. To examine whether FAK similarly mediates SMG-dependent changes to Wnt/ß-catenin in osteoblasts, we characterized mouse MC3T3-E1 cells cultured under clinostat-modeled SMG (µg) conditions. Compared to cells cultured under ground (1 g) conditions, SMG reduces focal adhesions, alters cytoskeleton structures, and down-regulates FAK, Wnt/ß-catenin and Wnt/ß-catenin-regulated molecules. Consequently, protein-2 (BMP2), type-1 collagen (COL1), alkaline-phosphatase activity and matrix mineralization are all inhibited. In the mouse hindlimb unloading (HU) model, SMG-affected tibial trabecular bone loss is significantly reduced, according to histological and micro-computed tomography analyses. Interestingly, the FAK activator, cytotoxic necrotizing factor-1 (CNF1), significantly suppresses all of the SMG-induced alterations in MC3T3-E1 cells and the HU model. Therefore, our data demonstrate the critical role of FAK in the SMG-induced inhibition of OBD and bone loss via the Wnt/ß-catenin pathway, offering FAK signaling as a new therapeutic target not only for astronauts at risk of OBD inhibition and bone loss, but also osteoporotic patients.

Evaluating a learning health system initiative: Lessons learned during COVID-19 in Saskatchewan, Canada.

Introduction: Evaluating a learning health system (LHS) encourages continuous system improvement and collaboration within the healthcare system. Although LHS is a widely accepted concept, there is little knowledge about evaluating an LHS. To explore the outputs and outcomes of an LHS model, we evaluated the COVID-19 Evidence Support Team (CEST) in Saskatchewan, Canada, an initiative to rapidly review scientific evidence about COVID-19 for decision-making. By evaluating this program during its formation, we explored how and to what extent the CEST initiative was used by stakeholders. An additional study aim was to understand how CEST could be applied as a functional LHS and the value of similar knowledge-to-action cycles. Methods: Using a formative evaluation design, we conducted qualitative interviews with key informants (KIs) who were involved with COVID-19 response strategies in Saskatchewan. Transcripts were analyzed using reflexive thematic analysis to identify key themes. A program logic model was created to represent the inputs, activities, outputs, and outcomes of the CEST initiative. Results: Interview data from 11 KIs were collated under three overarching categories: (1) outputs, (2) short-term outcomes, and (3) long-term outcomes from the CEST initiative. Overall, participants found the CEST initiative improved speed and access to reliable information, supported and influenced decision-making and public health strategies, leveraged partnerships, increased confidence and reassurance, and challenged misinformation. Themes relating to the long-term outcomes of the initiative included improving coordination, awareness, and using good judgment and planning to integrate CEST sustainably into the health system. Conclusion: This formative evaluation demonstrated that CEST was a valued program and a promising LHS model for Saskatchewan. The future direction involves addressing program recommendations to implement this model as a functional LHS in Saskatchewan.

Developing a rapid evidence response to COVID-19: The collaborative approach of Saskatchewan, Canada.

Introduction: The COVID-19 Evidence Support Team (CEST) was a provincial initiative that combined the support of policymakers, researchers, and clinical practitioners to initiate a new learning health cycle (LHS) in response to the pandemic. The primary aim of CEST was to produce and sustain the best available COVID-19 evidence to facilitate decision-making in Saskatchewan, Canada. To achieve this objective, four provincial organizations partnered to establish a single, data-driven system. Methods: The CEST partnership was driven by COVID-19 questions from Emergency Operational Committee (EOC) of the Saskatchewan Health Authority. CEST included three processes: (a) clarifying the nature and priority of COVID-19 policy and clinical questions; (b) providing Rapid Reviews (RRR) and Evidence Search Reports (ESR); and (c) seeking the requestors' evaluation of the product. A web-based repository, including a dashboard and database, was designed to house ESRs and RRRs and offered a common platform for clinicians, academics, leaders, and policymakers to find COVID-19 evidence. Results: In CEST's first year, 114 clinical and policy questions have been posed resulting in 135 ESRs and 108 RRRs. While most questions (41.3%) originated with the EOC, several other teams were assembled to address a myriad of questions related to areas such as long-term care, public health and prevention, infectious diseases, personal protective equipment, vulnerable populations, and Indigenous health. Initial challenges were mobilization of diverse partners and teams, remote work, lack of public access, and quality of emerging COVID-19 literature. Current challenges indicate the need for institutional commitment for CEST sustainability. Despite these challenges, the CEST provided the Saskatchewan LHS with a template for successful collaboration. Conclusions: The urgency of COVID-19 pandemic and the implementation of the CEST served to catalyze collaboration between different levels of a Saskatchewan LHS.

Métis Peoples and Cancer: A Scoping Review of Literature, Programs, Policies and Educational Material in Canada.

Much of the existing Indigenous cancer research focuses on First Nation populations or reports on pan-Indigenous data that include First Nations, Métis, and Inuit metrics together, which fails to capture the distinct lived realities, experiences of colonialism, and culture of each Indigenous group. The purpose of this scoping review was to summarize existing knowledge on cancer among Métis peoples in Canada, offering direction to researchers, institutions, and policymakers for future actions that enhance Métis-specific cancer surveillance and cancer care. We searched Embase, Medline, iPortal, and Proquest Theses and Dissertations databases, Google Scholar and Google, alongside ten websites relevant to cancer and Métis peoples. Two reviewers gathered 571 records. After screening, 77 records were included. Data show that Métis peoples experience higher behavioral risk factors, lower screening participation, higher cancer incidence for some cancers, and higher mortality rates compared to the non-Indigenous population. Existing research is piece-meal and researchers emphasize that there is inadequate Métis-specific cancer data. There is a need for targeted, Peoples-specific cancer control interventions to reduce these health inequities and a coordinated, Peoples-specific approach to cancer research. These efforts must involve collaboration among Métis Nations and organizations, provincial governments and agencies, researchers, and policymakers.

Developing a patient-oriented realist evaluation for COVID-19 vaccine implementation in Saskatchewan: a methodologic framework.

BACKGROUND: There is an urgent need to inform decision-making and safe delivery of vaccines in a timely manner. Our objective is to describe the methods we used to perform a patient-oriented realist evaluation of COVID-19 vaccination implementation in Saskatchewan, Canada, in order to understand the underlying mechanisms and contexts of vaccination implementation and vaccine uptake. METHODS: This methodology paper describes a patient-oriented, realist, mixed-method evaluation to assess COVID-19 vaccination implementation in Regina, Saskatoon and Prince Albert, Saskatchewan. The study comprised 3 iterative phases guided by Realist And Meta-narrative Evidence Synthesis: Evolving Standards II (RAMESES II). In phase 1 (January-February 2021), we developed the initial program theory, in phase 2 (March-May 2021), we tested and refined the initial program theory, and in phase 3 (June-July 2021), we established the final program theory. Three patient and family partners with different backgrounds and experiences were selected purposively from various locations (urban and rural) in Saskatchewan to engage collaboratively in the evaluation. Data analysis and synthesis occurred at all 3 phases of the project. We analysed qualitative data from phases 2 and 3 using a "retroductive" approach. We used quantitative data to compare outcomes from the 3 sites. INTERPRETATION: This protocol describes how we developed a final program theory for COVID-19 vaccination implementation with patient and family partners to show for whom, under what circumstances, how and why Saskatchewan's COVID-19 vaccination program has led to vaccine uptake. With patient and family partners' engagement, the evaluation findings will be shared with the Saskatchewan Health Authority and provincial government policy-makers and communications departments, published in peer-reviewed journals, presented at provincial or national conferences, and disseminated through any additional media identified by the patient and family partners.

Distinct roles but cooperative effect of TLR3/9 agonists and PD-1 blockade in converting the immunotolerant microenvironment of irreversible electroporation-ablated tumors.

Irreversible electroporation (IRE) is a new cancer ablation technology, but methods to improve IRE-induced therapeutic immunity are only beginning to be investigated. We developed a mouse model bearing large primary (300 mm3) and medium distant (100 mm3) EG7 lymphomas engineered to express ovalbumin (OVA) as a nominal tumor antigen. We established experimental protocols including IRE alone and IRE combined with Toll-like receptor (TLR)3/9 agonists (poly I:C/CpG) (IRE + pIC/CpG), PD-1 blockade (IRE + PD-1 blockade), or both (IRE + Combo) to investigate therapeutic effects on primary and distant EG7 tumors and conversion-promoting effects on the immunotolerant tumor microenvironment (TME). We demonstrated that IRE alone simulated very weak OVA-specific CD8+ T cell responses and did not inhibit primary tumor growth. IRE + pIC/CpG synergistically stimulated more efficient OVA-specific CD8+ T cell responses and primary tumor growth inhibition than IRE + PD-1 blockade. IRE + pIC/CpG played a major role in the modulation of immune cell profiles but a minor role in the downregulation of PD-L1 expression in the TME and vice versa for IRE + PD-1 blockade. IRE + Combo cooperatively induced potent OVA-specific CD8+ T cell immunity and rescued exhausted intratumoral CD8+ T cells, leading to eradication of not only primary tumors but also untreated concomitant distant tumors and lung metastases. IRE + Combo efficiently modulated immune cell profiles, as evidenced by reductions in immunotolerant type-2 (M2) macrophages, myeloid-derived suppressor-cells, plasmacytoid dendritic cells, and regulatory T cells and by increases in immunogenic M1 macrophages, CD169+ macrophages, type-1 conventional dendritic cells, and CD8+ T cells, leading to conversion of immunotolerance in not only primary TMEs but also untreated distant TMEs. IRE + Combo also showed effective therapeutic effects in two breast cancer models. Therefore, our results suggest that IRE + Combo is a promising strategy to improve IRE ablation therapy in cancer.

A rapid realist review of patient engagement in patient-oriented research and health care system impacts: part one.

BACKGROUND: Patient-oriented research affords individuals with opportunities to genuinely contribute to health care research as members of research teams. While checklists and frameworks can support academic researchers' awareness of patient engagement methods, less guidance appears available to support their understanding of how to develop and maintain collaborative relationships with their patient partners. This knowledge is essential as patient partners report that the social atmospheres of research teams significantly impacts the quality of their experiences. This study sought to develop theory regarding how academic researchers support and sustain patient engagement in patient-oriented research. METHODS: A six-step, rapid realist review was conducted: (1) research question development, (2) preliminary theory development, (3) search strategy development; (4) study selection and appraisal, (4) data extraction, analysis and synthesis (5) identification of relevant formal theories, and (6) theory refinement with stakeholders. Findings were additionally distilled by collective competence theory. RESULTS: A program theory was developed from 62 international studies which illuminated mechanisms supporting academic researchers to engage patient partners, contexts supporting these mechanisms, and resources that enabled mechanism activation. Interaction between seven contexts (patient-oriented research belief, prior interaction with a healthcare system, prior interaction with a particular academic researcher, educational background of patient partner, prior experience with patient-oriented research, study type, and time lived in a rural-urban setting) and seven mechanisms (deciding to become involved in patient-oriented research, recognizing valuable experiential knowledge, cultural competence, reducing power differentials, respectful team environment, supporting patient partners to feel valued, and readiness to research) resulted in an intermediate outcome (sense of trust). Trust then acted as an eighth mechanism which triggered the final-level outcome (empowered patient-centred lens). CONCLUSIONS: Our theory posits that if patient partners trust they are a member of a supportive team working alongside academic researchers who authentically want to incorporate their input, then they are empowered to draw upon their experiential knowledge of health care systems and contribute as researchers in patient-oriented research. Our theory extends conceptual thinking regarding the importance of trust on patient-oriented research teams, how patient partners' trust is shaped by team interactions, and the role that academic researchers have within those interactions.

Patient-oriented research gives patients, families, and caregivers opportunities to become members of health care research teams. Although academic researchers may be aware of what patient engagement is, they may not understand how to develop effective relationships with their patient partners. Academic researchers need this guidance because earlier research has shown that patient partners want to be supported to feel like they are important members of research teams. This support empowers them to feel confident to share their lived experiences and make suggestions and decisions about a research study. If patient partners believe their experiences and knowledge were not used or valued by academic researchers, then they may feel that their involvement was tokenistic. Tokenistic experiences discourage patient partners from participating in another research study.We conducted a rapid realist review of 62 international studies to explore what works (and does not work) in patient-oriented research. This methodology supported us to examine existing research and better understand what contexts, how and why patient-oriented research led to outcomes on a health care system. The goal of this type of research study is to develop and refine a program theory that identifies how actions and activities lead to outcomes.Our program theory emphasizes that patient partners need to trust the academic researchers they are working with. Several categories of actions (academic researcher's behavior) helped researchers to gain the trust of their patient partners. Academic researchers were more (or less) likely to act in these ways depending on several contextual factors. Once patient partners trusted academic researchers on the team, they were empowered to draw upon their lived knowledge of health care systems and actively contribute as researchers. These findings are part of our complete theory about patient-oriented research impacts. They highlight why it is important to gain patient partners' trust and how a complex set of actions are required by academic researchers to gain that trust.

Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste.

BACKGROUND: Preoperative tests are done to determine a patient's fitness for anaesthesia and surgery. LOCAL PROBLEM: Although routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries. METHODS: A series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders. INTERVENTIONS: A clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy. RESULTS: After implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%-17%), 81% (41%-7%) and 68% (35%-11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery. CONCLUSIONS: A standardised preoperative investigational approach based on patients' medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.