The Key Digital Tool Features of Complex Telehealth Interventions Used for Type 2 Diabetes Self-Management and Monitoring With Health Professional Involvement: Scoping Review.

BACKGROUND: Therapeutic education and patient self-management are crucial in diabetes prevention and treatment. Improving diabetes self-management requires multidisciplinary team intervention, nutrition education that facilitates self-management, informed decision-making, and the organization and delivery of appropriate health care services. The emergence of telehealth services has provided the public with various tools for educating themselves and for evaluating, monitoring, and improving their health and nutrition-related behaviors. Combining health technologies with clinical expertise, social support, and health professional involvement could help persons living with diabetes improve their disease self-management skills and prevent its long-term consequences. OBJECTIVE: This scoping review's primary objective was to identify the key digital tool features of complex telehealth interventions used for type 2 diabetes or prediabetes self-management and monitoring with health professional involvement that help improve health outcomes. A secondary objective was to identify how these key features are developed and combined. METHODS: A 5-step scoping review methodology was used to map relevant literature published between January 1, 2010 and March 31, 2022. Electronic searches were performed in the MEDLINE, CINAHL, and Embase databases. The searches were limited to scientific publications in English and French that either described the conceptual development of a complex telehealth intervention that combined self-management and monitoring with health professional involvement or evaluated its effects on the therapeutic management of patients with type 2 diabetes or prediabetes. Three reviewers independently identified the articles and extracted the data. RESULTS: The results of 42 studies on complex telehealth interventions combining diabetes self-management and monitoring with the involvement of at least 1 health professional were synthesized. The health professionals participating in these studies were physicians, dietitians, nurses, and psychologists. The digital tools involved were smartphone apps or web-based interfaces that could be used with medical devices. We classified the features of these technologies into eight categories, depending on the intervention objective: (1) monitoring of glycemia levels, (2) physical activity monitoring, (3) medication monitoring, (4) diet monitoring, (5) therapeutic education, (6) health professional support, (7) other health data monitoring, and (8) health care management. The patient-logged data revealed behavior patterns that should be modified to improve health outcomes. These technologies, used with health professional involvement, patient self-management, and therapeutic education, translate into better control of glycemia levels and the adoption of healthier lifestyles. Likewise, they seem to improve monitoring by health professionals and foster multidisciplinary collaboration through data sharing and the development of more concise automatically generated reports. CONCLUSIONS: This scoping review synthesizes multiple studies that describe the development and evaluation of complex telehealth interventions used in combination with health professional support. It suggests that combining different digital tools that incorporate diabetes self-management and monitoring features with a health professional's advice and interaction results in more effective interventions and outcomes.

Cross-Sector Collaboration to Improve Access to Community Services for People Living With Diabetes: Contributions From Actor-Network Theory.

Diabetes is a global public health issue. The Public Health Agency of Canada published a Diabetes Framework 2022 which recommends collaborative work across sectors to mitigate the impact of diabetes on health and quality of life. Since 2020, the INMED-COMMUNITY pathway has been implemented in Laval, Québec developing collaboration between healthcare and community sectors through a participatory action research approach. The aim of this article is to gain a better understanding of the INMED-COMMUNITY pathway implementation process, based on the mobilization of network actor theory. Qualitative analysis of semi-structured interviews conducted from January to March 2023 with 12 participants from 3 different sectors (community, health system, research), were carried out using actor-network theory. The results explored the conditions for effective intersectoral collaboration in a participatory action research approach to implement the INMED-COMMUNITY pathway. These were: (1) contextualization of the project, (2) a consultation approach involving various stakeholders, (3) creation of new partnerships, (4) presence of a project coordinator, and (5) mobilization of stakeholders around a common definition of diabetes. Mediation supported by a project coordinator contributed to the implementation of an intersectoral collaborative health intervention, largely due to early identification of controversies.

[Sondage sur les pratiques des médecins de famille et sur la collaboration interprofessionnelle avec des ergothérapeutes en GMF quant au dépistage des conducteurs à risque].

Cette étude a sondé 46 médecins de famille québécois quant à leurs pratiques pour l'évaluation et le dépistage des conducteurs à risque afin 1) de mieux comprendre leur niveau de compétence perçu; 2) de recenser les difficultés rencontrées dans le processus de prise de décision et 3) de documenter leurs besoins et attitudes quant à une collaboration plus étroite avec les ergothérapeutes. Les participants (femmes : 84,8 %; moyenne d'expérience : 15,7 (±12,1) ans) ont répondu à un sondage en ligne de 30 questions. Les résultats de cette étude démontrent que malgré un certain confort à effectuer l'évaluation et le dépistage des conducteurs à risque, les médecins ne se considèrent pas comme les professionnels les mieux qualifiés pour ce faire. Ils reconnaissent également le rôle que jouent les ergothérapeutes dans le dépistage de cette clientèle et l'intervention auprès d'elle. Ils voient ainsi la pertinence d'avoir accès aux services de ces professionnels en soins de première ligne.

Implementation model for a national learning health system (IMPLEMENT-National LHS): a concept analysis and systematic review protocol.

INTRODUCTION: Despite efforts and repeated calls to improve the organisation and quality of healthcare and services, and in view of the many challenges facing health systems, the results and capacity to adapt and integrate innovations and new knowledge remain suboptimal. Learning health systems (LHS) may be an effective model to accelerate the application of research for real quality improvement in healthcare. However, while recognising the enormous potential of LHS, the literature suggests the model remains more of an aspiration than a reality. METHODS AND ANALYSIS: To reach a fine understanding of the implementation of the concepts involved in LHS, we will use a hybrid method which combines concept analyses with systematic review methodology. We will use a two-step analysis, a content analysis to analyse the definitions, uses and attributes of the concept and a systematic review to analyse the concept's implementation mechanisms. We will search eight databases and grey literature and present a broad synthesis of the available evidence regarding design, implementation and evaluation of LHS in a multilevel perspective. We will follow the latest Preferred Reporting Items for Systematic Review and Meta-Analysis statement for conducting and reporting a systematic review. Two reviewers will independently screen the titles and abstracts against the eligibility criteria followed by full-text screening of potentially relevant articles for final inclusion decision. Conflicts will be resolved with a senior author. We will include published primary studies that use qualitative, quantitative or mixed methods. The assessment of risk of bias will be made using the Mixed-Methods Appraisal Tool. ETHICS AND DISSEMINATION: This systematic review is exempt from ethics approval. The results formulated will highlight evidence-based interventions that support the implementation of a national LHS. They will be of particular interest to decision makers, researchers, managers, clinicians and patients allowing finally to implement the promising proposal of LHSs at national scale. PROSPERO REGISTRATION NUMBER: CRD42023393565.

Clinical Integration of Digital Patient-Reported Outcome Measures in Primary Health Care for Chronic Disease Management: Protocol for a Systematic Review.

BACKGROUND: Health measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation. OBJECTIVE: We will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs' implementation strategies. METHODS: We will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis. RESULTS: This study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022. CONCLUSIONS: Results from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48155.

Identify and classify interprofessional primary care performance indicators: a scoping review protocol.

INTRODUCTION: Measuring the performance of interprofessional primary care is needed to examine whether this model of care is achieving its desired outcomes on patient care and health system effectiveness as well as to guide quality improvement initiatives. The aim of this scoping review is to map the literature on primary care performance measurement indicators to determine the extent to which current indicators capture or could be adapted to capture processes, outputs and outcomes that reflect interprofessional primary care. METHODS AND ANALYSIS: The review will be guided by the six-stage framework by Arksey and O'Malley (2005). MEDLINE, Embase, CINAHL, grey literature and the reference list of key studies will be searched to identify any study, published in English or French between 2000 and 2022, related to the concepts of performance indicators, frameworks, interprofessional teams and primary care. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Eligible indicators will be classified according to process, output and outcome domains proposed by two validated frameworks. This study started in November 2022 and is expected to be completed by July 2023. ETHICS AND DISSEMINATION: This review does not require ethical approval. The results will be disseminated through a peer-reviewed publication, conference presentations and presentations to stakeholders.

Structuring and organizing interprofessional healthcare in partnership with patients with diabetes: the INterprofessional Management and Education in Diabetes care (INMED) pathway.

Type 2 diabetes is a complex chronic disease that requires ongoing monitoring by an interprofessional team to prevent complications. The INMED (INterprofessional Management and Education in Diabetes) care pathway was developed by our team to optimize primary care services for these patients and their families. The objective of this study is to describe the preliminary results of its adoption and implementation. The INMED care pathway is organized into four axes: (a) continuing professional education, (b) self-management support, (c) case management, and (d) ongoing evaluation of the quality of diabetes care and services. A multiple-case study is underway to document its effects on practice change using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Preliminary results on the adoption and implementation revealed some strengths: (a) regular patient follow-up by the case manager, (b) scheduling of physician appointments when required, and (c) regular screening for risk factors. Barriers were also identified: (a) lack of clear understanding of the case manager role, (b) lack of referrals to team members, and (c) lack of use of the motivational interview approach. The INMED care pathway is being adopted by primary care teams but challenges need to be overcome to improve its reach and effectiveness.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic.

OBJECTIVE: This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth. METHOD: A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers. RESULTS: Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients. CONCLUSION: The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BACKGROUND: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25619.

The challenges of measuring quality-of-care indicators in rural emergency departments: a cross-sectional descriptive study.

BACKGROUND: Evidence-based indicators of quality of care have been developed to improve care and performance in Canadian emergency departments. The feasibility of measuring these indicators has been assessed mainly in urban and academic emergency departments. We sought to assess the feasibility of measuring quality-of-care indicators in rural emergency departments in Quebec. METHODS: We previously identified rural emergency departments in Quebec that offered medical coverage with hospital beds 24 hours a day, 7 days a week and were located in rural areas or small towns as defined by Statistics Canada. A standardized protocol was sent to each emergency department to collect data on 27 validated quality-of-care indicators in 8 categories: duration of stay, patient safety, pain management, pediatrics, cardiology, respiratory care, stroke and sepsis/infection. Data were collected by local professional medical archivists between June and December 2013. RESULTS: Fifteen (58%) of the 26 emergency departments invited to participate completed data collection. The ability to measure the 27 quality-of-care indicators with the use of databases varied across departments. Centres 2, 5, 6 and 13 used databases for at least 21 of the indicators (78%-92%), whereas centres 3, 8, 9, 11, 12 and 15 used databases for 5 (18%) or fewer of the indicators. On average, the centres were able to measure only 41% of the indicators using heterogeneous databases and manual extraction. The 15 centres collected data from 15 different databases or combinations of databases. The average data collection time for each quality-of-care indicator varied from 5 to 88.5 minutes. The median data collection time was 15 minutes or less for most indicators. INTERPRETATION: Quality-of-care indicators were not easily captured with the use of existing databases in rural emergency departments in Quebec. Further work is warranted to improve standardized measurement of these indicators in rural emergency departments in the province and to generalize the information gathered in this study to other health care environments.