Recreating the village: the patient experience with a hybrid model of Group Perinatal Care (GPPC) in an academic family health team.

BACKGROUND: Group prenatal care (GPC) has been shown to have a positive impact on social support, patient knowledge and preparedness for birth. We developed an interprofessional hybrid model of care whereby the group perinatal care (GPPC) component was co-facilitated by midwives (MW) and family medicine residents (FMR) and alternating individual visits were provided by family physicians (FP's) within our academic family health team (FHT) In this qualitative study, we sought to explore the impact of this program and how it supports patients through pregnancy and the early newborn period. METHODS: Qualitative study that was conducted using semi-structured telephone interviews with 18 participants who had completed GPPC in the Mount Sinai Academic Family Health Team in Toronto, Canada and delivered between November 2016 and October 2018. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted by team members using grounded theory. RESULTS: Four over-arching themes emerged from the data: (i) Participants highly valued information they received from multiple trusted sources, (ii) Participants felt well cared for by the collaborative and coordinated interprofessional team, (iii) The design of GPPC enabled a shared experience, allowing for increased support of the pregnant person, and (iv) GPPC facilitated a supportive transition into the community which positively impacted participants' emotional well- being. CONCLUSIONS: The four constructs of social support (emotional, informational, instrumental and appraisal) were central to the value that participants found in GPPC. This support from the team of healthcare providers, peers and partners had a positive impact on participants' mental health and helped them face the challenges of their transition to parenthood.

Building Healthy Babies: A Mixed-Methods Needs Assessment for a Pre-Conception Program in Ontario.

OBJECTIVES: The objective of this study was to gather Ontario clinicians' and public members' views on the design of a pre-conception patient education program. METHODS: In this mixed-methods study, online surveys comprised of rank order, multiple choice, and short answer questions were completed by clinicians and public members. Semi-structured focus groups consisting of 2-6 participants each were then held via videoconference. Demographic variables and survey responses were analyzed quantitatively using descriptive and summary statistics. Descriptive thematic qualitative analysis using the constant comparative method of grounded theory was completed on each transcript to generate themes. RESULTS: A total of 168 public members and 43 clinicians in Ontario completed surveys, while 11 clinicians and 11 public members participated in the focus groups. A pre-conception program in Ontario was felt to be important. An individual appointment with a primary care provider was the favoured program format per survey responses, whereas a virtual format with an interactive component was preferred among focus group participants. Important topics to include were pre-conception health (infertility, genetic screening, folic acid), prenatal and postpartum counselling (diet, activity, substance use, prenatal care, postpartum course), and medical optimization in pregnancy (high-risk medical conditions, medications, mental health). Both groups emphasized the need to consider accommodations for marginalized populations and various cultures and languages. CONCLUSION: A standardized pre-conception patient education program is felt to be of high value by Ontario clinicians and public members. A pre-conception program may help improve obstetrical outcomes and decrease rates of major congenital anomalies in Ontario.

Investigating the effect of providing monetary incentives to participants on completion rates of referred co-respondents: An embedded randomized controlled trial.

Background: The use of a second informant (co-respondent) is a common method of identifying potential bias in outcome data (e.g., parent-report child outcomes). There is, however, limited evidence regarding methods of increasing response rates from co-respondents. The use of financial incentives is associated with higher levels of engagement and follow-up data collection in online surveys. This study investigated whether financial incentives paid to index participants in an online trial of a parenting-focused intervention, would lead to higher levels of co-respondent data collection. Methods: A study within a trial (SWAT) using a parallel group RCT design. Participants in the host study (an RCT of an online intervention) were randomised into one of two SWAT arms: received/did not receive a £15 voucher when referred co-respondent completed baseline measures. Primary outcome was completion (No/Yes) of Spence Children's Anxiety Scale (SCAS or SCAS-Pre) at baseline. Additional analysis explored impact of incentives on data quality. Results: Intention to treat analysis of 899 parents (183 co-respondents) in the no-incentive arm, and 911 parents (199 co-respondents) in incentive arm. Nomination of co-respondents was similar between incentive arms. The RR for the incentive arm compared to the no incentive arm was 1.13 (95% CI: 0.91 to 1.41, p = 0.264) indicating that incentives did not impact completion of outcomes by consented co-respondents. There were no indications of different data quality between arms. Discussion: The finding that payment of financial incentives to index participant does not lead to greater levels of co-respondent outcome completion suggests that careful consideration should be made before allocating resources in this way in future trials. Trial registration: The host study was registered at Study Record | ClinicalTrials.gov and the SWAT study was registered in the SWAT Store | The Northern Ireland Network for Trials Methodology Research (qub.ac.uk): SWAT number 143: Filetoupload,1099612,en.pdf (qub.ac.uk).

Investigating the effect of providing monetary incentives to participants on completion rates of referred co-respondents: An embedded randomized controlled trial. Study within a trial (SWAT) protocol.

Background: Parent-report questionnaires are a common method of generating data on child outcomes in mental health studies. A second report from another person who knows the child (co-respondent) is implemented to reduce bias and increase objectivity. The success of this approach is dependent on the engagement of co-respondents, which can be difficult. Financial incentives are used to increase data return in clinical trials, and to promote referral rates in online marketing. This protocol describes the use of an embedded randomised controlled trial (RCT) to investigate the effect of financial incentives on rates of co-respondent data completion. In the host RCT (of an online intervention designed to reduce the impact of a parent's anxiety on their child) index participants (i.e. parents) are asked to invite a co-respondent to complete measures on the index child. This study will test the hypothesis that providing monetary incentives to index participants will increase the outcome measure completion rate of co-respondents. Methods: Embedded RCT of two parallel groups. Participants in the intervention arm will be sent a £10 voucher if their chosen co-respondent completes online baseline measures. Participants in the control arm will not be offered payment regardless of their chosen co-respondent's behaviour. 1754 participants will take part. Analysis will compare co-respondent outcome measure completion rates between the two arms at baseline and follow-up. Conclusion: Findings from this study will provide evidence on the impact of offering payment to index participants on return rates of co-respondent data. This will inform resource allocation within future clinical trials.

Effectiveness of a Web-Based Intervention to Prevent Anxiety in the Children of Parents With Anxiety: Protocol for a Randomized Controlled Trial.

BACKGROUND: Anxiety is the most common childhood mental health condition and is associated with impaired child outcomes, including increased risk of mental health difficulties in adulthood. Anxiety runs in families: when a parent has anxiety, their child has a 50% higher chance of developing it themselves. Environmental factors are predominant in the intergenerational transmission of anxiety and, of these, parenting processes play a major role. Interventions that target parents to support them to limit the impact of any anxiogenic parenting behaviors are associated with reduced anxiety in their children. A brief UK-based group intervention delivered to parents within the UK National Health Service led to a 16% reduction in children meeting the criteria for an anxiety disorder. However, this intervention is not widely accessible. To widen access, a 9-module web-based version of this intervention has been developed. This course comprises psychoeducation and home practice delivered through text, video, animations, and practice tasks. OBJECTIVE: This study seeks to evaluate the feasibility of delivering this web-based intervention and assess its effectiveness in reducing child anxiety symptoms. METHODS:  This is the protocol for a randomized controlled trial (RCT) of a community sample of 1754 parents with self-identified high levels of anxiety with a child aged 2-11 years. Parents in the intervention arm will receive access to the web-based course, which they undertake at a self-determined rate. The control arm receives no intervention. Follow-up data collection is at months 6 and months 9-21. Intention-to-treat analysis will be conducted on outcomes including child anxiety, child mental health symptoms, and well-being; parental anxiety and well-being; and parenting behaviors. RESULTS: Funding was received in April 2020, and recruitment started in February 2021 and is projected to end in October 2022. A total of 1350 participants have been recruited as of May 2022. CONCLUSIONS: The results of this RCT will provide evidence on the utility of a web-based course in preventing intergenerational transmission of anxiety and increase the understanding of familial anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT04755933; https://clinicaltrials.gov/ct2/show/NCT04755933. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40707.

Co-designing a web-based education platform for patients with early pregnancy loss.

Canadian emergency departments (EDs) frequently provide care to patients undergoing early pregnancy loss. Unfortunately, in this setting, patients commonly have negative experiences, in part due to lack of appropriate follow-up and education on symptoms that may arise after discharge. In response to this gap, our team created a free, web-based, patient-informed educational platform for women to access accurate information on early pregnancy loss. This free and publicly accessible resource was launched in May 2022 at Mount Sinai Hospital in Toronto and was shared with EDs across Canada.

RéSUMé: Les services d'urgence (SU) canadiens fournissent fréquemment des soins aux patientes qui subissent une perte de grossesse précoce. Malheureusement, dans ce contexte, les patientes ont souvent des expériences négatives, en partie à cause du manque de suivi approprié et d'éducation sur les symptômes qui peuvent apparaître après la sortie de l'hôpital. Pour combler cette lacune, notre équipe a créé une plate-forme éducative gratuite, basée sur le Web et informée par les patientes, permettant aux femmes d'accéder à des informations précises sur la perte de grossesse précoce. Cette ressource gratuite et accessible au public a été lancée en mai 2022 à l'hôpital Mount Sinai de Toronto et a été partagée avec les services d'urgence de tout le Canada.

Routine childhood vaccination rates in an academic family health team before and during the first wave of the COVID-19 pandemic: a pre-post analysis of a retrospective chart review.

BACKGROUND: There has been concern about declining routine vaccination rates during the COVID-19 pandemic. We evaluated the impact of the COVID-19 pandemic on early childhood vaccination rates at 2 sites of an academic family health team in the Greater Toronto Area, Ontario, serving both an urban and suburban patient population. METHODS: We conducted a pre-post analysis of vaccination records from Jan. 1, 2018, to Nov. 30, 2020, for a cohort of children born between Jan. 1, 2018, and Aug. 31, 2020, from the electronic medical record (EMR) of the Mount Sinai Academic Family Health Team (including an urban academic site in Toronto and a suburban community site in Vaughan, Ontario). We estimated the proportion of children receiving timely, delayed or no vaccination for 10 publicly funded vaccines in the Ontario immunization schedule for the pre-COVID-19 (Jan. 1, 2018, to Mar. 16, 2020) and COVID-19 (Mar. 17 to Nov. 30, 2020) pandemic periods. We determined timeliness in accordance with the recommended age of administration, with a 28-day window; we considered vaccines administered after this window to be delayed. We estimated the median time to vaccination for each vaccine and present cumulative incidence curves. RESULTS: The patient population was balanced between boys (52.4%) and girls (47.6%), with an average age of 18.5 months and representation across low-, middle- and high-income groups. Of the 506 children in our cohort, 422 were up to date with vaccinations (83.4%) by the end of the study period. Comparatively, 308 (83.2%) of the 370 eligible patients were up to date for all required vaccinations by the end of the pre-COVID-19 period. Among children younger than 12 months, vaccination rates were similar in the pre-COVID-19 and COVID-19 pandemic periods. Lower rates of timely vaccination for children between 12 and 18 months of age were amplified during the pandemic. Cumulative incidence curves were suggestive of a decrease in the timeliness of vaccinations in the COVID-19 period for the vaccines administered at 12, 15 and 18 months, compared with the pre-COVID-19 period. INTERPRETATION: Our local findings suggest a deterioration in the uptake of routine childhood vaccines in children aged 12 to 18 months in the first year of the COVID-19 pandemic. Further study is needed to determine the extent of the vaccination gap in children across Canada, including the impact of subsequent waves of the COVID-19 pandemic.

UpToDate versus DynaMed: a cross-sectional study comparing the speed and accuracy of two point-of-care information tools.

OBJECTIVE: To compare the accuracy, time to answer, user confidence, and user satisfaction between UpToDate and DynaMed (formerly DynaMed Plus), which are two popular point-of-care information tools. METHODS: A crossover study was conducted with medical residents in obstetrics and gynecology and family medicine at the University of Toronto in order to compare the speed and accuracy with which they retrieved answers to clinical questions using UpToDate and DynaMed. Experiments took place between February 2017 and December 2019. Following a short tutorial on how to use each tool and completion of a background survey, participants attempted to find answers to two clinical questions in each tool. Time to answer each question, the chosen answer, confidence score, and satisfaction score were recorded for each clinical question. RESULTS: A total of 57 residents took part in the experiment, including 32 from family medicine and 25 from obstetrics and gynecology. Accuracy in clinical answers was equal between UpToDate (average 1.35 out of 2) and DynaMed (average 1.36 out of 2). However, time to answer was 2.5 minutes faster in UpToDate compared to DynaMed. Participants were also more confident and satisfied with their answers in UpToDate compared to DynaMed. CONCLUSIONS: Despite a preference for UpToDate and a higher confidence in responses, the accuracy of clinical answers in UpToDate was equal to those in DynaMed. Previous exposure to UpToDate likely played a major role in participants' preferences. More research in this area is recommended.

How Teachers Adapt Their Cognitive Strategies When Using Entrustment Scales.

PURPOSE: Rater cognition is a field of study focused on individual cognitive processes used by medical teachers when completing assessments. Much has been written about the role of rater cognition in the use of traditional assessment scales. Entrustment scales (ES) are becoming the tool of choice for workplace-based assessments. It is not known how moving to an entrustment framework may cause teachers to adapt their cognitive rating strategies. This study aimed to explore this gap by asking teachers to describe their thinking when making rating decisions using a validated ES. METHOD: Using purposive sampling, family medicine teachers supervising obstetrical care were invited to participate in cognitive interviews. Teachers were interviewed between December 2018 and March 2019 using retrospective verbal protocol analysis. They were asked to describe their experiences of rating residents in the last 6 months using new ES. Constructivist grounded theory guided data collection and analysis. Interviews were recorded, transcribed, and analyzed iteratively. A constant comparative approach was used to code and analyze the data until consensus was reached regarding emerging themes. RESULTS: There was variability in how teachers used the ES. Faculty describe several ways in which they ultimately navigated the tool to say what they wanted to say. Four key themes emerged: (1) teachers interpreted the anchors differently based on their cognitive framework, (2) teachers differed in how they were able to cognitively shift away from traditional rating scales, (3) teachers struggled to limit assessments to a report on observed behavior, and (4) teachers contextualized their ratings. CONCLUSIONS: Variability in teachers' interpretation of learner performance persists in entrustment frameworks. Rater's individual cognitive strategies and how they observe, process, and integrate their thoughts into assessments form part of a rich picture of learner progress. These insights can be harnessed to contribute to decisions regarding readiness for unsupervised practice.

Mutant p53 in bone marrow stromal cells increases VEGF expression and supports leukemia cell growth.

OBJECTIVE: Genetic alterations, including p53 mutations, have been identified in the stroma of solid tumors and are thought be involved in the induction of tumor growth and metastasis. We tested the hypothesis that somatic molecular alterations in bone marrow stromal cells provide a favorable growth environment for leukemic cells. MATERIALS AND METHODS: We established an in vitro model consisting of stroma expressing mutant p53 (Cys135Ser) to study its ability to support growth of cells from a pre-B acute lymphoblastic leukemia (ALL) cell line. Normal and leukemic bone marrow stromal cells were screened for p53 mutations by mutant-specific ELISA, SSCP, and direct sequencing. Secretion of vascular endothelial growth factor (VEGF) was measured by quantitative ELISA. RESULTS: Transfection of stromal cells with mutant p53 increased synthesis of VEGF and supported the growth of leukemic cells. An ELISA-based assay suggested the occurrence of in vivo p53 alterations in bone marrow stromal cells from 2 of 12 ALL patients screened. Direct sequencing of one of these samples revealed a somatic heterozygous p53 gene mutation (Asp49His). This sample secreted more VEGF and provided increased growth support to leukemic cells. The ability of Asp 49His-p53 to increase the expression of VEGF was confirmed with transfection experiments in a p53-null cell line. CONCLUSION: Our findings indicate that genetic alterations, such as p53 mutations, in stromal cells can increase stromal-derived support of leukemia growth. Increased synthesis of pro-angiogenic cytokines, such as VEGF, may constitute one possible pathway by which this process is mediated.