Colorectal Cancer Patients' Reported Frequency, Content, and Satisfaction with Advance Care Planning Discussions.

(1) Background: This observational cohort study describes the frequency, content, and satisfaction with advance care planning (ACP) conversations with healthcare providers (HCPs), as reported by patients with advanced colorectal cancer. (2) Methods: The patients were recruited from two tertiary cancer centers in Alberta, Canada. Using the My Conversations survey with previously validated questions, the patients were asked about specific ACP elements discussed, with which HCPs these elements were discussed, their satisfaction with these conversations, and whether they had a goals of care designation (GCD) order. We surveyed and analyzed data from the following four time points: enrollment, months 1, 2, and 3. (3) Results: In total, 131 patients were recruited. At enrollment, 24% of patients reported discussing at least one ACP topic. From enrollment to month 3, patients reported a high frequency of discussions (80.2% discussed fears, 71.0% discussed prognosis, 54.2% discussed treatment preferences at least once); however, only 44.3% of patients reported discussing what is important to them in considering health care preferences. Patients reported having ACP conversations most often with their oncologists (84.7%) and cancer clinic nurses (61.8%). Patients reported a high level of satisfaction with their ACP conversations, with over 80% of patients reported feeling heard and understood. From enrollment to month 3, there was an increase in the number of patients with a GCD order from 53% to 74%. (4) Conclusions: Patients reported more frequent conversations compared to the literature and clinical documentation. While the satisfaction with these conversations is high, there is room for quality improvement, particularly in eliciting patients' personal goals for their treatment.

Forward with Dementia: process evaluation of an Australian campaign to improve post-diagnostic support.

BACKGROUND: Forward with Dementia is a co-designed campaign to improve communication of dementia diagnosis and post-diagnostic support. METHODS: Webinars, a website, social and traditional media, and promotions through project partners were used to disseminate campaign messages to health and social care professionals (primary audience) and people with dementia and carers (secondary audience). The campaign ran between October 2021 and June 2022, with 3-months follow-up. The RE-AIM framework was used for process evaluation. Measurements included surveys and interviews, a log of activities (e.g. webinars, social media posts) and engagements (e.g. attendees, reactions to posts), and Google Analytics. RESULTS: There were 29,053 interactions with campaign activities. More than three-quarters of professionals (n = 63/81) thought webinars were very or extremely helpful. Professionals and people with dementia and carers reported that the website provided appropriate content, an approachable tone, and was easy to use. Following campaign engagement, professionals planned to (n = 77/80) or had modified (n = 29/44) how they communicated the diagnosis and/or provided post-diagnostic information and referrals. Qualitative data suggested that the campaign may have led to benefits for some people with dementia and carers. CONCLUSIONS: Forward with Dementia was successful in terms of reach, appropriateness, adoption and maintenance for professionals, however flow-through impacts on people with dementia are not clear. Targeted campaigns can potentially change health professionals' communication and support around chronic diseases such as dementia.

Primary care providers' perceptions on the integration of community-led advance care planning activities with primary care: a cross-sectional survey.

BACKGROUND: Advance care planning (ACP) is a process intended to help ensure people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness. Barriers to implementing ACP in primary care settings exist. Community-led ACP initiatives exist in British Columbia to engage the public directly. These initiatives may help prepare people for conversations with their primary care providers. The objectives of this study were to elicit primary care providers' perceptions of the utility and desired content of community-led ACP activities and suggestions for integrating community-led ACP activities with primary care. METHODS: We conducted an online cross-sectional survey of primary care providers practicing in British Columbia, Canada in 2021. Both quantitative and qualitative survey questions addressed ACP engagement in practice, the perceived role and desired outcomes of community-led ACP activities, and ways to integrate community-led ACP activities with primary care. RESULTS: Eighty-one providers responded. Over 80% perceived a moderate or greater potential impact of community-led ACP activities. The most common reasons for not referring a patient to a community-led ACP activity were lack of awareness of the option locally (62.1%) and in general (44.8%). Respondents wanted their patients to reflect on their values, wishes and preferences for care, to have at least thought about their goals of care and to have chosen a substitute decision maker in the community. They indicated a desire for a summary of their patient's participation and a follow-up discussion with them about their ACP. They suggested ways to integrate referral to programs into existing health care system structures. CONCLUSIONS: Community-led ACP activities were perceived to be useful to engage and prepare patients to continue ACP discussions with clinicians. Efforts should be made to establish and integrate community-based ACP initiatives within existing primary care systems to ensure awareness and uptake.

Embedding anti-racism in Schools of Public Health: a pathway to accountability for progress towards equity.

The importance of seeing race as a socially constructed idea continues to produce unfair differences between humans and establishes power relations that lead to injustice and exposure to death. Since the racial justice movement in early 2020, there has been a heightened awareness of, and increased interest in, addressing historic racial disparities across Schools of Public Health (SPH) in Canada. Steps have been taken to recognize systemic racism and increase diversity through structural reforms to advance equity and inclusion; however, addressing racism demands collectively uprooting racist institutional designs still inherent in learning, teaching, research, service, and community engagement. This commentary highlights the need for sustained commitment to establishing longitudinal benchmarks for greater racial equity among students, staff, and faculty; revising curricula to include historic and contemporary narratives of colonialism and slavery; and providing community-engaged learning opportunities as instrumental to dismantle systemic drivers of racial health inequities locally and globally. We also advocate for intersectoral collaboration, mutual learning, and sharing of resources across SPH and partner agencies to accomplish a continual collective agenda for racial health equity and inclusion that is intersectional in Canada, while being held accountable to Indigenous and racialized communities.

RéSUMé: L'importance de voir la race comme une idée socialement construite continue de produire des différences inéquitables entre les gens et d'établir des relations de pouvoir qui mènent à l'injustice et à l'exposition à la mort. Depuis que le mouvement pour la justice raciale s'est enclenché au début de 2020, il existe une conscience aiguë des disparités raciales historiques entre les écoles de santé publique (ESP) du Canada et un intérêt accru pour le redressement de ces disparités. Des mesures ont été prises pour reconnaître le racisme systémique et accroître la diversité par des réformes structurelles visant à promouvoir l'équité et l'inclusion; cependant, pour aborder le racisme, il faut collectivement arracher les modèles institutionnels racistes qui font encore partie intégrante de l'apprentissage, de l'enseignement, de la recherche, des services et de la participation de la communauté. Dans notre commentaire, nous soulignons le besoin d'un engagement soutenu à établir des repères longitudinaux pour une plus grande équité raciale dans la population étudiante, au sein du personnel et dans le corps professoral, à revoir les programmes d'études pour y inclure les discours historiques et contemporains du colonialisme et de l'esclavage, et à offrir des possibilités d'enseignement faisant appel aux communautés, car elles contribueront à démanteler les moteurs systémiques des iniquités raciales en santé à l'échelle locale et mondiale. Nous promulguons aussi la collaboration intersectorielle, l'apprentissage mutuel et le partage des ressources entre les ESP et les organismes partenaires afin de concrétiser un plan d'action collective continue en faveur de l'équité raciale en santé et de l'inclusion ­ un plan qui sera intersectionnel au Canada et qui rendra des comptes aux communautés autochtones et racisées.

Fgf, Hh, and pax2a differentially regulate expression of pax5 and pou3f3b in vestibular and auditory maculae in the zebrafish otic vesicle.

BACKGROUND: The vertebrate inner ear contains distinct sensory epithelia specialized for auditory or vestibular function. In zebrafish, the first sensory epithelia form at opposite ends of the otic vesicle and are functionally distinct: the anterior utricular macula is essential for vestibular function whereas the posterior saccular macula is critical for hearing. Mechanisms distinguishing these maculae are not clear. Here, we examined the effects of manipulating Fgf or Hh on expression of pax5 and pou3f3b, unique markers of utricular and saccular identity. We also examined the roles of pax2a and atoh1a/b, early regulators of sensory specification. RESULTS: fgf3 and fgf8a were uniquely required for pax5 and pou3f3b, respectively. Elevating Fgf or blocking Hh expanded expression of pax5 but repressed pou3f3b, while blocking Fgf had the opposite effect. Blocking sensory specification did not affect pax5 or pou3f3b, but both markers were lost in pax2a-/- mutants. Maintenance of pax2a expression requires Fgf, Hh and Pax2a itself. CONCLUSION: Specification of utricular identity requires high Fgf and is repressed by Hh, whereas saccular identity requires Hh plus low Fgf. pax2a acts downstream of Fgf and Hh to maintain both fates. Comparison with mouse suggests this may reflect a broadly conserved developmental mechanism.

Multimorbidity and Complexity Among Patients with Cancer in Ontario: A Retrospective Cohort Study Exploring the Clustering of 17 Chronic Conditions with Cancer.

BACKGROUND: Multimorbidity is a concern for people living with cancer, as over 90% have at least one other condition. Multimorbidity complicates care coming from multiple providers who work within separate, siloed systems. Information describing high-risk and high-cost disease combinations has potential to improve the experience, outcome, and overall cost of care by informing comprehensive care management frameworks. This study aimed to identify disease combinations among people with cancer and other conditions, and to assess the health burden associated with those combinations to help healthcare providers more effectively prioritize and coordinate care. METHODS: We used a population-based retrospective cohort design including adults with a cancer diagnosis between March-2003 and April-2013, followed-up until March 2018. We used observed disease combinations defined by level of multimorbidity and partitive (k-means) clusters, ie groupings of similar diseases based on the prevalence of each condition. We assessed disease combination-associated health burden through health service utilization, including emergency department visits, primary care visits and hospital admissions during the follow-up period. RESULTS: 549,248 adults were included in the study. Anxiety, diabetes mellitus, hypertension, and osteoarthritis co-occurred with cancer 1.1 to 5.3 times more often than expected by chance. Disease combinations varied by cancer type and age but were similar between sexes. The largest partitive cluster included cancer and anxiety, with at least 25% of individuals also having osteoarthritis. Cancer also tended to co-occur with hypertension (8.0%) or osteoarthritis (6.2%). There were differences between clusters in healthcare utilization, regardless of the number of disease combinations or clustering approach used. CONCLUSION: Researchers, clinicians, policymakers, and other stakeholders can use the clustering information presented here to improve the healthcare system for people with cancer multimorbidity by developing cluster-specific care management and clinical guidelines for common disease combinations.

Pax2a, Sp5a and Sp5l act downstream of Fgf and Wnt to coordinate sensory-neural patterning in the inner ear.

In zebrafish, sensory epithelia and neuroblasts of the inner ear form simultaneously in abutting medial and lateral domains, respectively, in the floor of the otic vesicle. Previous studies support regulatory roles for Fgf and Wnt, but how signaling is coordinated is poorly understood. We investigated this problem using pharmacological and transgenic methods to alter Fgf or Wnt signaling from early placodal stages to evaluate later changes in growth and patterning. Blocking Fgf at any stage reduces proliferation of otic tissue and terminates both sensory and neural specification. Wnt promotes proliferation in the otic vesicle but is not required for sensory or neural development. However, sustained overactivation of Wnt laterally expands sensory epithelia and blocks neurogenesis. pax2a, sp5a and sp5l are coregulated by Fgf and Wnt and show overlapping expression in the otic placode and vesicle. Gain- and loss-of-function studies show that these genes are together required for Wnt's suppression of neurogenesis, as well as some aspects of sensory development. Thus, pax2a, sp5a and sp5l are critical for mediating Fgf and Wnt signaling to promote spatially localized sensory and neural development.

Short Graphic Values History Tool for decision making during serious illness.

OBJECTIVES: To develop and validate a values clarification tool, the Short Graphic Values History Tool (GVHT), designed to support person-centred decision making during serious illness. METHODS: The development phase included input from experts and laypersons and assessed acceptability with patients/family members. In the validation phase, we recruited additional participants into a before-after study. Our primary validation hypothesis was that the tool would reduce scores on the Decisional Conflict Scale (DCS) at 1-2 weeks of follow-up. Our secondary validation hypotheses were that the tool would improve values clarity (reduce scores) more than other DCS subscales and increase engagement in advance care planning (ACP) processes related to identification and discussion of one's values. RESULTS: In the development phase, the tool received positive overall ratings from 22 patients/family members in hospital (mean score 4.3; 1=very poor; 5=very good) and family practice (mean score 4.5) settings. In the validation phase, we enrolled 157 patients (mean age 71.8 years) from family practice, cancer clinic and hospital settings. After tool completion, decisional conflict decreased (-6.7 points, 95% CI -11.1 to -2.3, p=0.003; 0-100 scale; N=100), with the most improvement seen in the values clarity subscale (-10.0 points, 95% CI -17.3 to -2.7, p=0.008; N=100), and the ACP-Values process score increased (+0.4 points, 95% CI 0.2 to 0.6, p=0.001; 1-5 scale; N=61). CONCLUSIONS: The Short GVHT is acceptable to end users and has some measure of validity. Further study to evaluate its impact on decision making during serious illness is warranted.

Evaluating the Efficacy of Eradicating Gardnerella vaginalis Vaginal Colonization With Amoxicillin: A Randomized, Double-Blind, Phase 2 Study.

BACKGROUND: Research suggests that Gardnerella vaginalis (GV) is the keystone pathogen in bacterial vaginosis (BV). Knowledge gaps exist regarding the role of GV eradication in the development of BV. This study was designed to test the hypothesis that vaginal colonization with GV could be eradicated by treatment of women without BV with amoxicillin, a drug highly active against GV. If GV is necessary for the development of BV, then eradication of GV may prevent the development of BV. METHODS: We conducted a randomized control trial of amoxicillin 500 mg twice daily versus placebo for 7 days in women aged 18 to 45 years without vaginitis who screened positive for vaginal colonization with GV by quantitative polymerase chain reaction. Test-of-cure visit for GV was conducted at day 21. RESULTS: One hundred seventy-two women met preliminary criteria and were screened for enrollment. Ninety-seven GV-positive women were randomized to receive amoxicillin versus placebo. Eradication of GV occurred in 21% of women randomized to amoxicillin versus 16% on placebo (P = 0.757). In the 4 weeks between screening and test-of-cure visit, 16 of 92 (17%) of participants developed Nugent scores greater than 3 with 8 of 92 (9%) having BV. All of these were in participants in whom GV was not eradicated (P = 0.035). CONCLUSIONS: The study failed to show a benefit of treatment with amoxicillin to eradicate GV. No participants in whom GV was eradicated had progression to abnormal vaginal flora during the study period.

Family physicians supporting patients with palliative care needs within the patient medical home in the community: an appreciative inquiry study.

OBJECTIVES: Canadians want to live and die in their home communities. Unfortunately, Canada has the highest proportion of deaths in acute care facilities as compared with other developed nations. This study aims to identify the essential components required to best support patients and families with palliative care needs in their communities to inform system changes and empower family physicians (FPs) in providing community-based palliative care for patients. DESIGN: Appreciative inquiry (AI) methodology with individual interviews. Interview transcripts were analysed iteratively for emerging themes and used to develop 'possibility statements' to frame discussion in subsequent focus groups. A conceptual framework emerged to describe the 'destiny' state as per AI methods. SETTING: FPs, palliative home care providers, patients and bereaved caregivers were recruited in the urban and surrounding rural health authority zones of Calgary, AB, Canada. PARTICIPANTS: 9 females and 9 males FPs (range of practice years 2-42) in interviews; 8 bereaved caregivers, 1 patient, 26 palliative home care team members in focus groups. Interviews and focus groups were recorded digitally and transcribed with consent. RESULTS: The identified themes that transcended all three groups created the foundation for the conceptual framework. Enhanced communication and fostering team relationships between all care providers with the focus on the patient and caregivers was the cornerstone concept. The FP/patient relationship must be protected and encouraged by all care providers, while more system flexibility is needed to respond more effectively to patients. These concepts must exist in the context that patients and caregivers need more education regarding the benefits of palliative care, while increasing public discourse about mortality. CONCLUSIONS: Key areas were identified for how the patient's team can work together effectively to improve the patient and caregiver palliative care journey in the community with the cornerstone element of building on the trusting FP-patient longitudinal relationship.

Priorities for family physician and general practitioner recruitment and retention in Singapore: a PRIORITIZE study.

BACKGROUND: A shortage of primary care physicians has been reported in many countries. Primary care systems are diverse and the challenges leading to a decline in workforce are at times context-specific and require tailored solutions. Inviting frontline clinicians to share their insights can help identify optimal strategies for a particular setting. To determine priorities for family physicians' and general practitioners' recruitment and retention in Singapore, we invited primary care physicians to rank pertinent strategies using PRIORITIZE, a transparent, systematic priority-setting approach. METHODS: The study advisory board, consisting of representatives of Singapore's key primary care stakeholders, determined the criteria for prioritising of general practitioners (GPs) and family physicians (FPs) recruitment and retention strategies in Singapore. A comprehensive list of GPs and FPs recruitment and retention strategies was extracted from a recent systematic review of the relevant literature. A questionnaire listing the strategies and the scoring criteria was administered online to doctors practicing in public and private sector in Singapore. Respondents' scores were combined to create a ranked list of locally most relevant strategies for improving GPs and FPs recruitment and retention. RESULTS: We recruited a diverse sample of 50 GPs and FPs practicing in a variety of primary care settings, many with a range of additional professional responsibilities. Around 60 and 66% of respondents thought that there was a problem with recruitment and retention of GPs and FPs in Singapore, respectively. Strategies focusing on promoting primary care by emphasizing the advantages and enhancing the status of the profession as well as training-related strategies, such as sub-specialisation and high-quality rotations were considered priorities for improving recruitment. For retention of GPs and FPs, improving working conditions by increasing GPs' and FPs' salary and recognition, as well as varying or reducing time commitment, were seen as the most important strategies. The ranking between physicians working in public and private sector was mostly similar, with nine out of the top ten recruitment and retention strategies being the same. CONCLUSION: Primary care physicians' ranking of recruitment and retention strategies for GPs and FPs in Singapore provide important insight into the challenges and the solutions as seen by the members of the profession themselves. This information can guide future policy and decision making in this area.

Perspectives of Australian GPs on tailoring fall risk management: a qualitative study.

Falls among older people are highly prevalent, serious and costly, and translation of evidence about falls prevention needs to occur urgently. GPs can identify older people at risk of falling and put preventative measures in place before a fall. Because GPs are key to identifying older people at risk of falls and managing falls risk, this study explored how GPs adapted to the iSOLVE (Integrated SOLutions for sustainable falls preVEntion) process to embed evidence-based falls prevention strategies within primary care, and whether and how they changed their practice. A theoretically informed qualitative study using normalisation process theory was conducted in parallel to the iSOLVE trial to elicit GPs' views about the iSOLVE process. Data were coded and a thematic analysis of interview transcripts was conducted using constant comparison between the data and themes as they developed. In all, 24 of 32 eligible GPs (75%) from general practices located in the North Sydney Primary Health Network, Australia, were interviewed. Six themes were identified: (1) making it easy to ask the iSOLVE questions; (2) internalising the process; (3) integrating the iSOLVE into routine practice; (4) addressing assumptions about patients and fall prevention; (5) the degree of change in practice; and (6) contextual issues influencing uptake. The iSOLVE project focused on practice change, and the present study indicates that practice change is possible. How GPs addressed falls prevention in their practice determined the translation of evidence into everyday practice. Support tools for falls prevention must meet the needs of GPs and help with decision making and referral. Fall prevention can be integrated into routine GP practice through the iSOLVE process to tailor fall risk management.

Maternal vitamin B12 status in early pregnancy and its association with birth outcomes in Canadian mother-newborn Dyads.

Vitamin B12 (B12) is a co-enzyme essential for fetal growth and development. Lower maternal B12 status has been associated with preterm birth (<37 gestational weeks) and low birth weight (<2500 g), which are linked to morbidity and mortality across the lifespan. In Canada, 17-25 % of women in early pregnancy had a serum total B12 concentration <148 pmol/l and maternal total B12 concentration decreased throughout pregnancy. This study aimed to determine the association between maternal B12 status and birth outcomes in Canadian mother-newborn dyads. A secondary analysis of 709 mother-newborn dyads in British Columbia (BC), Canada, was conducted. Bio-banked first- (n 656) and second-trimester (n 709) maternal serum samples of apparently healthy South Asian (50 %) and European (50 %) women from the BC Prenatal Genetic Screening Program were quantified for B12 biomarkers (total B12, holotranscobalamin (holoTC), methylmalonic acid (MMA) and total homocysteine (tHcy)). Obstetric history and birth outcome data were obtained from the BC Perinatal Data Registry. All associations were determined using multiple linear regression. Maternal serum total B12, holoTC, MMA and tHcy had a mean weekly decrease of 3·64 pmol/l, 1·04 pmol/l, 1·44 nmol/l and 0·104 µmol/l, respectively (P < 0·001). Despite a total B12 concentration <148 pmol/l among 20-25 % of the women, maternal B12 biomarker concentrations were not associated with birth weight z-score, head circumference z-score and gestational age at birth (P > 0·05). Additional research in women at high risk of adverse birth outcomes and the association between maternal B12 status and functional, for example, cognitive, outcomes is needed.

Real World Implementation of the Serious Illness Care Program in Cancer Care: Results of a Quality Improvement Initiative.

Purpose: Guidelines suggest that advance care planning (ACP) and goals-of-care discussions should be conducted for patients with advanced cancer early in the course of their disease. A recent audit of our health system found that these discussions were rarely being documented in the electronic medical record (EMR). We conducted a quality improvement initiative to improve rates of documentation of goals and wishes among patients with advanced cancer. Methods: On the basis of previous analyses of this problem, we determined that provider capability and opportunity were the main barriers to conducting and documenting serious illness conversations. We implemented the serious illness care program (SICP), a systematic multicomponent intervention that has shown potential for conducting and documenting ACP discussions in two oncology clinics. Our goal was to conduct at least 24 serious illness conversations over the implementation period, with documentation of at least 95% of all conversations. Results: The SICP was implemented in two outpatient medical oncology clinics. A total of 15 serious illness care conversations occurred and 14 (93%) of these conversations were documented in the EMR. Total rates of documentation increased between the preimplementation and implementation period (4.2%-5.4% for clinician A and 0%-7.3% for clinician B). Conclusion: Implementation of the SICP resulted in increased rates of documentation, but the target number of conversations was not met. Further improvement cycles are required to address barriers to conducting and documenting routine serious illness conversations.

Effect of "Speak Up" educational tools to engage patients in advance care planning in outpatient healthcare settings: A prospective before-after study.

BACKGROUND: Tools for advance care planning (ACP) are advocated to help ensure patient values guide healthcare decisions. Evaluation of the effect of tools introduced to patients in clinical settings is needed. OBJECTIVE: To evaluate the effect of the Canadian Speak Up Campaign tools on engagement in advance care planning (ACP), with patients attending outpatient clinics. Patient involvement: Patients were not involved in the problem definition or solution selection in this study but members of the public were involved in development of tools. The measurement of impacts involved patients. METHODS: This was a prospective pre-post study in 15 primary care and two outpatient cancer clinics. The outcome was scores on an Advance Care Planning Engagement Survey measuring Behavior Change Process on 5-point scales and Actions (0-21-point scale) administered before and six weeks after using a tool, with reminders at two or four weeks. RESULTS: 177 of 220 patients (81%) completed the study (mean 68 years of age, 16% had cancer). Mean Behavior Change Process scores were 2.9 at baseline and 3.5 at follow-up (mean change 0.6, 95% confidence interval 0.5 to 0.7; large effect size of 0.8). Mean Action Measure score was 3.7 at baseline and 4.8 at follow-up (mean change 1.1, 95% confidence interval 0.6-1.5; small effect size of 0.2). PRACTICAL VALUE: Publicly available ACP tools may have utility in clinical settings to initiate ACP among patients. More time and motivation may be required to stimulate changes in patient behaviors related to ACP.

Developing Virtual Reality Trauma Training Experiences Using 360-Degree Video: Tutorial.

Historically, medical trainees were educated in the hospital on real patients. Over the last decade, there has been a shift to practicing skills through simulations with mannequins or patient actors. Virtual reality (VR), and in particular, the use of 360-degree video and audio (cineVR), is the next-generation advancement in medical simulation that has novel applications to augment clinical skill practice, empathy building, and team training. In this paper, we describe methods to design and develop a cineVR medical education curriculum for trauma care training using real patient care scenarios at an urban, safety-net hospital and Level 1 trauma center. The purpose of this publication is to detail the process of finding a cineVR production partner; choosing the camera perspectives; maintaining patient, provider, and staff privacy; ensuring data security; executing the cineVR production process; and building the curriculum.

Systematic Review and Meta-Analysis of Intervention Studies with General Practitioner Involvement Focused on Falls Prevention for Community-Dwelling Older People.

Objectives: Falls are a significant health problem for the ageing population. This review aimed to identify effective falls prevention interventions with involvement of general practitioners (GPs). Methods: Systematic review of randomised controlled trials conducted from 1999-2019, with meta-analysis. Searches located 2736 articles. A quality assessment was conducted of all included studies. Results: 21 randomised controlled trials met the inclusion criteria and 19 studies could be included in a meta-analysis. Overall, studies were not effective for reducing multiple falls (Relative Risk (RR) 1.16, 95% CI .97-1.39 and p = .10) or reducing one or more falls (RR .91, 95% CI: .82-1.01 and p = .08), but were effective for reducing injurious falls (RR .76, 95% CI: .66-.87 and p = .001). Discussion: Studies involving the GP in an active role and aligned with the primary care context were effective. The fidelity of interventions was limited by independent GP decisions and older participants being required to initiate the intervention.

Exploring patient-reported barriers to advance care planning in family practice.

BACKGROUND: Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people's expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients' wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP. METHODS: In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients' knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic analysis and form the basis of this paper. RESULTS: One hundred two participants provided an analyzable response to the survey when asked why they haven't talked to someone about ACP. Two hundred fifty-four answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The Medical Doctor (MD) should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It's not a priority; and 8. A lack of knowledge about ACP. CONCLUSIONS: Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients' knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person- centred relationship they have with patients to mitigate some of these barriers.

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings.

PURPOSE: Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www.prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics. METHODS: We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement. RESULTS: In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations. CONCLUSIONS: Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.