BC-PHCRN members are involved in many SPOR-funded research projects, including the PREFeR (PRioritiEs For Research) Project, which aims to identify patient-generated priorities for primary care research in BC. Projects listed below are BC-PHCRN-supported projects funded through SPOR PIHCI grants.
Clinician-Patient Communication Interaction and Health Outcomes
BC, MB, QC: Lorienne Jenstad, Gayle Halas, Olivier Jamoulle, Marie-Thérèse Lussier, Michael Ross McKenzie, Monika Wetzel
This study involves a large, multidisciplinary, cross-jurisdictional team that includes patients, researchers, clinicians, and decision-makers from across Canada. We are seeking to investigate how communication between health care provider and patient/caregiver is linked to health outcomes and aiming to create a map of the existing literature on the topic, along with recommendations for the level of description to use when researching communication. We have published the protocol for our scoping literature review. We have screened close to 10,000 articles for inclusion and exclusion, developed our plan for data extraction, and have continued to track patient impact on the project. We presented our first poster at the International Association for the Scientific Study of Intellectual and Developmental Disabilities World Congress in Glasgow in August 2019. In the fall of 2019 we will convene two stakeholder groups in Vancouver and Winnipeg to discuss the preliminary results and to gather input on the interpretation and dissemination of the findings.
Impact: This grant has facilitated new collaborations and conversations. As we near the end of the project we are thinking ahead to next steps: possible primary research inspired by gaps identified by our literature search; possible secondary publications based on methodology and findings we hadn’t expected; and possible interdisciplinary, cross-jurisdictional projects with new-found collaborators. Further, we have had two patient partners who have been extremely involved throughout the project, beyond our expectations. Their contributions have been invaluable in shaping our work.
Supporting Integration Through Primary Health Care Teams: A Comparative Policy Analysis Across Five Canadian Provinces
BC, AB, ON, QC: Nelly Oelke, Darlene Arsenault, Shannon M Berg, Phil Graham, Brenda Jagroop, Genevieve Landry, Shana Ooms, Mylaine Breton, Sharon E Johnston, Stephanie R Montesanti
This cross-jurisdictional patient-oriented project aims to conduct a comparative policy analysis across BC, Alberta, Ontario, and Quebec to examine the policies and structures that support service integration for complex patients through primary health care teams. Case study methods will be used to conduct policy analysis across three phases. Currently, individual case studies are being done for each of the participating provinces, and then a cross case analysis will be completed. We are in the process of writing up the individual case studies. The second phase is focused on patient, family, and caregiver involvement in policy development, implementation and evaluation. This phase will begin shortly with interviews and deliberative dialogue.
Impact: Some of the biggest learnings so far for BC include:
- BC policies on primary health care do for the most part promote the use of primary health care teams to provide improved services for patients with complex conditions; however, policies do not clearly address the operationalization of primary health care teams;
- Remuneration models for team members continues to be an issue;
- Primary health care teams are not directly linked to integration;
- We are seeing more focus on patient-oriented care;
- We are seeing more focus on Indigenous peoples, due to the First Nations Health Authority.
Some key findings emerging from cross-jurisdictional discussions:
- Policymakers and researchers are looking for different things in the analysis, but all want to get out of this what will be most helpful to provinces to move primary health care reform forward;
- There is a lack of common definitions for integration and patients with complex needs;
- What is a team? Are they only those that work directly together? Or do they include a second layer of providers as well?
A Scoping Review of the Literature on Different Models of Allocating Funds to Facilitate Integrated Care
AB, BC: Pierre-Gerlier Forest, Gail MacKean, Nicolette McGuire, Judy Seidel, Jason Sutherland
Integrated care is viewed widely as a potential solution to overcome some of the major challenges faced by health and social care systems (e.g. duplication, fragmentation, poor care coordination). This scoping review aims to assess published international experience of different models of allocating funds to facilitate care integration and the evidence on their impacts. We followed the framework developed by Arksey and O’Malley that entails six steps:
- Identify research question(s);
- Search for relevant studies;
- Select studies;
- Chart the data;
- Collate, summarize, and report results;
- Conduct consultation exercises.
Impact: Currently we are writing the primary manuscript and an in-person meeting among stakeholders is being planned for early 2020.
Policies and Program Innovations that Connect Primary Health Care, Social Services, Public Health and Community Supports in Canada: A Comparative Policy Analysis
QC, PE, NS, ON, BC, NL, NB, MB, NS: Jeannie Haggerty, Marilyn Barrett, Shannon M Berg, Anne Junker, Denis Roy, Cheryl Tschupruk, Yves Couturier, Leanne Currie, Russell Dawe, Shelly Doucet, William Montelpare, Catherine Scott, Tara Stewart, Jason Sutherland, Robin Urquhart
Children, youth, and older adults with serious chronic conditions and limited or diminishing independence often need their primary care providers to connect them to social services, public health services, and community supports. Failure to connect to needed services leads to negative experiences for patients, caregivers and health professionals alike; it also leads to poor health
outcomes and health system inefficiencies. The goal of this work was to help future development of models of care that connect smoothly across health, social and community services.
In each province we studied the policies and governing structures that restrict or allow connections. Then we identified examples of successful and unsuccessful programs that were designed to connect services in order to learn from best practices and failures. Data collection and coding of transcripts are now complete.
Impact: The primary manuscript is being drafted.
Integrating Paramedics into Primary Care to Optimize Patient Time in the Community at End of Life
BC, NS: Alix Carter, Judah Goldstein, Fred Burge, Grace Warner, Doris Barwich, Jennifer Kryworuchko, Kim McGrail, Sabrina Wong
The purpose of this study was to examine the implementation of paramedics in provision of palliative care at home. The specific research questions were:
- Is the Paramedics Providing Palliative Care at Home program in Nova Scotia associated with an increase in the proportion of days spent in the community during the last six months of life compared to: (a) having no program, and (b) pre-implementation of this program?
- Is dying in Nova Scotia post-implementation associated with an increase in deaths out of hospital, compared to BC, and compared to pre-implementation?
How can essential elements of the program be successfully implemented in other jurisdictions?
We completed two deliberative dialogues with paramedics, primary care providers and others—one in BC and one in Nova Scotia. We are writing up two manuscripts from these dialogues. We have obtained the data for the quantitative analysis in BC and have begun analysis but continue to wait for the data in Nova Scotia.
Validation of Administrative and Primary Care Electronic Medical Record Derived Frailty Algorithms
BC, AB, MB: Sabrina Wong, Tyler Williamson, Alan Katz
The objective of this work was to:
- Use available data to determine a definition of frailty that can be used in electronic medical record (EMR) and administrative data sources; and
- Examine whether there are differences in demographics or health conditions among those identified as frail in either the EMR or administrative data.
Impact: A manuscript about the use of machine learning to create the EMR frailty definition is under review. We found that about one-third (n=302) were identified as frail and 573 (65.5%) were not frail. Key features of frailty included: ICD-9 Code-Dementia (code 290), prescribed medications including: furosemide and vitamins, and the word “obstruction” used within billing notes.
A second manuscript, Challenges Associated with Cross-Jurisdictional Analyses using Administrative Health Data and Primary Care Electronic Medical Records in Canada, was published in the International Journal of Population Data Science in 2018. The purpose of this paper was to compare and contrast the data access procedures in three Canadian jurisdictions (Manitoba, Alberta and BC), and to describe how we addressed the challenges presented by differences in data governance and architecture in a Canadian cross-jurisdictional research study. We characterized common stages in gaining access to administrative data among jurisdictions, including obtaining ethics approval, applying for data access from data custodians, and ensuring the extracted data are released to accredited individuals in secure data environments. We identified advantages of Manitoba’s flexible ‘stewardship’ model over the more restrictive ‘custodianship’ model in BC, and highlight the importance of communication between analysts in each jurisdiction to compensate for differences in coding variables and poor quality data.
This project generated national interest that has resulted in an additional $1M from the Canadian Frailty Network. These funds have allowed for further frailty case validation across multiple provinces (BC, AB, MB, ON, NS) and the creation of an electronic tool to allow primary care clinicians to visualize their patient panel by frailty. This work also enabled the BC-PHCRN to work with the Fraser Health Authority with the purpose of using the BC Canadian Primary Care Sentinel Surveillance Network (BC-CPCSSN) in further case validation in the Fraser Health region. This partnership has also been active in developing educational opportunities for undergraduate nursing students and now has a PhD student completing their dissertation work in the area of frailty.
The PREFeR (PRioritiEs For Research) Project: Results from a Multistage Patient Priority Setting Project for Primary Care Research in BC
BC: Ruth Lavergne, Louisa Edwards, Vanessa Brcic, Carolyn Canfield, Rita McCracken, Kim McGrail, Sabrina Wong
Despite the fact that much of primary care research focuses on studying patient needs and gaps in care, patients are not frequently included in prioritizing research ideas. This project aimed to identify patient priorities for primary care research in BC, then requested that both clinicians and patients across the province rank these priorities in terms of their importance. A dialogue event took place in September 2018.
Impact: A research article co-authored by patient advisory members was published in BMJ Open in 2019. The main findings were that there is considerable overlap between patient and provider priorities, including the top-rated topics of being unable to find a regular family doctor/other primary healthcare provider; support for living with chronic conditions; mental health resources; and information sharing, including electronic medical records. The findings from this project were integrated into the BC-PHCRN Strategic Plan and have also been disseminated to the BC Ministry of Health and some of the regional health authorities in BC.
CompaReport: A User-centered EMR Tool for Querying and Comparison Among Clinicians
BC: Billy Augustine, Abdulai Abdul-Fatawu, Natalya Lebedeva, Hanieh Shakeri
This project was undertaken by students from UBC’s Designing for People research cluster and was completed in May 2019. The objective was to design and evaluate a tool for family physicians and nurse practitioners that would make the EMR data retrieval process efficient and effective and allow users compare their practices with the wider network for quality improvement purposes. Using qualitative interviews, the team examined the ways in which the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data presentation tool could meet the needs of primary care clinicians. The findings highlighted that quality improvement was a key interest of clinicians.
The team designed a system and conducted usability tests with clinicians to evaluate the ease of use, transparency and customizability of the ‘audit and feedback’ system. The project provided numerous recommendations for future CPCSSN interfaces, including the ability to customize pages, editable reports to promote ownership and control, and visible signifiers for supported interaction.
Impact: This project is being presented at the 2019 Family Medicine Forum and suggestions for the improved user interface are being used to modify the CPCSSN data presentation tool.
A Comparative Analysis of Centralized Waiting Lists for Unattached and Complex Patients Implemented in Six Canadian Provinces
BC, MB, ON, QB, NS, NB, PEI: Mylaine Breton, Michael Green, Jalila Jbilou, Sara Kreindler, Jason Sutherland, Valorie Crooks, Damien Contandriopoulos, Mélanie Ann Smithman, Astrid Brousselle, Jay Shaw, Emily Marshall, Sabrina Wong
The main objective of this study was to compare the different models of centralized waiting lists (CWL) for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. We used a logic analysis approach developed in three steps:
- Build logic models that describe each province’s CWL through interviews with key stakeholders in each province;
- Develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of CWLs for unattached patients and factors influencing their implementation through a literature review and interviews with experts;
- Compare the logic models to the conceptual framework to make recommendations to improve CWLs in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers.
Impact: We published a protocol paper in BMC Health Services Research in 2017 and the main results in Healthcare Policy in 2018. Logic models of each province’s intervention were built after a grey literature review. We conducted 42 semi-structured interviews and performed a validation process with key stakeholders. Our analysis showed variability and common features in the design of CWLs, such as same main objective to attach patients to a primary care provider; implementation as a province-wide program (with the exception of BC); management at a regional level; voluntary participation for providers (except in two provinces where it was mandatory for providers to attach CWL patients); similar registration processes; some forms of prioritization of patients, either using simple criteria or assessing for vulnerability (except in New Brunswick).
Despite differences in design, CWLs face common issues and challenges regarding provider capacity to address the demand for attachment, barriers to the attachment of more vulnerable and complex patients, and non-standardized approaches to evaluating their effectiveness.
This project originally started with six provinces but was so compelling to Nova Scotia decision makers that they joined. As of September 2019, BC now joins the rest of Canada in having a provincially funded CWL, and adopts a model of managing the wait list similar to what was done in two different divisions of family practice. This was significant because we were able to provide the BC Ministry of Health with evidence to inform their decision-making and because we could draw on learnings from across Canada. This project has also led to a new CIHR funded grant, led by Emily Marshall, to examine the effect of CWLs across seven provinces.