Improving the design of heart failure care from the perspective of frontline providers and administrators: A qualitative case study of a large, urban health system.

Background: Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for optimal chronic care management.

Effect of Academic Detailing on Promoting Appropriate Prescribing of Antipsychotic Medication in Nursing Homes: A Cluster Randomized Clinical Trial.

Importance: Strategies to reduce the inappropriate prescription of antipsychotics have been the focus of recent attention but have shown considerable variation in their effectiveness.

Objective: To evaluate the effectiveness of academic detailing in nursing homes targeting appropriate prescribing of antipsychotics.

Design, Setting, And Participants: We conducted a pragmatic, cluster randomized clinical trial comparing the effect of academic detailing vs usual care on prescribing antipsychotics in 40 nursing homes with 5363 residents in Ontario, Canada.

Feasibility of an Electronic Health Tool to Promote Physical Activity in Primary Care: Pilot Cluster Randomized Controlled Trial.

Background: Physical inactivity is associated with increased health risks. Primary care providers (PCPs) are well positioned to support increased physical activity (PA) levels through screening and provision of PA prescriptions. However, PCP counseling on PA is not common.

Quality Gaps of Electronic Health Records in Diabetes Care.

Objectives: Electronic health records (EHRs) allow standardized data capture for robust quality and performance assessments, but data quality issues may exist. This study compared extracted structured EHR data with chart review from endocrinologists' health-care records at a large, academic ambulatory hospital in Toronto, Ontario.

Methods: Consecutive chart review for the first 10 patients with either type 1 or type 2 diabetes seen between January 1, 2015 and March 1, 2016 was sampled for each of the 10 endocrinologists within the diabetes program, and electronic data extraction was also completed for a core set of structured diabetes care elements.

Exposure to and attitudes regarding electronic healthcare (e-Health) among physician assistants in Canada: A national survey study.

Physician assistants (PAs) are a growing group of healthcare providers who could facilitate the adoption of electronic healthcare (e-Health) into practice. In 2018, we conducted a Canada-wide web-based survey study of practicing PAs and student PAs regarding their current exposure to e-Health, as well as their perceived value for its use and interest in future adoption. For this study, e-Health was defined as technology that allows direct communication between patients and healthcare providers or facilitates patient self-management for the purpose of assessment and management.

Effect on Treatment Adherence of Distributing Essential Medicines at No Charge: The CLEAN Meds Randomized Clinical Trial.

Importance: Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no charge to patients.

Objective: To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence.

Linking Quality Improvement and Health Information Technology through the QI-HIT Figure 8.

The implementation of health information technology (HIT) is complex. A method for mitigating complexity is incrementalism. Incrementalism forms the foundation of both incremental software development models, like agile, and the Plan-Do-Study-Act cycles (PDSAs) of quality improvement (QI), yet we often fail to be incremental at the union of the disciplines.

The 3i Conceptual Framework for Recognizing Patient Perspectives of Type 1 Diabetes During Emerging Adulthood.

Importance: Early emerging adulthood, the developmental life stage roughly spanning between the ages of 18 and 24 years, can be a challenging time for individuals living with type 1 diabetes, being associated with an increased risk of acute complications, loss to follow-up, and the emergence of long-term diabetes complications. Few evidence-based interventions exist, and practice guidelines instead emphasize the importance of delivering individualized, developmentally appropriate care.

Objective: To inform the provision of tailored care and education by illuminating the individual lived experiences of emerging adults with type 1 diabetes.

Extending access to a web-based mental health intervention: who wants more, what happens to use over time, and is it helpful? Results of a concealed, randomized controlled extension study.

Background: Web-based mental health applications may be beneficial, but adoption is often low leaving optimal implementation and payment models unclear. This study examined which users were interested in extended access to a web-based application beyond an initial 3-month trial period and evaluated if an additional 3 months of access was beneficial.

Methods: This study was a concealed extension of a multi-center, pragmatic randomized controlled trial that assessed the benefit of 3 months of access to the Big White Wall (BWW), an anonymous web-based moderated, multi-component mental health application offering self-directed activities and peer support.

Mapping variation in intervention design: a systematic review to develop a program theory for patient navigator programs.

Background: There is a great deal of variation in the design and delivery of patient navigator (PN) programs, making it difficult to design or adopt these interventions in new contexts. We (1) systematically reviewed the literature to generate a preliminary program theory to describe how patient navigator interventions are designed and delivered; and (2) describe how the resulting program theory was applied in context to inform a prototype for a patient navigator program.

Methods: The current study includes a secondary review of a larger systematic review.

Routine use of chest x-ray for low-risk patients undergoing a periodic health examination: a retrospective cohort study.

Background: Many evidence-based recommendations advocate against the use of routine chest x-rays for asymptomatic, low-risk outpatients; however, it is unclear how regularly chest x-rays are ordered in primary care. Our study aims to describe the frequency of, and variation in, routine chest x-ray use in low-risk outpatients among primary care physicians.

Methods: In this retrospective cohort study, Ontario residents aged 18 years and older with a periodic health examination (PHE) between Apr.

Public reporting of antipsychotic prescribing in nursing homes: population-based interrupted time series analyses.

Background: Although sometimes appropriate, antipsychotic medications are associated with increased risk of significant adverse events. In 2014, a series of newspaper articles describing high prescribing rates in nursing homes in Ontario, Canada, garnered substantial interest. Subsequently, an online public reporting initiative with home-level data was launched.

Projected Real-World Effectiveness of Using Aggressive Low-Density Lipoprotein Cholesterol Targets Among Elderly Statin Users Following Acute Coronary Syndromes in Canada.

Background: The extent to which outcome benefits may be achieved through the implementation of aggressive low-density lipoprotein (LDL) cholesterol targets in real world settings remains unknown, especially among elderly statin users following acute coronary syndromes.

Methods And Results: A population-based cohort study consisting of 19 544 post-acute coronary syndrome statin-users aged ≥66 years between January 1, 2017 and March 31, 2014 was used to project the number of adverse outcome events (acute myocardial infarction or death from any cause) that could be prevented if all post-acute coronary syndrome elderly statin users were treated to 1 of 2 LDL cholesterol target levels (≤50 and ≤70 mg/dL). The number of preventable adverse outcomes was estimated by using model-based expected event probabilities as derived from Cox Proportional hazards models.

Understanding the impact of accreditation on quality in healthcare: A grounded theory approach.

Objective: To explore how organizations respond to and interact with the accreditation process and the actual and potential mechanisms through which accreditation may influence quality.

Design: Qualitative grounded theory study.

Setting: Organizations who had participated in Accreditation Canada's Qmentum program during January 2014-June 2016.

Population-Based Study on Patterns of Cardiac Stress Testing After Percutaneous Coronary Intervention.

Background: The appropriate use criteria considers cardiac stress testing within 2 years after percutaneous coronary intervention (PCI) to be rarely appropriate, unless prompted by symptoms or change in clinical status. Little is known about the patterns of cardiac stress testing after PCI in the single-payer Canadian healthcare system, where mechanisms for reimbursement are different from the United States.

Methods And Results: Frequency and timing of cardiac stress testing within 2 years of PCI performed between April 2004 and March 2013 in Ontario, Canada, was determined from linked provincial databases.

Improving the Appropriate Use of Transthoracic Echocardiography: The Echo WISELY Trial.

Background: Appropriate use criteria (AUC) have defined transthoracic echocardiogram (TTE) indications for which there is a clear lack of benefit as rarely appropriate (rA).

Objectives: This study sought to investigate the impact of an AUC-based educational intervention on outpatient TTE ordering by cardiologists and primary care providers.

Methods: The authors conducted a prospective, investigator-blinded, multicenter, randomized controlled trial of an AUC-based educational intervention aimed at reducing rA outpatient TTEs.

Testing feedback message framing and comparators to address prescribing of high-risk medications in nursing homes: protocol for a pragmatic, factorial, cluster-randomized trial.

Background: Audit and feedback (AF) interventions that leverage routine administrative data offer a scalable and relatively low-cost method to improve processes of care. AF interventions are usually designed to highlight discrepancies between desired and actual performance and to encourage recipients to act to address such discrepancies. Comparing to a regional average is a common approach, but more recipients would have a discrepancy if compared to a higher-than-average level of performance.

Protocol for a randomised controlled trial evaluating the effects of providing essential medicines at no charge: the Carefully seLected and Easily Accessible at No Charge Medicines (CLEAN Meds) trial.

Introduction: Cost-related non-adherence to medicines is common in low-income, middle-income and high-income countries such as Canada. Medicine non-adherence is associated with poor health outcomes and increased mortality. This randomised trial will test the impact of a carefully selected list of essential medicines at no charge (compared with usual medicine access) in primary care patients reporting cost-related non-adherence.

Stress testing after percutaneous coronary interventions: a population-based study.

Background: Routine stress testing is commonly used after percutaneous coronary intervention (PCI) to detect in-stent restenosis or suboptimal procedure results; however, recent studies suggest that such testing is rarely indicated. Our main objectives were to assess temporal trends in utilization of stress testing and to determine factors associated with its use.

Methods: We conducted an observational study involving all patients who had undergone PCI in Ontario, Canada, from Apr.

Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis.

Background: Echocardiography is important for the diagnosis of infective endocarditis (IE), for which transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE).

Methods: A systematic review and meta-analysis of observational studies was performed with the objective of evaluating diagnostic properties of TTE, with transesophageal findings of IE as the reference standard in patients with suspected IE.

Results: The literature search yielded 377 unique articles, of which 16 met the inclusion criteria.

High Prevalence of Inappropriate Benzodiazepine and Sedative Hypnotic Prescriptions among Hospitalized Older Adults.

Background: Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions.

Objective: To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions.

The Cardiovascular Health in Ambulatory Care Research Team performance indicators for the primary prevention of cardiovascular disease: a modified Delphi panel study.

Background: High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting.

Methods: As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care.

Regional variations in ambulatory care and incidence of cardiovascular events.

Background: Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates.

Methods: We conducted a cohort study involving 5.

A randomized wait-list control trial to evaluate the impact of a mobile application to improve self-management of individuals with type 2 diabetes: a study protocol.

Background: Management of diabetes through improved glycemic control and risk factor modification can help prevent long-term complications. Much diabetes management is self-management, in which healthcare providers play a supporting role. Well-designed e-Health solutions targeting behavior change can improve a range of measures, including glycemic control, perceived health, and a reduction in hospitalizations.