Health Professional-Investigator – Page 8

Women taking charge of changing childbirth in BC

Childbearing women in Canada are speaking out about their desire for respectful maternity care. The Vancouver Foundation funded Phase 1 of our provincial, community-led participatory action research project entitled "Changing Childbirth in BC: Women exploring access to high quality maternity care". A steering group of women from different cultural and socioeconomic backgrounds worked with researchers and community agencies to study access to preferred models of maternity care and experiences of autonomy, respect, discrimination, or coercion when participating in a decision-making process. Community leaders developed an online survey and focus group questions including items targeted for marginalized populations: street-entrenched, formerly incarcerated, and immigrant and refugee groups. The response from women from all communities was overwhelming: 4,082 respondents (392 from vulnerable populations) provided survey data, and 135 women in 20 focus groups.

Our preliminary analysis of this rich mixed-methods dataset suggests it will reveal detailed information on how model of care and patient-provider communication affect women's experience of care. Some women say they have a trusting relationship with a maternity provider who involves them in decision-making, but others report being treated in an impersonal, condescending manner; receiving fragmented care and false information; and feeling lonely, disregarded, and abandoned by care providers. Marginalized and immigrant women seem to experience higher rates of disrespect and lack access to maternity care options. Now we must confirm our findings, decide how best to tell these stories, and effect change.

We will work with community members to interpret and translate our findings into practice and policy. We will complete our analysis and examine differences in needs and preferences among women from varied regional and cultural contexts. We will hold town meetings to discuss the findings and decide how the community wants to tell the stories. To make an effective multimedia knowledge translation plan, we will link community members with health professional educators, public information specialists, and parents who have relevant technical expertise. Our partners will help us to create multilingual, culturally appropriate multimedia dissemination tools. Together we will lead implementation activities targeted at institutions, clinicians, and policymakers.

Implementing concussion return to activity guidelines in primary care

Throughout the history of medicine, patients who had a disease that was poorly understood were advised to rest. As scientists and doctors learned more, early mobilization and active therapies (e.g., exercise) gradually replaced rest as the conventional treatment for a variety of medical conditions, such as chronic fatigue, whiplash, stroke, low back pain, and cardiac arrest. We have now reached this same juncture for concussion care. The proposed project aims to figure out how to support doctors in implementing new science-informed return to activity guidelines for concussion.

By way of background, concussions (also known as mild traumatic brain injuries) are very common, affecting more than 20,000 people each year in British Columbia's lower mainland alone. Concussions have been historically treated with rest. An explosion of concussion research over the past decade has led to several important insights. One such insight is that resting for more than a few days does not speed up recovery, and in fact, may cause harm (for example, lead to social isolation and depression). There is also emerging evidence that exercise is an effective treatment. Guidelines for clinical care prepared by Canadian and international concussion experts now emphasize that patients should gradually return to activity (e.g., school, work, recreation) soon after injury, as tolerated. Nevertheless, rest remains the most common treatment prescribed by doctors. It is promoted in pamphlets and websites designed to educate patients about their injury.

The goal of the proposed research is to bridge the gap between concussion science and clinical care, and study how effective this knowledge translation effort is. We focus on family doctors because they are best positioned to counsel patients about returning to activity after concussion. We have assembled a package of knowledge translation strategies based on behaviour change theory, prior research on how to best implement new clinical care guidelines, and input from the kind of doctors and patients who could most benefit from this knowledge. The study plan involves learning about doctors' behaviour through an online survey tool each time they see a patient with a concussion, and measuring patient outcomes through telephone-based assessments. We will measure changes in how doctors manage concussions and whether those changes result in corresponding improvements in how quickly patients recover from a concussion.

BCaLM research program: A safe & effective lyophilized fecal microbiota transplantation program for chronic gut disorders

Many Canadians live with debilitating chronic gut disorders such as Crohn's or ulcerative colitis (also known as inflammatory bowel disease, or IBD), Clostridium difficile infection (CDI), or both. These disorders lead to increased morbidity and reduce quality of life and productivity for patients and their families. One in every 150 Canadians has IBD, which is the highest rate worldwide. CDI is the number one cause of health care-associated infection (HAI) in Canada, and associated costs are approximately $300 million per year. An added concern is the recent sharp increase in community-associated CDI rates in previously healthy individuals. Recurrence of CDI following treatment with antibiotics is approximately 30%, increasing to 60% after two or more recurrences.

The key reason for IBD and CDI is thought to be a major imbalance between good and harmful bacteria in the gut (also known as dysbiosis). Current treatments for these conditions are ineffective and costly, and do not establish beneficial bacteria (or microbiota) in the gut. Fecal transplantation, also known as fecal microbiota transplantation (FMT), is a promising new treatment that uses stool from a healthy screened donor to restore the healthy microbiota in the colon. However, FMT remains unavailable in most health care facilities in Canada despite high demand. Dr. Lee regularly receives phone calls and e-mails from patients with chronic gut conditions requesting FMT. FMT is not yet licensed for routine clinical use and out of desperation, some patients have explored the option of performing FMT at home using unscreened donor stools. One of the major challenges of establishing and sustaining an FMT program is the lack of suitable donors and the laboratory support to manufacture FMT. In order to improve availability and reduce cost, this program will use Lyophilized (freeze-dried) FMT, L-FMT. Dr. Lee has used L-FMT to 60 patients with CDI and its result is similar to fresh/frozen FMT.

The BCaLM (British Columbia Associated Lyophilized Microbiota Program) aims to: 1) establish the safety of L-FMT through long-term follow-up of recipients; and 2) establish an effective and safe program to deliver L-FMT across Canada. A multi-site study will evaluate the efficacy of L-FMT, and the results will be used to direct further research and establish capacity for L-FMT. The findings can offer a readily available, cost-effective, and improved treatment option for people with chronic gut disorders.

TEC4Home: Telehealth for emergency-community continuity of care connectivity via home monitoring

Patients with long term medical conditions like heart failure or chronic lung diseases typically get admitted to and discharged from hospitals frequently because their conditions fluctuate. For example, one out of four patients older than 65 with heart failure often needs to return to hospital within one month of a previous emergency room or hospital stay. Today, using electronic monitors, patients can measure their own blood pressure, weight, and blood oxygen from home, and send their measurements to doctors or nurses so they can supervise the patient’s state of health. We are testing this home health monitoring approach to see if it can help patients with heart failure or chronic lung diseases stay healthy and safe at home.

In our research program called TEC4Home, we hope to show that home monitoring: 1) helps patients to manage their illnesses better themselves because they know their own bodies best, and 2) allows nurses and doctors to follow patients closely without needing to visit them. We expect to show that these patients will stay well and not need to revisit emergency departments, thereby helping hospitals to save money or save the beds for sicker patients.

We will first invite 90 patients with heart failure from Vancouver General and St. Paul’s Hospitals to test the home monitoring approach after they go home. Findings will allow us to make improvements before we expand to enroll 900 patients in 30 hospitals in BC in a formal clinical study.

Provided TEC4Home is found to help patients and decrease hospital costs, we will expand this service to be offered to other patients with heart failure across BC. We will invite companies that make monitoring equipment to develop newer and better versions, and use our experimental approach to test these devices to ensure they are safe and useful. We will also test TEC4Home with patients with chronic lung diseases to expand TEC4Home to serve patients with more than one type of long term disease.

We will work closely with doctors, nurses, patients and families, hospital managers, government leaders, technology companies, and health researchers. Patients will not only test the approach, but will also be involved in planning and carrying out the research. We will share findings with governments and health organizations so that home health monitoring, if proven effective, will become a routine part of treating patients. We will present at medical conferences and publish to share learnings beyond BC.

End of award update: June 2021

Most exciting outputs:
The home health monitoring (HHM) research is now being applied in practice, within the fabric of the health system. What we have learned is being applied and has been used in policy making. Methods and an evaluation framework have informed not only this project, but the evidence used in the real world.

While results from the full randomized controlled trial are forthcoming, the findings from our feasibility study showed signals of overall positive impact. This included reduction of emergency department revisits, hospital readmissions, and hospital length of stay. Results also showed an improvement in quality of life and self-efficacy. Further, feedback from patient participants indicate the HHM service was well received and helped participants feel safer and more supported at home after discharge from the hospital.

The TEC4Home Heart Failure study also resulted in the expansion of the concept to new conditions (like hypertension) and new technologies (such as an in-home medication dispenser). These new projects will continue to collect and build a body of evidence to best inform how digital health can help support the transition of care from hospital to home for a variety of patient populations in BC.

Impact so far
The findings from this project have been used to inform the ongoing implementation of home health monitoring in BC. It is our goal to continue to add to this evidence and see the application of these findings in the health system.

Potential future influence
At a provincial level, as noted above, the PI, K. Ho, is a member of the Digital Health Committee in BC. This involvement allows for project findings to be applied in alignment with existing policies and to inform emerging policies.

Further, the PI, K. Ho, is also a member of multiple national committees, such as the Canadian Virtual Care Task Force (focused on digital health implementation and education); the National Research Council (focused on medical device research with influence on national digital health research in practice); and the Health Canada scientific advisory committee (focused on the regulation and support of industry in digital health). All of these memberships provide opportunities for health policy influence.

Next steps
Over the course of the next year (to Mar 2022), we will be completing the final analysis of our TEC4Home Heart Failure randomized controlled trial. The results will be shared back to our various project committees and partners, including all of the patient participants. We will also seek more dissemination opportunities, such as publication in a high impact journal and presentation at conference(s).

In addition, as previously mentioned, with recently acquired funding, we are applying the TEC4Home concept to new conditions (hypertension) and new areas of impact (medication adherence). We are also incorporating the use of data analytics to deepen our understanding and the application of home health monitoring. This expansion of TEC4Home will continue to develop the evidence base of the use of technology to support patients safely at home, as they transition from acute to community care.

Useful Links
Digital Emergency Medicine (DigEM) website: TEC4Home Heart Failure | Digital Emergency Medicine (ubc.ca)
https://digem.med.ubc.ca/projects/tec4home-telehealth-for-emergency-community-continuity-of-care-connectivity-via-home-telemonitoring/

Feasibility Study publication: Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study – PubMed (nih.gov) https://pubmed.ncbi.nlm.nih.gov/34081015/

Trial Protocol publication: Supporting Heart Failure Patient Transitions From Acute to Community Care With Home Telemonitoring Technology: A Protocol for a Provincial Randomized Controlled Trial (TEC4Home) – PubMed (nih.gov)
https://pubmed.ncbi.nlm.nih.gov/27977002/

VCH news article about launch of trial: TEC4Home moves forward to clinical trials – Vancouver Coastal Health (vch.ca)
http://www.vch.ca/about-us/news/news-releases/tec4home-moves-forward-to-clinical-trials

Blog post by HeartLife: TEC4Home: Improving self-care management for heart failure patients – HeartLife Foundation
https://heartlife.ca/2019-3-1-tec4home-improving-self-care-management-for-heart-failure-patients/

Addressing morbidity, mortality and health care costs among patients evaluated for addiction care in acute care settings

Substance use disorders account for a significant burden of disease among Canadians and place an enormous burden on the acute care system. The annual cost of harms associated with substance use in Canada is estimated to be approximately $40 billion, with health care being the single largest contributor. In British Columbia (BC) there is clear urgency to address this challenge, given the recent steady increase in hospitalization rates due to substance use and the unprecedented number of drug overdose deaths prompting the recent declaration of a public health emergency.

While in hospital, individuals with a substance use disorder often have access to evidence-based addiction care, though successfully transitioning these individuals from acute to community settings remains a key clinical and research challenge. Specifically, this patient population often leaves hospital against medical advice, may be non-adherent to addiction care recommendations and often requires costly repeat hospital readmissions. Addressing these circumstances is critical, given the enormous cost implications and opportunity for more effective addiction services to dramatically reduce morbidity and mortality.

Specifically, investigating acute substance use needs and long-term solutions in acute care through after-care environments presents an urgent clinical health research priority given the frequent intersection between individuals with a substance use disorder and hospital environments. To address this, the proposed research project will establish a prospective cohort study of hospitalized individuals with a substance use disorder who are assessed for treatment of their addiction. Individuals will complete a one-time questionnaire and provide consent to the use of their personal identifiers for linkage to a variety of health care databases to allow for ongoing community follow-up over a five-year period. Creation of this study will offer the unique opportunity to identify patient characteristics of individuals accessing addiction care in the hospital setting, evaluate patient flow and predictors of outcome between hospital and community settings and determine subsequent health outcomes and health care utilization. In doing so, this research platform will generate evidence that will contribute to future interventions and knowledge advancement, and help inform best practices for the optimal delivery of addiction treatment to this population with high morbidity and mortality.