The opioid crisis has been hardest felt in British Columbia (BC), which declared a public health emergency in 2016. Last year, there were 1510 drug overdose deaths recorded in BC, which represented 4.5 times the deaths from motor vehicle accidents. The overdose crisis has been largely driven by increasing contamination of the illicit drug supply with powerful synthetic opioids (e.g., fentanyl). Despite efforts to expand harm reduction services and treatments for opioid use disorder, these have had limited success in curbing the current crisis. Innovative strategies to mitigate the crisis have become an urgent public health priority. This includes a critical need to evaluate the response to the overdose crisis to help develop and implement a comprehensive addiction treatment program across BC and ultimately prevent future drug-related fatalities. Vancouver Coastal Health (VCH) provides services to more than 1.25 million residents in BC (nearly 25% of the population), and has been a primary player at the heart of the overdose crisis response. As such, alongside the newly implemented VCH Regional Addiction Program, VCH has identified key policy-related challenges that the proposed work will seek to address: prevent fatal overdoses, reduce drug-related harms, increase access to low barrier services, and improve integration of harm reduction and treatment. The proposed work will consist of several overlapping components to achieve the overarching goal to establish comprehensive and integrated addiction care programs across the region. This will include evaluating the impacts of 'naturally occurring' interventions (e.g., supervised consumption sites) and efficacy of novel clinical therapies, conducting health system and program evaluation to identify gaps in care and healthcare provider capacity, and engaging in integrated knowledge translation to mobilize research into evidence-based policies and practices across the health system.
Program: Health System Impact Fellowship
Evaluating and optimizing rural and urban lesbian, gay, bisexual, transgender, queer, intersex, and Two-Spirit (LGBTQI2S) engagement with hospice and palliative care in the Island Health Region
This Health System Impact Fellowship is co-funded by CIHR, Michael Smith Health Research BC, and Victoria Hospice (health system partner), to help build BC’s health policy research capacity for the integration of policy research into decision-making.
Existing research focused on the experiences of gay and lesbian older adults with the health care system report that there is a general distrust and reluctance to access healthcare based upon the cumulative effect of discrimination over the life course. At present, while 75% of Canadians have indicated they would like to die at home, 45% of Vancouver Island residents die of in acute care. Clearly there exists a service gap and it appears possible that such a gap may be larger in the LGBTQI2S community. It is therefore vital to explore the level of LGBTQI2S engagement with hospice and palliative care, in order to ensure this population is not further marginalized in end-of-life. Victoria Hospice and Island Health will facilitate access to healthcare service providers, and I will recruit rural and urban LGBTQI2S participants and their families throughout the Island Health region via the relationships I have built with community gatekeepers. A Participatory Action Research strategy will be used and a Community Steering Committee of older LGBTQI2S people representing various geographies as well as sexual orientations and gender identities will be established. The Community Steering Committee will become an integral part of the Project Working Group, comprised of healthcare service providers, Island Health, Victoria Hospice, and the University of Victoria supervisory team and will be integrated into every step of the research process including development of research questions, refining research objectives, participant recruitment, data collection and analysis, evaluation of our findings, and knowledge translation.
Supporting a Learning Health System in British Columbia Through Developing the BC Academic Health Science Network (AHSN)
In partnership with the BC Academic Health Science Network and the UBC Centre for Health Services and Policy Research (CHSPR) Singal will support the strategic and operational development of the BC AHSN.
Priority 1 is to develop and execute a regional level initiative that contributes to the provincial priority of enhancing primary health care delivery in BC and contributing to the development of a robust data platform.
Priority 2 is to use that specific initiative to identify and resolve systemic issues necessary to ensure initiative success, and to guide development of the AHSN overall to support a learning health system in British Columbia.
Economic evaluation and cost valuation of a province-wide quality improvement initiative: a case study of ‘Call for Less Antipsychotics in Residential Care’ (CLeAR) in British Columbia
British Columbia has 62,000 people living with dementia and this number is expected to rise to 87,000 by 2024. A common challenge for many seniors is the behavioural and psychological symptoms of dementia. In October 2013, the British Columbia Patient Safety & Quality Council (BCPSQC) launched its initial cohort of care homes participating in a 'Call for Less Antipsychotics in Residential Care' (CLeAR) quality improvement (QI) initiative in response to rising concerns over inappropriate antipsychotic use in residential care.
This study will include a comprehensive economic evaluation and cost valuation of a province-wide QI initiative. A mixed-methods approach to economic evaluation will be embedded into the third cohort of CLeAR. Data collection and analysis will take place in three phases, starting with literature review of available economic studies on quality improvement and related patients outcomes; approximately 30 qualitative interviews with care home residents to explore their perspective in the design and execution of CLeAR; secondary data analysis to determine costs and patient-level clinical outcomes, and finally cost-effectiveness analysis to estimate cost per life year gained.
The findings will inform stakeholders and the Ministry of Health about decisions on resource allocation for interventions designed to address both technical and non-technical (e.g. culture, teamwork) aspects to improve quality of care.
Measuring the impact of current and future harm reduction strategies in the ongoing opioid overdose epidemic in British Columbia
North America is currently experiencing an opioid overdose crisis and this has been particularly pronounced in British Columbia (BC). In this jurisdiction there has been a rapid increase in overdose deaths since 2012, which has largely been driven by an increasing concentration of synthetic and more potent opioids in the illegal drug supply market.
Despite a large effort within the province to reduce opioid-related harm, overdose deaths have continued to rise. Efforts include a scaling-up of BC's Take Home Naloxone program, a non-clinician administered therapy that is highly effective at reducing the effects of an overdose. More novel interventions have also included the introduction of opioid overdose sites, where people who use drugs can be observed and helped if they overdose. There is therefore a greatly urgent and important need to estimate the impact of these interventions and where new resources would be best positioned to have the most impact.
In collaboration with the BC Ministry of Mental Health and Addictions and with support from BC Centre for Disease Control and the Ministry of Health, Irvine will estimate the impact of the current interventions to date as well as project the impact of future interventions and scale-up. Combining cutting-edge mathematical modelling and statistical techniques with provincial administrative datasets will support an evaluation of the current provincial interventions and estimate the number of deaths averted due to current intervention scale-up and proposed novel interventions. The collaboration with both Ministries will ensure modelled scenarios will reflect policy proposals and help to support and inform their decisions.
Moving beyond headcounts: improved physician workforce planning for primary care in BC
This Health System Impact Fellowship is co-funded by CIHR, Michael Smith Health Research BC, and the BC Ministry of Health (health system partner), to help build BC’s health policy research capacity for the integration of policy research into decision-making.
Consistent access to high-quality family medicine improves the health of the population and lowers the costs of health care. Reports of family medicine shortages and of difficulties in accessing family physicians are ubiquitous in British Colombia (BC). To address shortages and access challenges, the Ministry of Health needs a clear understanding of how many active family doctors are working within provincial borders, how many are providing comprehensive and patient-centered care, how they structure their practices, and how patients access (or do not access) the services they provide.
The Ministry also needs a method to accurately estimate the future supply of family physicians and services in order to proactively design and implement policies that will address upcoming accessibility issues. These challenges are particularly salient given the upcoming rollout of team-based care across the province.
To address these issues, this fellowship will integrate the results of several ongoing studies into a strategy for proactive physician workforce planning, supporting recruitment and retention efforts and the development and evaluation of new models of family medicine practice. It will provide granular data on the supply of comprehensive care, identify current and future gaps, and inform policy on training, recruitment and retention of family physicians. Ultimately, it will enhance the capacity for evidence-informed workforce planning within BC’s Ministry of Health, leading to downstream improvements in access to family medicine across the province.
Patient/Public Engagement Measurement and Evaluation Project (PEMEP) within the British Columbia Ministry of Health’s Patients as Partners Initiative
In 2010, the Patients as Partners Initiative of the British Columbia (BC) Ministry of Health began work to improve the BC healthcare system by partnering with patients to empower patients and to develop and support the implementation of sustainable healthcare policies. This quality improvement initiative provides leadership, strategy, policy, collaboration, and funding to bring patient voice, choice, and representation to the forefront of the health sector.
This initiative's spectrum of patient engagement activities is performed across many projects using the International Association of Public Participation (IAP2) approach of inform, consult, involve, collaborate and empower at the individual, community, and health system levels. A small but growing number of publications cover the principles, measurement, and evaluation of patient engagement in various aspects of the healthcare system. But to date, no measures or quality indicators have been validated to assess the outcome and impact of patient engagement activities. Further research is vital to providing evidence-informed tools to quantitatively evaluate both the impact of integrating the patient/public perspective into planning, policy and services of BC's healthcare system and the impact that engagement is having on health outcomes.
The overall aim of this project is to identify, validate, and implement quality indicators of patient engagement at the individual, community, and system level within the Patients as Partners Initiative by the BC Ministry of Health. This will be conducted in a three-phase study: 1) a scoping review will identify key quality indicators from the published and grey literature; 2) a Delphi study with a 20-member panel of key stakeholders will validate the identified indicators; and 3) a stakeholder consultation workshop will facilitate creation of a plan to pilot test and routinely collect the quality indicator to measure and evaluate the success of patient engagement.
Utilizing a syndemic approach for population level prevention, care and treatment cascades of hepatitis C virus and related epidemics
Different distributions of social conditions, vulnerabilities, (e.g. drug use, mental illness) or other infections (HIV, HBV, TB), contribute to differences among populations affected by hepatitis C virus (HCV) infection. The different distribution of these comorbidities drives differences in cascades of care (diagnosis, initiation of treatment, cure and retention in care).
This study aims to improve HCV treatment and prevention by applying concepts of syndemic theory (how co-occuring conditions interact) to improve the integration and delivery of health services among populations affected by HCV infection, such as people born 1945-65 (“Baby Boomers”) and people who inject drugs (PWID). Using the British Columbia Hepatitis Testers Cohort (BC-HTC), which includes all individuals tested for HCV, HIV, HBV, sexually transmitted infections or TB since 1990, linked with administrative and healthcare data, the study will extend the HCV cascade of care to include prevention and care related to underlying syndemic factors (e.g. drug use, mental illness and other co-infections).
Identifying and investigating gaps in HCV care cascades, and syndemic factors associated with these gaps, will help identify avenues for shared and integrated interventions to improve prevention and care for HCV, and underlying substance use.
End of award update: December 2021
Following the end of her award term, Dr. Bartlett has provided the following brief update on this project’s progress.
Key impacts arising from fellowship program of work
Impact goal:
Help BC Centre for Disease Control analyze whether their investment in expensive hepatitis C medications are worthwhile.
Impact summary:
Dr. Bartlett’s research evaluated the impact of introducing new medications, called Direct Acting Antivirals (DAAs) used for treating HCV infection. It led to the only HCV care cascade in Canada in the DAA era and provided crucial data that can help drive policy changes aimed at eliminating HCV across the country. It also showed how useful linked administrative health data platforms are to improving the surveillance and monitoring of infections and chronic diseases, such as HCV.
Read more about the impact of Dr. Bartlett’s fellowship in the CIHR HSIF 2017-19 Embedded Research Impact Casebook.