Falls are a major public health problem in BC and around the world. Every year, approximately one third of adults in the community aged 65 years and older will fall. In BC, falls are responsible for 85 per cent of the $211 million annual direct cost of unintentional injuries. In New Zealand, a physiotherapist-initiated, progressive, home-based strength and balance training program reduced falls by 35 per cent; it proved cost-effective in persons aged 80 years and older. This program is currently undergoing a randomized clinical trial in BC for high-risk seniors. However, no economic outcomes have been published for any intervention to prevent falls in Canada. Jennifer Davis was previously funded by MSFHR for her early PhD work with the Falls Prevention Clinic at Vancouver General Hospital. Her current studies use economic data from the BC fall prevention trial to determine the cost implications of this program. Comparing this new program with the current standard of care, she will calculate the dollar cost per fall avoided, and the dollar cost per Quality Adjusted Life Year (a measure of disease burden, including both the quality and the quantity of life lived). She aims to perform cost-effectiveness and cost-utility analyses of the possible benefit of various types of exercise interventions compared with usual care. Davis’ long term research goal is to pioneer the improved economic evaluation of the burden of falls among seniors in Canada. This work will provide essential data for policy makers allocate health care resources in the most effective way.
Research Pillar: Health Services
Statin therapy in the prevention and management of rheumatoid arthritis
Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the immune system attacks its own joints and organs. Aside from painful symptoms, people with RA are more likely to get heart disease and die at a younger age. Statins are drugs that lower cholesterol and are used in the treatment and prevention of heart disease. Recent studies have shown that statins also have anti-inflammatory properties that may help prevent the development of RA. They may also provide a benefit to people with RA by reducing heart disease and death. However, there have been no studies that have examined the association between statin use and the onset of RA, or whether statin use can lower heart disease and death in people with RA. Mary De Vera is investigating the potential role of statins in RA through a population-based analysis of British Columbians and their encounters with the health system. She is analyzing health care and prescription drug use of the general BC adult population to compare rates of new RA cases between statin users and non-users. She will use similar analysis in adults with RA to compare the rates of heart disease and deaths between statin users and non-users. By learning about the relationships between statin use and RA, this study has important implications for informing and improving care for people with RA. In addition, this study could provide information that will lead to a better understanding of how this devastating disease may be prevented.
Barriers to methadone maintenance therapy access in British Columbia
Methadone maintenance therapy (MMT) is the most widely used and well-researched treatment for opioid dependency in Canada. MMT is regarded as an essential means to overcoming the health, social, and economic harms associated with opiate addiction, including preventing new HIV infections, reducing mortality, criminal activity, syringe sharing and unprotected sex. British Columbia was the first worldwide to launch a methadone program, and has long represented a model of excellence in MMT provision. However, barriers to MMT access continue to occur, particularly among Aboriginal people and the most marginalized members of society. The number of patients receiving MMT has declined since 2002, in spite of a reported unmet need for MMT provision. Canadian health care providers and the patients they serve continue to regard MMT as a controversial treatment. At the root of the concern may be feelings by patients that their needs are not being met, barriers with patients’ ability to carry on with their lives and access other treatments, and differences in treatment goals between patients and health care providers. Azar Mehrabadi is investigating policies, attitudes and access related to MMT provision in BC. She is conducting interviews with family physicians and the patients they care for from private and public clinics across BC, drug user advocacy groups, decision-makers, and MMT regulatory body representatives, and gauging their attitudes and beliefs around optimal MMT outcomes. Mehrabadi’s work has important implications for health policy related to addiction, infectious disease prevention, and primary health care provision for marginalized populations in Canada. In particular, best practices for MMT delivery in BC have an important influence on addictions health policies in the rest of Canada and the United States.
An application of situational awareness to child resuscitation
An estimated 23,000 preventable deaths occur annually in Canadian hospitals. One area of practice that is particularly time-sensitive and prone to errors is child resuscitation. The range of medical conditions underlying the need for child resuscitation, and the broad range in age and size of children, make this event one of the most stressful for healthcare providers. As a first responder, nurse performance is crucial to resuscitation outcomes. Situational awareness (SA) describes an individual’s awareness of what is happening, why it is happening and what will happen next. SA has been proposed as the primary basis for decision-making and performance in complex, dynamic systems and has been used extensively in high risk industries such as aviation and the military to understand how people assess threats and ensure safety within the work environment. Kimberley Shearer was previously funded by MSFHR for her early PhD work in situational awareness. She is continuing her research into the SA requirements for nurses during child resuscitation, determining what nurses need to pay attention to and anticipate in order to prevent error. She is developing a tool for objectively measuring nurse SA based on information gathered from a series of in-depth interviews with resuscitation team nurses. The tool will be validated by comparing the performance and stress levels demonstrated by novice and expert nurses during a simulated child resuscitation. Shearer’s research has implications for simulation teaching to reduce clinician error in pediatric settings. The development of an objective measure of SA can assist in the evaluation of clinician performance, facilitate understanding of differences between novices and experts, and permit testing of the effects of changes in technology on clinician performance.
Improving Access to Quality Cancer Care using Operations Research Methods
Radiotherapy is used for curative and palliative (symptom relief) purposes for patients with cancer, with 30 to 40% of patients receiving radiotherapy during some point in their illness. Wait times for radiotherapy have been shown to lead to poorer outcomes for those treated as part of curative treatment, and to increased suffering for those treated for palliative reasons. Wait times occur either because of equipment and/or staff shortages, or due to resources not being used in the most optimal manner. Demand for radiotherapy fluctuates over time, leading to unpredictable surges in demand that are difficult to meet in a timely fashion.
Dr. Scott Tyldesley is working to improve understand of the root causes of the fluctuation in demand for radiotherapy, and to develop approaches to predict and address demands. He, and his colleagues, are creating a detailed model of the radiotherapy system, which will allow him to simulate current cancer patient flow, and to test proposed improvements to the system. Development of the model will also allow the group to explore how the radiotherapy system can improve how it forecasts demand for services, and how it deploys its resources. These results will be tested in system-wide models and then considered for implementation at the BC Cancer Agency (BCCA). The research team is a unique collaboration between specialists in operations research from the Sauder School of Business at UBC and clinical decision-makers and administrators from BCCA. The results of Tyldesley’s research will directly affect clinical practice for patients with cancer and be transferable to other health care environments.
British Columbia Burden of Injury
Injuries are a significant public health problem in BC. Every year about 1,600 British Columbians die due to injury, 42,000 are hospitalized, and an estimated 400,000 people throughout the province sustain some sort of injury. The cumulative effect of injury on a population is known as the burden of injury. Burden of injury data help policy makers and practitioners determine the effectiveness of current services in injury prevention and injury treatment, and provide direction about new interventions that would have the greatest impact. They also help provide estimates for recovery time across different injuries. However, very little is known about the burden of injury, making this an important priority for research.
Dr. Mariana Brussoni is leading a longitudinal study in BC to quantify the impacts of injury on individuals and on the health system. Drawing on her experience working in England with international experts in injury research and prevention, Brussoni is recruiting more than 1,400 injured people of all ages across urban and rural settings in BC. They will be followed for 12 months post-injury, with the research team tracking their quality of life and recovery, use of health and social services, and time away from school or work. The goal of this research is to more fully describe the various impacts of injury in British Columbia, and to identify areas where prevention and treatment interventions could make the biggest difference.
Sex differences in patients presenting with acute myocardial infarction or chest pain without angiographic evidence of coronary disease
Although heart disease is a leading cause of death for men and women, sex/gender differences in the disease have only recently received attention. Evidence suggests there are sex/gender differences relating to prevalence, presentation, diagnosis, treatment and outcomes of heart disease, but little is known about the underlying causes. An emerging area of interest is the fact the magnitude of the sex/gender difference in outcomes following a heart attack (favoring men) is much greater among younger women and men than among older patients. Research in this area suggests that this difference persists even after adjusting conventional risk factors.
A leading investigator in the area of cardiac health outcomes, Dr. Karin Humphries has found in previous research that among women and men with chest pain but no evidence of heart disease, women’s outcomes are worse. Now she is focusing on two primary questions: why these women have worse outcomes than men, and what is the relevance of non-traditional risk factors, such as quality of life and psychosocial factors, in young women and men who present to hospital with a heart attack. The results of these studies will provide new knowledge about sex/gender differences and heart disease. Humphries aims to increase understanding of quality of life differences between young men and women who suffer a heart attack, which may help explain the different outcomes and help with the development of new strategies for diagnosis, treatment and support of women with heart disease.
Building the Evidence-base to Support Rural Maternity Health Services Policy and Planning
Dr. Stefan Grzybowski is a family physician clinical investigator and co director of the Centre for Rural Health Research within the Vancouver Coastal health Research institute. He is co-Principal Investigator of the Rural Maternity New Emerging Team, funded by the Canadian Institutes of Health Research and also co directs the British Columbia Rural and Remote Health Research Network, a Health of Population Network funded by the Michael Smith foundation. Prior to moving to Vancouver in 1994, Dr. Grzybowski practiced for 12 years as a family physician on the Queen Charlotte Islands/Haida Gwaii.
Dr. Grzybowski’s research has focused on building an evidence base supporting sustainable maternity health services for rural parturient women, translating this evidence into policy and practice and building research capacity for primary care clinician researchers. His interest in rural health services research was fostered by his experiences in facing the challenges of providing limited maternity services in an isolated hospital on the Queen Charlotte Islands without local access to Cesarean Section. His current projects include developing a Logic Model for sustainable rural maternity care in three isolated BC communities, investigating mechanisms in which GP surgery can be supported in BC, measuring population based maternal and newborn outcomes for rural service catchment areas across BC, and measuring stress associated with pregnancy for parturient women living in rural communities.
Reconceptualizing the Formation of the Therapeutic Alliance from the Patient’s Viewpoint using a Mixed Methods Research Design
The nature of the relationship between a healthcare provider and an individual receiving care has an impact on the success of psychotherapy and drug therapy. A strong professional working relationship can not only enhance the effect of psychological and psychiatric interventions, but can be therapeutic in and of itself. This has even been found in the treatment of very serious psychiatric conditions such as bipolar disorder and schizophrenia. Researchers have estimated that as least 30% of the effectiveness of psychotherapy and drug therapy can be accounted for by the quality of the professional relationship between an individual and his/her mental healthcare provider. There is a lack of understanding about the factors that are most important for developing a solid working relationship from the perspective of the individuals receiving the mental health services. Expanding upon research he conducted as a MSFHR trainee, Dr. Robinder (Rob) Paul Bedi is exploring this area. He is interviewing individuals currently receiving mental health services and analyzing the variables that they identify. The result: identifying the most common factors found to be essential in the development of positive therapeutic relationships. Bedi’s research aims to help mental healthcare providers develop strong working relationships with the individuals they treat, resulting in improved overall effectiveness of the mental health services that individuals receive.
Development of a screening strategy for community-based adverse drug related events in the emergency department
Adverse Drug Related Events (ADREs) are the most common type of preventable non-surgical adverse event related to medical care, and represent a leading cause of death. Each year, in BC alone, Emergency Departments treat an estimated 130,000 patients for ADREs, most of which are caused by medications prescribed in community settings. Unfortunately, community-based programs aimed at detecting and reducing drug-related problems have not led to a significant decline in morbidity, mortality or health services utilization. Emergency Department practitioners are well situated to play a pivotal role in the timely recognition and treatment of community-based ADREs. Unfortunately, Emergency Physicians currently detect only 50% of ADREs, missing opportunities to intervene.