Research Pillar: Health Services

Incentivizing the delivery of sustainable care of chronic diseases in Canada: Case studies in musculoskeletal disease

Concerns about the sustainability of publicly funded health systems and the rising cost of care abound, yet there is little research that explores health care efficiency. Simple cost-saving exercises (i.e. cutting services) may risk harming patients, while more sophisticated, efficiency-saving approaches aim to provide health care at a greater benefit per unit of cost. Encouraging quality and value of health care delivery, whilst reducing waste, is also an indirect way to control health care costs. Undertreatment (failure to use best available care), overtreatment (treatment contrary to best-available evidence or preferences of patients), and poor coordination of care are three key clinical sources of waste. Many large-scale schemes aim to incentivize better health care, but show mixed results.

Dr. Harrison’s research will translate aspects of successful schemes and inform sustainable health care provision in Canada, focusing on musculoskeletal (MSK) diseases as they have been central to successful schemes. MSK diseases affect 11 million Canadians, and contribute hugely to the economic burden of disease in Canada. They have extensive impacts on people’s lives, including their health-related quality of life, ability to work, financial situation and reliance on the health care system. Additionally, high quality care of rheumatic disease requires early access to treatments which are often complex and considerably different from one another. Therefore, it is increasingly recognized that patients need coordinated, multidisciplinary support and care.

Dr. Harrison’s program will encompass policy-focused health economics and outcomes research to inform the design of financial and non-financial incentives to improve the efficiency of health care delivery.

End of Award Update: September 2022

Most exciting outputs

The project allowed me to explore whether a change to introduce a billing code for multidisciplinary care in rheumatology changed the experience of patients visiting rheumatologists in BC. We found that rheumatologists who used multidisciplinary care were able to expand services for patients.

 

Impacts so far

Our work adds to the evidence around incentives for multidisciplinary care in chronic disease. This will help inform future policy decisions.

 

Next steps

I continue to work on the evaluation of incentives and changes in policy for health care. I am currently co-leading a project evaluating the biosimilars initiative in BC.

 

Useful links

Examining the addiction treatment and recovery trajectories of youth in British Columbia’s Lower Mainland

Addiction treatment is critical to addressing the tremendous health and social harms experienced by street-involved youth (SY) with substance use disorders (SUD), including the current fentanyl overdose crisis. To date, the addiction treatment and recovery landscape in British Columbia (BC) reflects a mix of regulated, publicly funded programs (e.g., methadone and Suboxone programs, residential detoxification and treatment programs), as well as unregulated privately and publicly funded programs (e.g., informal recovery houses, Twelve Step programs) that span acute and community healthcare settings. Sustained drug use cessation is an important goal of these programs. However, it is recognized that for many youth their addiction treatment trajectories include periods of engagement, dis-engagement, and re-engagement with various programs, as they move in and out of periods of relapse, increases and reductions in drug use, and drug use cessation. The recovery trajectories of youth who remain largely outside of healthcare settings are also often characterized by this kind of dynamic process.

Dr. Fast will examine and inform ongoing efforts in the Lower Mainland to create a more comprehensive and coordinated system of addiction services for youth, and generate new knowledge to optimize the integration of evidence based addiction treatment across the acute and community healthcare settings accessed by SY. Integrating the methods and perspectives of medical anthropology and implementation science she will advance understandings of how individual, interpersonal, organizational, and structural factors operating in, but also across, acute and community health care settings in the Lower Mainland shape the delivery, uptake, and outcomes of youth addiction treatment interventions.

A nuanced, ethnographic understanding of these places and contexts will inform policy and practice recommendations to improve the addiction services system for adolescents and young adults so that it meets the needs of SY, pursuant to the goal of addressing SUD and the overdose crisis among this population. Dr. Fast will employ innovative and participatory arts-based methods to generate and disseminate policy and practice recommendations that align with the complex realities and everyday lived experiences of SY.

Opioid addiction research program to improve prescribing practices and reduce overdose

Canada is amid an opioid crisis, with six or seven deaths a day due to opioid overdose. Prescription opioid misuse can also transition to illicit opiate and intravenous drug use, substantially increasing the risk for overdose and blood-borne infections. Rates of overdose death due to counterfeit fentanyl have also risen and represent a growing crisis in most regions in Canada, with British Columbia (BC) being particularly hard hit. Half of the 800 anticipated overdose deaths for 2016 in BC are expected to involve fentanyl.

Dr. Fairbairn’s research will:

  • Address the effectiveness of a randomized controlled trial to evaluate a designated opioid prescriber intervention using BC’s centralized prescription network to reduce inappropriate opioid dispensation and overdose risk.
  • Inform overdose prevention strategies by characterizing the inter-relationships between medication prescribing patterns and patterns of illicit drug use.
  • Evaluate the longitudinal impacts of new overdose prevention initiatives and addiction treatment guidelines on overdose outcomes.

This research directly responds to BC’s recent declaration of a public health emergency, Health Canada’s urgent call to develop strategies to tackle the overdose epidemic, and the global challenge of prescription opioid abuse by generating evidence for safer prescribing practices and informing and broadening the evidence base for the treatment of opioid addiction.

Canada-wide comparison of patient reported outcomes by complexity of radiotherapy technique for bone metastases

Radiotherapy (RT) is a common and cost effective treatment for patients with painful bone metastases (BoM). Complex and lengthy RT courses are increasingly used for BoM, despite substantial evidence and Choosing Wisely Canada guidelines recommending the use of single fraction RT (SFRT) over lengthy courses. Reluctance to adopt SFRT is based on lack of evidence of its effectiveness in patients ineligible for trials, such as those with poor performance status and BoM complicated by fracture or neurological compromise. Unfortunately, guidelines recommending SFRT use in Ontario did not lead to a durable change in practice. Therefore, evidence of SFRT’s effectiveness in a broad population is necessary, including patients ineligible for trials. Comparison of SFRT to lengthier and complex techniques, such as intensity modulated RT (IMRT) and Stereotactic Ablative Body RT (SABR), will build a population-level evidence base to support increased prescription of SFRT in BC and across Canada.

My research team has demonstrated it is feasible to collect and use Patient Reported Outcomes (PRO) on a population scale in BC. We used these PRO to demonstrate that pain improvement is similar between SFRT and weeklong RT courses, the results of which have led to increased prescription of SFRT across all six BC cancer centres. This gained international attention and the Canadian Partnership for Quality Radiotherapy (CPQR) has since invited me to lead PRO collection across the Canadian RT community. Under the current proposal, we will apply a similar integrated knowledge translation (iKT) approach used in our BC-based research to demonstrate evidence for SFRT on a population-level.

Our primary KT goal is to use our research results to increase evidence-based prescription of SFRT. As we did in BC, we will integrate nursing, radiation therapy, and oncology into all stages of PRO collection and comparison between treatments, with subsequent educational outreach and centre-specific interactive small group discussions of research results. We will engage with various levels of health government, leverage our existing relationship with CPQR and the Canadian Partnership Against Cancer, and create an advisory committee of key stakeholders including policy makers, oncologists, and allied health professionals from each province. Impact evaluation of end-of-grant KT activities will focus on reach, collaboration, practice change indicators, and behaviour changes to increased use of SFRT.

 

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.

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.

Evidence-informed decision making in cancer survivorship: evaluating a comprehensive, multi-disciplinary prostate cancer supportive care program

Approximately 24,000 Canadian men were diagnosed with prostate cancer in 2015, and the majority of them will face long-term treatment-related health effects that will impact their quality of life, and have significant cost implications for our health system. Examples of these effects include sexual, urinary and bowel dysfunctions, as well as depression, anxiety and other psychological or psychosocial problems. Comprehensive, evidence-based supportive care programs that address these concerns are needed.

Recognizing this gap prompted the development of a survivorship supportive care program for prostate cancer patients at the Vancouver Prostate Centre. This program addresses both the physical and psychological needs of prostate cancer survivors and their partners from the time of diagnosis. It is comprised of six complementary educational modules and individual clinic visits with providers, and administered by a multi-disciplinary team (urologists, radiation/medical oncologists, and professionals in sexual medicine, psychology, counselling, nutrition, and physiotherapy). This research will assess the costs and benefits of the survivorship program, and will consider the incremental benefits associated with each module in order to improve the program. We will address the following questions: 

  1. Do men who have been diagnosed with prostate cancer and have participated in a program have a different pattern of health services use in the year following primary treatment compared to non-participants?
  2. Do participants of the program self-report better quality of life and symptom management than non-participants?
  3. Is the program cost-effective compared to usual standard of supportive care for individuals with prostate cancer?

The project will use a combination of administrative data, patient medical records, patient self-reported outcomes and primary cost data to develop and populate a simulation model that will track patients along care pathways within/outside the program. The model will provide an overall estimate of the program’s cost-effectiveness.

This evaluation will improve the quality and efficiency of the program and will inform the development of other cancer supportive care programs across BC. Ultimately, it has the potential to have a significant and lasting impact on the landscape of supportive care for cancer survivors.

Exploring the factors that influence implementation of mifepristone abortion practice in Canada: The CART-Mife Study

Approximately one-third of Canadian women will have an abortion in their lifetime. About 100,000 occur annually, of which 96 percent are provided using surgery. Mifepristone, the gold standard for medical abortion, was recently approved by Health Canada with availability anticipated in 2016. Mifepristone abortion delivered in primary care settings has been shown to be safe, effective, and not to increase abortion rates. However, international implementation of this practice varies and may be due to differences in health systems, provider training and supports, and regulations.

Best practices in knowledge translation indicate that, to maximize the impact of this health service innovation, it is necessary first to understand the barriers and facilitators that will influence mifepristone implementation in Canada. Health Canada has specified several extraordinary restrictions, including that physicians and pharmacists who provide mifepristone must be certified through an accredited training program. We propose that training and certification alone will be insufficient to support adoption and distribution of this innovation, especially in rural areas and among clinicians not currently providing abortion care.

This study seeks to explore the question “What are the barriers and facilitators that influence successful implementation and ongoing provision for medical abortion service?” Specific research objectives include:

  1. Exploring health policy, system, and service barriers and facilitators to physicians and pharmacists’ adoption of mifepristone practice.
  2. Developing a theoretically informed framework for supporting the implementation of mifepristone practice in Canada.

This research is embedded within a larger mixed methods program of study. I will use qualitative methods founded on Diffusion of Innovation theory. The results of the study will inform the development of a theory-based knowledge translation framework for promoting the implementation of mifepristone practice in Canada. Findings may be generalizable to implementation of other health service innovations in sexual and reproductive health in the Canadian health services context. Knowledge about the effect of the full range of health policy, system, and service determinants on access to mifepristone abortion is needed to realize the potential to increase equitable, safe, confidential abortion care closer to home.

Development and Validation of the Patient Engagement In Research Scale (PEIRS)

Patient engagement in research occurs when patients meaningfully and actively take part in the conduct and decision-making at any stage of the research process from inception through impact evaluation. There is a paucity of validated measurement tools to evaluate whether interventions to improve patient engagement in research support their successful engagement.

This project aims to develop and validate the Patient Engagement In Research Scale (PEIRS) for use by patients who partner in health research (i.e. patient partners), and to evaluate the degree to which they are meaningfully and effectively engaged in the research process. PEIRS will be developed with patients for patients. Our key objectives are to generate an item-bank reflecting the elements of patients’ experiences as partners in research; use the most relevant experiences to develop the PEIRS; then, evaluate the validity and reliability of PEIRS.

We will used a mixed qualitative and quantitative study design. First, a secondary thematic analysis will be conducted on in-depth interviews of 20 patients with arthritis who have experience as research partners. An extensive list of items relevant to the quality of patient-researcher partnership will be developed. Second, we will invite 10 patient partners to participate in a Delphi process to prioritize, select, and modify the items. We will then conduct usability testing with another 10 patient partners to identify and address any problems in the provisional PEIRS. Third, we will recruit 100 patient partners from across Canada to test the PEIRS’s validity and reliability. Specifically, factor analysis will examine its structural validity. Concurrent validity of PEIRS will be tested against an established measure of overall satisfaction and experiences of the public and patients as project partners in a health system organization. In addition, we will assess the association between PEIRS scores and participants’ ratings of the “meaningfulness” of their engagement.

This research project employs an integrated knowledge translation approach, in which researchers and experienced patient partners are working together at every stage of the research process, from inception through knowledge translation. PEIRS will address an important barrier to advancing the science and practice of engaging patients in research, namely the lack of a validated measure to assess effectiveness of patient engagement strategies. As such, this research contributes to support meaningful engagement of patients in health research.