"Flying a plane and building it at the same time": Lessons learned from the dynamic implementation of mass vaccination clinics in the Region of Waterloo, Ontario, Canada

BACKGROUND

Vaccination plays a critical role during pandemics, and mass vaccination clinics are often an imperative public health measure. These clinics usually consist of multi-disciplinary teams, which can pose significant coordination challenges, yet also present an opportunity for collectively contributing towards mitigating the impact of infection within communities. This study explores the coordination dynamics of the Region of Waterloo's coronavirus disease of 2019 (COVID-19) mass vaccination clinics in Ontario, Canada, between July 2021 and April 2022.

METHODS

This qualitative study included 16 purposively selected participants working in mass vaccination clinics. Participants were individually interviewed for 40-60 min. An inductive and iterative thematic analysis was undertaken, including open coding, grouping, labelling, regrouping and making sense of the themes.

RESULTS

Three interrelated themes were created: (1) unpredictable work environment, which was comprised of changing clinic processes and the impact of clinic adjustments to the running of the clinics; (2) clinic cohesion challenges, which included staff role disparities, limited job preparation and clinic system silos; and (3) adaptable and supportive work environment, which was comprised of staff adaptability, dispositional flexibility and a supportive work environment. While the first two themes created a precarious situation in the clinics, the third countered it, leading to a largely successful clinic implementation.

CONCLUSIONS

The rapid evolution and high transmissibility of COVID-19 in communities required a public health response that felt like flying and building a plane simultaneously - a seemingly impossible yet necessary task. However, an adaptable and supportive work environment was critical for establishing an atmosphere that can overcome challenges from a constantly changing pandemic and the guidance of public health officials. Such lessons gained from understanding the dynamic experiences in mass vaccination clinics are essential for improving the development and operation of future immunization campaigns.

Community efforts to promote vaccine uptake in a rural setting: a qualitative interview study

Vaccine hesitancy has been identified as one of the top 10 threats to global health. The causes of low vaccine uptake are many and vary at micro and macro levels. However, rural and remote coastal areas in the UK experience unique vaccine inequalities due to high levels of deprivation and their unique and complex access-related problems. This study aimed to explore community efforts to promote vaccine uptake during the COVID-19 pandemic and understand how the COVID-19 vaccination campaign was experienced by the public. We conducted an exploratory descriptive qualitative study using semi-structured interviews with decision-makers, health professionals and community members in Lincolnshire, a predominantly rural county with a long coastline, a large population of white minority ethnicities, and those living in caravan and temporary housing. Data were analysed using conventional content analysis. Overcoming the various access barriers to vaccination uptake involved working with local media stations, local communities and local community groups, translation of information, bringing vaccines closer to the people through pop-up and mobile clinics and provision of transport and ensuring confidentiality. There is a need to employ inclusive targeted non-conventional care interventions whilst dealing with complex problems as occur in rural and remote coastal regions.

Role satisfaction among community volunteers working in mass COVID-19 vaccination clinics, Waterloo Region, Canada

INTRODUCTION

Unpaid community volunteers are a vital public health resource in times of crisis. In response to the COVID-19 pandemic, community volunteers were mobilized to support mass vaccination efforts in many countries. To have this group's continued engagement, it is essential to understand the community volunteer experience, including the opportunities and challenges they encounter and how these contribute to their role satisfaction. This qualitative study investigated the factors contributing to community volunteers' role satisfaction at COVID-19 mass vaccination clinics in the Region of Waterloo, Canada.

METHODS

Qualitative data were analyzed from 20 volunteers (aged 48-79 years) who had worked at one of four COVID-19 vaccination clinics in the Region of Waterloo, Canada. Data were analyzed thematically using an inductive coding process followed by an iterative process of grouping and identifying linkages and relationships within the themes.

RESULTS

Four interrelated themes were developed from the inductive analysis process. The theme of community volunteers feeling valued or disesteemed in their role depends on the interaction between the three themes of role description, role preparation, and clinic context.

CONCLUSIONS

For volunteers in crises such as the COVID-19 pandemic, volunteer role satisfaction depends on how their contributions are valued, the clarity of their role descriptions, volunteer-specific training, and the sentiments of volunteers and staff within the clinic context. Greater role satisfaction can help with retention as volunteers become more resilient and adaptable to the complex dynamic circumstances of a crisis response. Activities such as training and materials development for role preparations should be explicitly planned and well-resourced, even in crisis/pandemic situations. Building clinic managers' or supervisors' skills in communication during crisis/pandemic situations and the skills for the creation of team cohesion are critical investment areas.

Unintended consequences of communicating rapid COVID-19 vaccine policy changes- a qualitative study of health policy communication in Ontario, Canada

BACKGROUND

The success of the COVID-19 vaccination roll-out depended on clear policy communication and guidance to promote and facilitate vaccine uptake. The rapidly evolving pandemic circumstances led to many vaccine policy amendments. The impact of changing policy on effective vaccine communication and its influence in terms of societal response to vaccine promotion are underexplored; this qualitative research addresses that gap within the extant literature.

METHODS

Policy communicators and community leaders from urban and rural Ontario participated in semi-structured interviews (N = 29) to explore their experiences of COVID-19 vaccine policy communication. Thematic analysis was used to produce representative themes.

RESULTS

Analysis showed rapidly changing policy was a barrier to smooth communication and COVID-19 vaccine roll-out. Continual amendments had unintended consequences, stimulating confusion, disrupting community outreach efforts and interrupting vaccine implementation. Policy changes were most disruptive to logistical planning and community engagement work, including community outreach, communicating eligibility criteria, and providing translated vaccine information to diverse communities.

CONCLUSIONS

Vaccine policy changes that allow for prioritized access can have the unintended consequence of limiting communities' access to information that supports decision making. Rapidly evolving circumstances require a balance between adjusting policy and maintaining simple, consistent public health messages that can readily be translated into action. Information access is a factor in health inequality that needs addressing alongside access to vaccines.

Understanding the COVID-19 Vaccine Policy Terrain in Ontario Canada: A Policy Analysis of the Actors, Content, Processes, and Context

(1) Background: Canada had a unique approach to COVID-19 vaccine policy making. The objective of this study was to understand the evolution of COVID-19 vaccination policies in Ontario, Canada, using the policy triangle framework. (2) Methods: We searched government websites and social media to identify COVID-19 vaccination policies in Ontario, Canada, which were posted between 1 October 2020, and 1 December 2021. We used the policy triangle framework to explore the policy actors, content, processes, and context. (3) Results: We reviewed 117 Canadian COVID-19 vaccine policy documents. Our review found that federal actors provided guidance, provincial actors made actionable policy, and community actors adapted policy to local contexts. The policy processes aimed to approve and distribute vaccines while continuously updating policies. The policy content focused on group prioritization and vaccine scarcity issues such as the delayed second dose and the mixed vaccine schedules. Finally, the policies were made in the context of changing vaccine science, global and national vaccine scarcity, and a growing awareness of the inequitable impacts of pandemics on specific communities. (4) Conclusions: We found that the triad of vaccine scarcity, evolving efficacy and safety data, and social inequities all contributed to the creation of vaccine policies that were difficult to efficiently communicate to the public. A lesson learned is that the need for dynamic policies must be balanced with the complexity of effective communication and on-the-ground delivery of care.

Multi-Disciplinary Design and Implementation of a Mass Vaccination Clinic Mobile Application to Support Decision-Making

Mass vaccination clinics are complex systems that combine professionals who do not typically work together. Coordinating vaccine preparation and patient intake is critically important to maintain patient flow equilibrium, requiring continuous communication and shared decision-making to reduce vaccine waste.

OBJECTIVES

(1) To develop a mobile application (app) that can address the information needs of vaccination clinic stakeholders for end-of-day doses decision-making in mass immunization settings; and (2) to understand usability and clinical implementation among multi-disciplinary users.

METHODS

Contextual inquiry guided 71.5 hours of observations to inform design characteristics. Rapid iterative testing and evaluation were performed to validate and improve the design. Usability and integration were evaluated through observations, interviews, and the system usability scale.

RESULTS

Designing the app required consolidating contextual factors to support information and workload needs. Twenty-four participants used the app at four clinics who reported its effectiveness in reducing stress and improving communication efficiency and satisfaction. They also discussed positive workflow changes and design recommendations to improve its usefulness. The average system usability score was 87 (n = 22).

DISCUSSION

There is significant potential for mobile apps to improve workflow efficiencies for information sharing and decision-making in vaccination clinics when designed for established cultures and usability, thereby providing frontline workers with greater time to focus on patient care and immunization needs. However, designing and implementing digital systems for dynamic settings is challenging when healthcare teams constantly adapt to evolving complexities. System-level barriers to adoption require further investigation. Future research should explore the implementation of the app within global contexts.

Documenting the indication for antimicrobial prescribing: a scoping review

BACKGROUND

Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.

OBJECTIVES

We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.

ELIGIBILITY CRITERIA

Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.

SOURCES OF EVIDENCE

A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.

CHARTING AND ANALYSIS

Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.

RESULTS

We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.

CONCLUSION

There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

Understanding racialised older adults' experiences of the Canadian healthcare system, and codesigning solutions: protocol for a qualitative study in nine languages

INTRODUCTION

Racialised immigrant older adults (RIOAs) in Canada have poorer self-rated health and are more likely to report chronic conditions, while they concurrently experience well-documented challenges in navigating and accessing the healthcare system. There is strong evidence that patient and caregiver engagement in their healthcare leads to improved management of chronic disease and better health outcomes. International research suggests that engagement has the potential to reduce health disparities and improve quality of care. We aim to (1) describe what role(s) RIOAs are/are not taking in their own healthcare, from the perspectives of participant groups (RIOAs, caregivers and healthcare providers (HCPs)); and (2) develop a codesign process with these participants, creating linguistically aligned and culturally aligned tools, resources or solutions to support patient engagement with RIOAs.

METHODS AND ANALYSIS

Using a cross-cultural participatory action research approach, our work will consist of three phases: phase 1, strengthen existing partnerships with RIOAs and appropriate agencies and cultural associations; phase 2, on receipt of informed consent, in-depth interviews with RIOAs and caregivers (n=~45) and HCPs (n=~10), professionally interpreted as needed. Phase 3, work with participants, in multiple interpreted sessions, to codesign culturally sensitive and linguistically sensitive/aligned patient engagement tools. We will conduct this research in the Waterloo-Wellington region of Ontario, in Arabic, Bangla, Cantonese, Hindi, Mandarin, Punjabi, Tamil and Urdu, plus English. Data will be transcribed, cleaned and entered into NVivo V.12, the software that will support team-based analysis. Analysis will include coding, theming and interpreting the data, and, preparing narrative descriptions that summarise each language group and each participant group (older adults, caregivers and HCPs), and illustrate themes.

ETHICS AND DISSEMINATION

Ethics clearance was obtained through the University of Waterloo Office of Research Ethics (ORE #43297). Findings will be disseminated through peer-reviewed publications, presentations and translated summary reports for our partners and participants.

Implementing Technology Literacy Programs in Retirement Homes and Residential Care Facilities: Conceptual Framework

Background

The COVID-19 pandemic caused widespread societal disruption, with governmental stay-at-home orders resulting in people connecting more via technology rather than in person. This shift had major impacts on older adult residents staying in retirement homes and residential care facilities, where they may lack the technology literacy needed to stay connected. The enTECH Computer Club from the University of Waterloo in Ontario, Canada created a knowledge translation toolkit to support organizations interested in starting technology literacy programs (TLPs) by providing guidance and practical tips.

Objective

This paper aimed to present a framework for implementing TLPs in retirement homes and residential care facilities through expanding on the knowledge translation toolkit and the framework for person-centered care.

Methods

Major concepts relating to the creation of a TLP in retirement homes and residential care facilities were extracted from the enTECH knowledge translation toolkit. The domains from the framework for person-centered care were modified to fit a TLP context. The concepts identified from the toolkit were sorted into the three framework categories: “structure,” “process,” and “outcome.” Information from the knowledge translation toolkit were extracted into the three categories and synthesized to form foundational principles and potential actions.

Results

All 13 domains from the framework for person-centered care were redefined to shift the focus on TLP implementation, with 7 domains under “structure,” 4 domains under “process,” and 2 domains under “outcome.” Domains in the “structure” category focus on developing an organizational infrastructure to deliver a successful TLP; 10 foundational principles and 25 potential actions were identified for this category. Domains in the “process” category focus on outlining procedures taken by stakeholders involved to ensure a smooth transition from conceptualization into action; 12 foundational principles and 9 potential actions were identified for this category. Domains in the “outcome” category focus on evaluating the TLP to consider making any improvements to better serve the needs of older adults and staff; 6 foundational principles and 6 potential actions were identified for this category.

Conclusions

Several domains and their foundational principles and potential actions from the TLP framework were found to be consistent with existing literatures that encourage taking active steps to increase technology literacy in older adults. Although there may be some limitations to the components of the framework with the current state of the pandemic, starting TLPs in the community can yield positive outcomes that will be beneficial to both older adult participants and the organization in the long term.

Integrating the CARD (Comfort Ask Relax Distract) system in a mass vaccination clinic to improve the experience of individuals during COVID-19 vaccination: a pre-post implementation study

Many people have negative experiences with vaccination due to stress-related reactions including fear and pain. We used a pre-post study design to evaluate the impact of implementing a modified version of the CARD (Comfort-Ask-Relax-Distract) system on stress-related reactions in individuals aged 12 y or older undergoing COVID-19 vaccinations in mass vaccination clinics. Vaccine recipients reported their level of pain, fear and dizziness during vaccination. Clinic staff reported their attitudes about CARD and use of CARD interventions. CARD improved client symptoms across genders and ages with an average reduction in needle pain, fear and dizziness of 75%, 40% and 44%, respectively. CARD was more effective in younger individuals. Clinic staff reported positive attitudes about CARD and uptake of selected CARD interventions. In summary, the modified CARD system reduced stress-related responses in a general population undergoing COVID-19 vaccinations in a mass vaccination clinic, was feasible and acceptable to staff. Future implementation efforts are recommended that include more diverse cultural contexts and incorporate education of individuals about CARD ahead of time.

Effectiveness of social giving on the engagement of pharmacy professionals with a computer-based education platform: a pilot randomized controlled trial

BACKGROUND

Computer-based education is gaining popularity in healthcare professional development education due to ease of distribution and flexibility. However, there are concerns regarding user engagement. This pilot study aims to: 1) assess the feasibility and acceptability of a social reward and the corresponding study design; and 2) to provide preliminary data on the impact of social reward on user engagement.

METHODS

A mixed method study combing a four-month pilot randomized controlled trial (RCT), surveys and interviews. The RCT was conducted using a computer-based education platform. Participants in the intervention group had access to a social reward feature, where they earned one meal for donation when completing a quiz with a passing score. Participants in the control group did not have access to this feature. Feasibility and acceptability of the social reward were assessed using surveys and telephone interviews. Feasibility of the RCT was assessed by participant recruitment and retention. User engagement was assessed by number of quizzes and modules completed.

RESULTS

A total of 30 pharmacy professionals were recruited with 15 users in each arm. Participants reported high acceptability of the intervention. The total number of quizzes completed by the intervention group was significantly higher compared to the control group (n = 267 quizzes Vs. n = 97 quizzes; p-value 0.023).

CONCLUSION

The study demonstrates the feasibility and acceptability of a web-based trial with pharmacy professionals and the social reward intervention. It also shows that the social reward can improve user engagement. A future definitive RCT will explore the sustainability of the intervention.

Protocol for the Optimizing Naloxone Dispensing in Pharmacies (ONDP) Online Continuing Education Program: A Randomized Controlled Trial

The number of opioid-related deaths in Canada has steadily increased since 2016 and the COVID-19 pandemic has worsened this trend. Naloxone has been pivotal for reducing opioid-related harms and death, and pharmacists play a crucial role in ensuring the supply of naloxone to Canadians through community pharmacies. However, naloxone dispensing by pharmacists is not optimal; in fact, in Ontario, only 50% of pharmacists offer naloxone, despite national guidelines that pharmacists should offer naloxone to everyone with an opioid prescription. When asked why pharmacists do not proactively offer naloxone, recent research has identified that pharmacists need continuing education to boost confidence and knowledge on how to start conversations with patients. The study involves a delayed start, double-blind randomized controlled trial, for Canadian licensed pharmacists and pharmacy technicians. The goals of the program are to increase Canadian pharmacy professional’s knowledge, confidence, and motivation to proactively offer naloxone, as well as to decrease stigma associated with naloxone. The program incorporates behaviour change techniques from the Theoretical Domains Framework and the Theory of Planned Behaviour. The intervention program includes three modules that focus on improving pharmacists’ communication skills by teaching them how to proactively offer naloxone, while the control group will complete a reading assignment on the naloxone consensus guidelines. The program will involve a process and outcome evaluation in addition to a contribution analysis. This program is important for breaking down previously identified barriers and knowledge gaps for why pharmacists currently do not proactively offer naloxone. This study will provide important new information about what behaviour change techniques are successful in improving confidence and motivation in the pharmacy profession and in an online environment. Findings from this study can be used to produce a national naloxone education program that can also be implemented into current pharmacy school curriculum.

Engagement of older adults in regional health innovation: The ECOTECH concept mapping project

Objectives:

Regional health innovation ecosystems can activate collaboration and support planning, self-management and development and commercialization of innovations. We sought to understand how older adults and their caregivers can be meaningfully engaged in regional health innovation ecosystems focused on health and aging–related technology innovation.

Methods:

A six-phase concept mapping technique gathered data over six time points across Canada. Brainstorming conducted online and in person identified engagement ideas. Statements were sorted by similarity and rated by participants on importance and feasibility. Qualitative approaches and multidimensional scaling, hierarchical cluster analysis, descriptive statistics and t tests were used for analysis.

Results:

Sixty-two unique ideas were assembled into a seven-cluster framework of priorities for engagement in regional health innovation ecosystems including public forums, co-production and partnerships, engagement, linkage and exchange, developing cultural capacity, advocacy and investment in the ecosystem.

Conclusions:

This study identified a framework of priorities for directions and strategies for older adult and caregiver engagement in regional health innovation ecosystems. Next steps include collaborations to develop regional health innovation ecosystems that actively engage older adults and their caregivers in health and aging–related technology innovation.

Integration of a smart multidose blister package for medication intake: A mixed method ethnographic informed study of older adults with chronic diseases

Smart adherence products are marketed to assist with medication management. However, little is known about their in-home integration by older adults. It is necessary to investigate the facilitators and barriers older adults face when integrating these products into their medication taking routines before effectiveness can be examined. The aim of this study was to (a) examine the integration of a smart multidose blister package and (b) understand medication intake behaviour of adults with chronic diseases using an integrated theoretical model comprised of the Technology Acceptance Model (TAM), Theory of Planned Behaviour (TPB) and Capacity, Opportunity, Motivation and Behaviour (COM-B) Model. An ethnographic-informed study was conducted with older adults using the smart multidose blister package to manage their medications for eight weeks. Data was collected quantitatively and qualitatively using in-home observations, photo-elicitation, field notes, semi-structured interviews, system usability scale (SUS) and net promoter scale (NPS). The interview guide was developed with constructs from the TAM, TPB and COM-B Model. Data were analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL) framework to generate themes and sub-themes which were mapped back to TAM, TBP and COM-B Model. Ten older adults with an average age of 76 years, of which 80% were female, participated in the study. On average, participants reported five medical conditions, while the average number of medications was 11.1. The mean SUS was 75.50 and overall NPS score was 0. Qualitative analysis identified three themes; (1) factors influencing medication intake behaviour (2) facilitators to the product use and, (3) barriers to the product use. The smart blister package was found to be easy to use and acceptable by older adults. Clinicians should assess an older adult’s medication intake behavior as well as barriers and facilitators to product use prior to recommending an adherence product for managing medications.

In-home medication management by older adults: a modified ethnography study using digital photography walkabouts

BACKGROUND

Medication mismanagement can lead to non-optimal management of chronic diseases and poor health outcomes.

OBJECTIVE

The purpose of this study was to better understand meanings associated with in-home medication management and storage practices of older adults with chronic diseases.

METHODS

A modified ethnographic approach using digital photography walkabouts, observation protocols and field notes were used to document in-home medication organisation and storage locations. Thematic analysis was used to generate themes and sub-themes.

RESULTS

Data from multiple home visits of 10 participants (mean age = 76 years; 80% females) including 30 photographs, 10 observation protocols and field notes were analysed. The average number of medications used was reported to be 11.1 (range: 5-20). Themes and sub-themes include choice of storage location (sub-themes: impact on medication behaviour, visibility of medications and storage with other items), knowledge regarding appropriate medication storage conditions (sub-themes: impact on safety of patient and impact on stability of medications) and systems to manage in-home medication intake.

DISCUSSION

In-home medication management reflects older adults perspectives regarding privacy, medication taking routine, knowledge about safe and effective storage and organisation systems. The lack of knowledge causing inappropriate medication storage not only impacts the stability of medications, but also increases risk of medication errors and safety, ultimately affecting medication intake behaviours.

Including the Reason for Use on Prescriptions Sent to Pharmacists: Scoping Review

BACKGROUND

In North America, although pharmacists are obligated to ensure prescribed medications are appropriate, information about a patient's reason for use is not a required component of a legal prescription. The benefits of prescribers including the reason for use on prescriptions is evident in the current literature. However, it is not standard practice to share this information with pharmacists.

OBJECTIVE

Our aim was to characterize the research on how including the reason for use on a prescription impacts pharmacists.

METHODS

We performed an interdisciplinary scoping review, searching literature in the fields of health care, informatics, and engineering. The following databases were searched between December 2018 and January 2019: PubMed, Institute of Electrical and Electronics Engineers (IEEE), Association for Computing Machinery (ACM), International Pharmaceutical Abstracts (IPA), and EMBASE.

RESULTS

A total of 3912 potentially relevant articles were identified, with 9 papers meeting the inclusion criteria. The studies used different terminology (eg, indication, reason for use) and a wide variety of study methodologies, including prospective and retrospective observational studies, randomized controlled trials, and qualitative interviews and focus groups. The results suggest that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. Reasons that may prevent prescribers from adding the reason for use information are concerns about workflow and patient privacy.

CONCLUSIONS

More research is needed to understand how the reason for use information should be provided to pharmacists. In the limited literature to date, there is a consensus that the addition of this information to prescriptions benefits patient safety and enables pharmacists to be more effective. Future research should use an implementation science or theory-based approach to improve prescriber buy-in and, consequently, adoption.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention

INTRODUCTION

Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches.

METHODS AND ANALYSIS

Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners.

TRIAL REGISTRATION NUMBER

NCT03442426;Pre-results.

Assessing pharmacists' knowledge and compliance with narcotic inventory management using a computer-based educational platform

OBJECTIVES

Pharmacy professionals are required to take all necessary steps to protect commonly misused drugs such as opioids at their pharmacies to minimize the risk of diversion. The aim of this study is to assess Canadian pharmacy professionals' knowledge and compliance with federal and provincial regulations using the computer-based educational platform Pharmacy5in5.

METHODS

A Narcotic Inventory module was created and reviewed by experts representing provincial and federal regulators. Descriptive statistics were used to analyze users' performance in quizzes. Binomial regression and logistic regression models were used to investigate the effect of demographic factors on users' performance. P-values less than 0.05 were considered statistically significant.

KEY FINDINGS

The analysis included data collected over a period of three months. A total of 792 users accessed the Narcotic Inventory module on the Pharmacy5in5 website between July 2019 and November 2019. Most of the users were licenced pharmacists (64%), female (72%), received their training in Canada (68%), and were practising in Ontario (80%). Users performed best on the quiz addressing the steps for reconciliation of inventory (93%), and worst on the quiz reviewing how to prepare for a Health Canada visit (66%).

CONCLUSIONS

Overall, pharmacy professionals showed adequate knowledge of the CDSA and provincial/territorial regulations regarding opioids inventory management. Conversely, the study highlighted poor compliance with the reporting of losses and theft of controlled substances by pharmacy professionals. Innovative approaches are needed to influence pharmacy professionals' behaviours to improve their compliance with best practices concerning inventory management to reduce drug diversion.

Effects of computer-based education on health professionals' knowledge, skills, and behavior: A scoping review

BACKGROUND

Computer-based platforms are rapidly growing as a promising way to deliver education to health professionals (HPs). However, evidence to support the use of computer-based education to change professional behavior and clinical practice and to guide the selection of design features of computer-based educational platforms is lacking in the existing literature.

OBJECTIVES

To address the current gaps in knowledge, a scoping review approach was used to explore the effects of computer-based education on HP knowledge, skills, and behavior as the primary objective. A secondary aim was to determine the design features of computer-based educational platforms that enhanced user satisfaction.

METHODS

The scoping review was conducted using the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Relevant studies were first identified through searches in 7 scientific databases. Studies were then selected through independent screening by 2 reviewers. Finally, the data of selected studies were extracted and charted using Excel (Microsoft Corporation).

RESULTS

Seventeen studies were selected for inclusion. The included studies were conducted on a wide range of HPs and used computer-based educational platforms with varying features, duration, clinical content, and offerings of accreditation. All studies reported at least 1 of the following outcomes: HPs' acceptance, attitude, and satisfaction; knowledge and skills; and behavior; however, none of the studies evaluated the degrees of change in patient outcomes. Only 2 studies used theoretical frameworks to develop their platform, with mixed impact on effectiveness and consistent effect on satisfaction. In addition, the platforms employed newer features such as tailored feedback and instant messaging.

CONCLUSION

Computer-based education can enhance HP knowledge, skills, and behavior. Future studies should explicitly outline the features that further improve learning outcomes and construct their interventions around well-grounded theory to improve the effectiveness of computer-based education on changing HP behavior.

Understanding the Feasibility of Implementing CAR T-Cell Therapies from a Canadian Perspective

In Canada, chimeric antigen receptor (CAR) T-cell therapy was recommended for funding for the treatment of select hematological cancers. Canadian hospitals have limited experience and capacity in administrating this therapy. We conducted a qualitative interview-based study with stakeholders in Canada. Questions were asked related to the development, administration, implementation and logistical planning of CAR T-cell therapy. Results were summarized into four main themes: (i) novel; (ii) patient characteristics and the delivery of care; (iii) processes from "bench-to-bedside"; and (iv) the future state, including both challenges and recommendations to ensure sustainability. Valuable perspectives from stakeholders highlight some of the unique challenges to implementing a highly personalized and expensive-to-deliver therapy.

Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis

BACKGROUND

The indication for prescribing a particular medication, or its reason for use (RFU) is a crucial piece of information for all those involved in the circle of care. Research has shown that sharing RFU information with physicians, pharmacists and patients improves patient safety and patient adherence, however RFU is rarely added on prescriptions by prescribers or on medication labels for patients to reference.

METHODS

Qualitative interviews were conducted with 20 prescribers in Southern Ontario, Canada, to learn prescribers' current attitudes on the addition of RFU on prescriptions and medication labels. A trained interviewer used a semi-structured interview guide for each interview. The interviews explored how the sharing of RFU information would impact prescribers' workflows and practices. Interviews were recorded, transcribed and thematically coded.

RESULTS

The analysis yielded four main themes: Current Practice, Future Practice, Changing Culture, and Collaboration. Most of the prescribers interviewed do not currently add RFU to prescriptions. Prescribers were open to sharing RFU with colleagues via a regional database but wanted the ability to provide context for the prescribed medication within the system. Many prescribers were wary of the impact of adding RFU on their workflow but felt it could save time by avoiding clarifying questions from pharmacists. Increased interprofessional collaboration, increased patient understanding of prescribed medications, avoiding guesswork when determining indications and decreased misinterpretation regarding RFU were cited by most prescribers as benefits to including RFU information.

CONCLUSIONS

Prescribers were generally open to sharing RFU and clearly identified the benefits to pharmacists and patients if added. Critically, they also identified benefits to their own practices. These results can be used to guide the implementation of future initiatives to promote the sharing of RFU in healthcare teams.

The Impact of Prescription Medication Cost Coverage on Oral Medication Use for Hypertension and Type 2 Diabetes Mellitus

BACKGROUND

No previous study, to the best of our knowledge, has examined both the time trend and impact of not having insurance or prescription medication cost coverage (PMCC) on the usage of type 2 diabetes and hypertension oral medications in Ontario and New Brunswick, Canada.

METHODS

We used data from the Canadian Community Health Survey (CCHS) from 2007 to 2014 to examine the time trend and impact of PMCC. A multivariable-adjusted logistic regression model was fitted.

RESULTS

The pseudo-cohort included 23,215 individuals representing a population of approximately 8.7 million people. Overall, 20.0% of respondents reported absence of PMCC. This proportion increased slightly from 19.6% (95% confidence interval [CI] 95% CI [17.5, 22.5]) to 20.7% (95% CI [16.9, 23.1]). Adjusted odds ratios (OR) showed that uninsured individuals were 23% less likely to use their medications (OR = 0.77, 95% CI [0.657, 0.911]).

CONCLUSION

There was a slight decline in PMCC over time and this decline was associated with reduced use of medications for type 2 diabetes and hypertension.

How do I keep myself safe? Patient perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis

ABSTRACT

BACKGROUND

Medications are crucial for maintaining patient wellness and improving health in modern medicine, but their use comes with risks. Helping patients to understand why they are taking medications is important for patient-centered care and facilitates patient adherence to prescribed medications. One strategy involves enhancing communication between patients, physicians, and pharmacists through the sharing of reason for use (RFU) information or the indication for medications.

METHODS

Semi-structured interviews were conducted with 20 patients in Ontario, Canada, to gain perspectives on how patients currently store their medication information and benefits and disadvantages of adding RFU to prescriptions and medication labels. An interview guide was used by the two interviewers, and the interviews were recorded, transcribed, and thematically coded.

RESULTS

The analysis yielded three main themes: patient decision making with RFU, RFU in modern, patient-centered care, and logistical aspects of communicating RFU. The patients that were interviewed expressed the value of having RFU when deciding if a medication was effective or to stop taking the medication. Patients felt comfortable with RFU being added to prescriptions and acknowledged the value in adding RFU to medication labels, helping patients and others identify and distinguish medications. Patients generally expressed interest in having RFU written in lay language and identified strengths and weaknesses of having access to RFU via a website or app.

CONCLUSIONS

Patients rated the importance of knowing RFU very highly, identified the value in sharing RFU with pharmacists on prescriptions, and in having RFU on medication labels. These results can be used to inform policy on the addition of RFU on prescriptions and medication labels and support improved communication between patients, pharmacists, and physicians about RFU.

Pharmacists' perspectives on the value of reason for use information

Background

The indication for a particular medication, or its reason for use (RFU), is important information for prescribers, pharmacists and patients but is not often communicated in writing from prescribers to pharmacists. Adding RFU to a prescription and a medication label would ensure that pharmacists are confident that they are providing high-quality, accurate patient care. This study aims to describe the perspectives of pharmacists on how receiving RFU from prescribers would affect their practice and how pharmacists putting this information on prescriptions would affect patients.

Methods

Semi-structured qualitative interviews were conducted with 20 pharmacists in Southwestern Ontario. Thematic analysis was used to analyze the interview transcripts, leading to 4 major themes.

Results

Pharmacists expressed that RFU should be formatted to ensure that it is of clinical utility via the use of written text and noted that either medical or lay (also known as plain) language would be appropriate for use. Pharmacists indicated that patient privacy should be considered when writing RFU on labels and that patient preference with respect to the addition of RFU should dictate its inclusion on a medication label. Pharmacist access to RFU was universally acknowledged to improve patient safety by providing pharmacists with more information to determine whether the given medication was indicated.

Conclusions

This study provides further information about the impact that having access to RFU would have on pharmacy practice and can be used to advocate for the inclusion of RFU information with prescriptions to improve patient outcomes. Can Pharm J (Ott) 2020;153:xx-xx.

Impact of Increasing Wait Times on Overall Mortality of Chimeric Antigen Receptor T-Cell Therapy in Large B-Cell Lymphoma: A Discrete Event Simulation Model

PURPOSE

The development of chimeric antigen receptor (CAR) T cells has transformed oncology treatment, with the potential to cure certain cancers. Although shown to be effective in selected populations and studies, CAR T-cell technology requires considerable health care resources, which may lead to additional wait times to access this type of treatment in future. The objective of our study was to estimate the potential impact of increasing wait times on CAR T-cell therapy effectiveness compared with standard chemotherapy for patients with relapsed/refractory diffuse large B-cell lymphoma.

METHODS

A health system-level discrete event simulation model was developed to project the potential impact of wait times on CAR T-cell therapy for patients with relapsed/refractory diffuse large B-cell lymphoma. Waiting queues and health states related to treatment and clinical progression were implemented. Using data from the literature, we evaluated nine scenarios of using CAR T-cell therapy with wait times ranging from 1 to 9 months. The outcome of interest was 1-year all-cause mortality.

RESULTS

Increasing the wait time of receiving CAR T-cell therapy from 1 to 9 months increased the predicted 1-year mortality rate from 36.1% to 76.3%. Baseline 1-year mortality was 34.0% in patients receiving CAR T-cell therapy with no wait times and 75.1% in patients treated with chemotherapy. This resulted in an increased relative mortality rate of 6.2% to 124.5% over a 1- to 9-month wait time compared with no wait time.

CONCLUSION

We found that modest delays in CAR T-cell therapy significantly hinder its effectiveness. Because CAR T-cell therapy offers a potential cure, it is expected that the uptake rate will be substantially increased once the therapy is regularly funded by a health care system. Wait times may be prolonged if system resource availability does not match the demand. Strategies must be developed to minimize the impact of delays and reduce complications during waiting.

"My pharmacist": Creating and maintaining relationship between physicians and pharmacists in primary care settings

BACKGROUND

Pharmacists and physicians are being increasingly encouraged to adopt a collaborative approach to patient care, and delivery of health services. Strong collaboration between pharmacists and physicians is known to improve patient safety, however pharmacists have expressed difficulty in developing interprofessional working relationships. There is not a significant body of knowledge around how relationships influence how and when pharmacists and physicians communicate about patient care.

OBJECTIVES

This paper examines how pharmacists and primary care physicians communicate with each other, specifically when they have or do not have an established relationship.

METHODS

Thematic analysis of data from semi-structured interviews with nine primary care physicians and 25 pharmacists, we examined how pharmacists and physicians talk about their roles and responsibilities in primary care and how they build relationships with each other.

RESULTS

We found that both groups of professionals communicated with each other in relation to the perceived scope of their practice and roles. Three emerging themes emerged in the data focusing on (1) the different ways physicians communicate with pharmacists; (2) insights into barriers discussed by pharmacists; and (3) how relationships shape collaboration and interactions. Pharmacists were also responsible for initiating the relationship as they relied on it more than the physicians. The presence or absence of a personal connection dramatically impacts how comfortable healthcare professionals are with collaboration around care.

CONCLUSION

The findings support and extend the existing literature on pharmacist-physician collaboration, as it relates to trust, relationship, and role. The importance of strong communication is noted, as is the necessity of improving ways to build relationships to ensure strong interprofessional collaboration.

Reason for Use: An Opportunity to Improve Patient Safety

The objective of this study is to understand how the reason for use (RFU) or the indication for medications are used, its effects on the decision-making process, the implications, and the willingness among prescribers, pharmacists, and patients to share RFU information. Methods, semi-structured interviews were conducted to retrieve the information needed from a total of 60 participants. Results, pharmacists, prescribers, and patients generally have positive opinions about including RFU information in their communications. Conclusion, there is a general agreement among participants that sharing RFU information will improve patient safety.

Evaluating authentication options for mobile health applications in younger and older adults

OBJECTIVE

Apps promoting patient self-management may improve health outcomes. However, methods to secure stored information on mobile devices may adversely affect usability. We tested the reliability and usability of common user authentication techniques in younger and older adults.

METHODOLOGY

Usability testing was conducted in two age groups, 18 to 30 years and 50 years and older. After completing a demographic questionnaire, each participant tested four authentication options in random order: four-digit personal identification number (PIN), graphical password (GRAPHICAL), Android pattern-lock (PATTERN), and a swipe-style Android fingerprint scanner (FINGERPRINT). Participants rated each option using the Systems Usability Scale (SUS).

RESULTS

A total of 59 older and 43 younger participants completed the study. Overall, PATTERN was the fastest option (3.44s), and PIN had the fewest errors per attempt (0.02). Participants were able to login using PIN, PATTERN, and GRAPHICAL at least 98% of the time. FINGERPRINT was the slowest (26.97s), had an average of 1.46 errors per attempt, and had a successful login rate of 85%. Overall, PIN and PATTERN had higher SUS scores than FINGERPRINT and GRAPHICAL. Compared to younger participants, older participants were also less likely to find PATTERN to be tiring, annoying or time consuming and less likely to consider PIN to be time consuming. Younger participants were more likely to rate GRAPHICAL as annoying, time consuming and tiring than older participants.

CONCLUSIONS

On mobile devices, PIN and pattern-lock outperformed graphical passwords and swipe-style fingerprints. All participants took longer to authenticate using the swipe-style fingerprint compared to other options. Older participants also took two to three seconds longer to authenticate using the PIN, pattern and graphical passwords though this did not appear to affect perceived usability.

Locking it down: The privacy and security of mobile medication apps

OBJECTIVE

To explore the privacy and security of free medication applications (apps) available to Canadian consumers.

METHODS

The authors searched the Canadian iTunes store for iOS apps and the Canadian Google Play store for Android apps related to medication use and management. Using an Apple iPad Air 2 and a Google Nexus 7 tablet, 2 reviewers generated a list of apps that met the following inclusion criteria: free, available in English, intended for consumer use and related to medication management. Using a standard data collection form, 2 reviewers independently coded each app for the presence/absence of passwords, the storage of personal health information, a privacy statement, encryption, remote wipe and third-party sharing. A Cohen's Kappa statistic was used to measure interrater agreement.

RESULTS

Of the 184 apps evaluated, 70.1% had no password protection or sign-in system. Personal information, including name, date of birth and gender, was requested by 41.8% (77/184) of apps. Contact information, such as address, phone number and email, was requested by 25% (46/184) of apps. Finally, personal health information, other than medication name, was requested by 89.1% (164/184) of apps. Only 34.2% (63/184) of apps had a privacy policy in place.

CONCLUSION

Most free medication apps offer very limited authentication and privacy protocols. As a result, the onus currently falls on patients to input information in these apps selectively and to be aware of the potential privacy issues. Until more secure systems are built, health care practitioners cannot fully support patients wanting to use such apps.

Behavior Change Techniques Present in Wearable Activity Trackers: A Critical Analysis

BACKGROUND

Wearable activity trackers are promising as interventions that offer guidance and support for increasing physical activity and health-focused tracking. Most adults do not meet their recommended daily activity guidelines, and wearable fitness trackers are increasingly cited as having great potential to improve the physical activity levels of adults.

OBJECTIVE

The objective of this study was to use the Coventry, Aberdeen, and London-Refined (CALO-RE) taxonomy to examine if the design of wearable activity trackers incorporates behavior change techniques (BCTs). A secondary objective was to critically analyze whether the BCTs present relate to known drivers of behavior change, such as self-efficacy, with the intention of extending applicability to older adults in addition to the overall population.

METHODS

Wearing each device for a period of 1 week, two independent raters used CALO-RE taxonomy to code the BCTs of the seven wearable activity trackers available in Canada as of March 2014. These included Fitbit Flex, Misfit Shine, Withings Pulse, Jawbone UP24, Spark Activity Tracker by SparkPeople, Nike+ FuelBand SE, and Polar Loop. We calculated interrater reliability using Cohen's kappa.

RESULTS

The average number of BCTs identified was 16.3/40. Withings Pulse had the highest number of BCTs and Misfit Shine had the lowest. Most techniques centered around self-monitoring and self-regulation, all of which have been associated with improved physical activity in older adults. Techniques related to planning and providing instructions were scarce.

CONCLUSIONS

Overall, wearable activity trackers contain several BCTs that have been shown to increase physical activity in older adults. Although more research and development must be done to fully understand the potential of wearables as health interventions, the current wearable trackers offer significant potential with regard to BCTs relevant to uptake by all populations, including older adults.

Acceptance of Commercially Available Wearable Activity Trackers Among Adults Aged Over 50 and With Chronic Illness: A Mixed-Methods Evaluation

Background

Physical inactivity and sedentary behavior increase the risk of chronic illness and death. The newest generation of “wearable” activity trackers offers potential as a multifaceted intervention to help people become more active.

Objective

To examine the usability and usefulness of wearable activity trackers for older adults living with chronic illness.

Methods

We recruited a purposive sample of 32 participants over the age of 50, who had been previously diagnosed with a chronic illness, including vascular disease, diabetes, arthritis, and osteoporosis. Participants were between 52 and 84 years of age (mean 64); among the study participants, 23 (72%) were women and the mean body mass index was 31 kg/m². Participants tested 5 trackers, including a simple pedometer (Sportline or Mio) followed by 4 wearable activity trackers (Fitbit Zip, Misfit Shine, Jawbone Up 24, and Withings Pulse) in random order. Selected devices represented the range of wearable products and features available on the Canadian market in 2014. Participants wore each device for at least 3 days and evaluated it using a questionnaire developed from the Technology Acceptance Model. We used focus groups to explore participant experiences and a thematic analysis approach to data collection and analysis.

Results

Our study resulted in 4 themes: (1) adoption within a comfort zone; (2) self-awareness and goal setting; (3) purposes of data tracking; and (4) future of wearable activity trackers as health care devices. Prior to enrolling, few participants were aware of wearable activity trackers. Most also had been asked by a physician to exercise more and cited this as a motivation for testing the devices. None of the participants planned to purchase the simple pedometer after the study, citing poor accuracy and data loss, whereas 73% (N=32) planned to purchase a wearable activity tracker. Preferences varied but 50% felt they would buy a Fitbit and 42% felt they would buy a Misfit, Jawbone, or Withings. The simple pedometer had a mean acceptance score of 56/95 compared with 63 for the Withings, 65 for the Misfit and Jawbone, and 68 for the Fitbit. To improve usability, older users may benefit from devices that have better compatibility with personal computers or less-expensive Android mobile phones and tablets, and have comprehensive paper-based user manuals and apps that interpret user data.

Conclusions

For older adults living with chronic illness, wearable activity trackers are perceived as useful and acceptable. New users may need support to both set up the device and learn how to interpret their data.