Canadian Institute Research Articles

Defining Social Prescribing: Fostering Common Understanding of a Vital Tool in the Integrated Care Toolbox

According to the World Health Organization, social prescribing is a holistic approach to health and wellbeing that promotes integrated care. There is growing interest in social prescribing around the world, with over 20 countries involved in the social prescribing movement. However, an agreed definition of social prescribing has yet to emerge. This is problematic for social prescribing research, policy, and practice. Since there are two types of definitions – conceptual and operational, agreement on both types of definitions is needed. The aim of this study was to establish internationally accepted conceptual and operational definitions of social prescribing. This study was conducted for the social prescribing community to support the advancement of the social prescribing movement. The research team – one doctoral student and four committee members, collectively designed, implemented, and monitored this research. This study involved an international, multidisciplinary panel of experts. The expert panel (n=48) represented 26 different countries across five continents and numerous expert groups, including service providers, service users, researchers, students, and representatives of the Global Social Prescribing Alliance, the Social Prescribing Network, the Social Prescribing Youth Network, the National Academy for Social Prescribing, and the Canadian Institute for Social Prescribing. A three-round Delphi study was conducted. Consensus was defined a priori as ≥80% agreement. In Round 1, participants were asked to list key elements that are essential to the conceptual definition of social prescribing and to provide corresponding statements that operationalize each of the key elements. In Round 2, participants were asked to rate their agreement with items from the first round for inclusion in the conceptual and/or operational definitions of social prescribing. Based on the findings from this round, the conceptual and operational definitions of social prescribing were developed, including long and short versions of the conceptual definition. In Round 3, participants were asked to rate their agreement with the conceptual and operational definitions of social prescribing. Consensus was reached on the definitions in this round, which signified the successful development of internationally accepted conceptual and operational definitions of social prescribing. The definitions were transformed into the Common Understanding of Social Prescribing (CUSP) conceptual framework. For the first time in the history of the social prescribing movement, we now have internationally accepted conceptual and operational definitions of social prescribing. Additionally, the conceptual definitions are distinct from pre-existing definitions, and to our knowledge, the operational definition is the first in the world. Together, the CUSP conceptual framework and the definitions offer a common thread – a shared sense of what social prescribing is. Social prescribing researchers, policymakers, and practitioners are encouraged to use the outputs of this work in social prescribing research, policy, and practice to foster common understanding of this concept.

How Do Professional Associations Influence Health System Transformation? Lessons from Ontario, Canada

Introduction: Internationally, there are increasing collaborative efforts to transform health care systems in ways that align with the principles of integrated care. Within the Canadian context, the current province-wide reorganization of health care into Ontario Health Teams (OHTs) is an example of a large-scale system transformation, requiring collaboration between system stakeholders at macro-, meso- and micro-levels. Literature on the topic inter-organizational collaboration does not fulsomely consider the role of local professional associations in health system transformations. There is value in examining the role of professional associations in influencing health system transformations, as they have significant expertise and influence, particularly in the domain of health policy. 
 Methods: We used a qualitative descriptive approach to explore the research question: what strategies have local professional associations used to influence the development of Ontario Health Teams? We collected data from eight, 60-minute interviews with senior level leaders from eight professional associations. Interviews were transcribed and data were analyzed using content analysis to construct four descriptive themes. 
 Results: During times of health system transformation, professional associations balance the functions of: (1) supporting members, (2) negotiating with government, (3) collaborating with stakeholders, and (4) reflecting on their role. In this presentation, we focus primarily on themes #2 and #3, given the specific relevance of governance, leadership, and collaboration. In both themes, participants emphasized the importance of findings areas of alignment with the government and other stakeholders; and using shared aims as way to amplify their influence. Characteristics of a “good” collaborator included consistent demonstration of mutual respect, clear communication, and interest in building trusting relationships. Participants also described barriers to collaboration, such as power imbalances and lack of role clarity. These challenges were heightened within the context of the “low rules” OHT rollout, in which OHTs had a high degree of control in adapting their team structures to ideally meet the needs of their local care partners and patient population(s),
 Conclusion and Implications: Professional associations are highly connected groups, deeply engaged with their members (often frontline clinicians) and regularly engaged with other key stakeholders and decision-makers (e.g., government). PAs play a critical role in influencing health system transformations, by bringing forward practical solutions to government that reflect the needs of their members, often frontline clinicians. Sharing insights from this work with an international audience could support global dialogues with health system leaders, policymakers, and researchers about leveraging the strengths of professional associations to enhance large-scale health system transformations via strategic collaboration.
 Next Steps: This research was conducted to fulfill the requirements of the Health System Impact Fellowship (doctoral level, funded by the Canadian Institutes of Health Research). We have continued to engage selected professional associations in building a collaborative framework, grounded in their experiences of participating the development of Ontario Health Teams.

Spontaneous Scaling of a Primary Care Innovation in Real-Life Conditions: Protocol for a Case Study.

Scaling effective primary care innovations to benefit more people is of interest to decision makers. However, we know little about how promising innovations are being scaled "spontaneously," that is, without deliberate guidance. We aim to observe, document, and analyze how, in real-life conditions, 1 primary care innovation spontaneously scales up across Quebec, Canada. We will conduct a participative study using a descriptive single-case study. It will be guided by the McLean and Gargani principles for scaling and reported according to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines. Informed by an integrated knowledge translation approach, our steering committee will include patient users throughout the project. Inspired by the Quebec College of Family Physician's "Dragons' Den" primary care program, we will identify a promising primary care innovation that is being or will be scaled spontaneously. We will interview the innovation team about their scaling experiences every month for 1 year. We will conduct interviews and focus groups with decision makers, health care providers, and end users in the innovation team and the target site about their experience of both scaling and receiving the scaled innovation and document meetings as nonparticipant observers. Interview transcripts and documentary data will be analyzed to (1) compare the spontaneous scaling plan and implementation with the McLean and Gargani principles for scaling and (2) determine how it was consistent with or diverged from the 4 McLean and Gargani guiding principles: justification, optimal scale, coordination, and dynamic evaluation. This study was funded in March 2020 by the Canadian Institutes of Health Research. Recruitment began in November 2023 and data collection began in December 2023. Results are expected to be published in the first quarter of 2024. Our study will advance the science of scaling by providing practical evidence-based material about scaling health and social care innovations in real-world settings using the 4 guiding principles of McLean and Gargani. PRR1-10.2196/54855.

A Framework to Support the Progressive Implementation of Integrated Team-Based Care for the Management of COPD: A Collective Case Study

Background: In Canada, there is consensus about the need for integrated, team-based care in primary care settings to help manage chronic conditions such as chronic obstructive pulmonary disease (COPD). Currently, there is limited understanding on how to support the continued growth and spread of such models; this is coupled with the fact that there is limited empirical evidence to support this process within chronic disease management. There is a need to understand how to support the implementation and spread of integrated, team-based chronic disease management programs in primary care settings, a process that we call progressive implementation.
 Methods: We studied the supporting and mitigating factors required to successfully implement and spread an integrated, team-based program for COPD management in primary care. We conducted a collective case study using an integrated knowledge translation approach involving key informants and our patient partner throughout the entire research process. Data collection included interviews, living documents, and a focus group. Our study explored an integrated, team-based model of care for COPD known as Best Care COPD (BCC). The BCC program has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants in our research included healthcare providers involved in the delivery of the BCC program.
 Results: We identified mechanisms influencing the spread of BCC and categorized them as foundational (evidence-based program, readiness to implement and a peer-led implementation team), transformative (adaptive process, provider empowerment and embedded evaluation), and enabling mechanisms (provider training, administrative support, role clarity, and patient outcomes) across three different implementation phases. We developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management within primary care settings.
 Conclusions: This study explores the implementation and spread of an integrated team-based COPD management program in primary care settings. Despite using COPD management program in Ontario, Canada as an exemplar, we believe the findings can be applied in other chronic disease contexts in primary care settings around the world. We provide a framework to support progressive implementation of integrated team-based care for chronic diseases with the potential to support patients and providers by understanding how to facilitate the continued growth of appropriate models of care. 
 Next Steps: The rapidly increasing prevalence of chronic diseases emphasizes the need to understand how to spread and sustain appropriate models of care to better support patients and providers. The next phase of this study will seek to understand how to support the sustainability of integrated, team-based chronic disease management programs in a primary care setting.
 Information on Financial Support: This study has received financial support from the Asthma Research Group Inc. and Canadian Institutes of Health Research.

Clinical and genetic keys to cerebellar ataxia due to FGF14 GAA expansions

SCA27B caused by FGF14 intronic heterozygous GAA expansions with at least 250 repeats accounts for 10-60% of cases with unresolved cerebellar ataxia. We aimed to assess the size and frequency of FGF14 expanded alleles in individuals with cerebellar ataxia as compared with controls and to characterize genetic and clinical variability. We sized this repeat in 1876 individuals from France sampled for research purposes in this cross-sectional study: 845 index cases with cerebellar ataxia and 324 affected relatives, 475 controls, as well as 119 cases with spastic paraplegia, and 113 with familial essential tremor. A higher frequency of expanded allele carriers in index cases with ataxia was significant only above 300 GAA repeats (10.1%, n=85) compared with controls (1.1%, n=5) (p<0.0001) whereas GAA250-299 alleles were detected in 1.7% of both groups. Eight of 14 index cases with GAA250-299 repeats had other causal pathogenic variants (4/14) and/or discordance of co-segregation (5/14), arguing against GAA causality. We compared the clinical signs in 127 GAA≥300 carriers to cases with non-expanded GAA ataxia resulting in defining a key phenotype triad: onset after 45 years, downbeat nystagmus, episodic ataxic features including diplopia; and a frequent absence of dysarthria. All maternally transmitted alleles above 100 GAA were unstable with a median expansion of+18 repeats per generation (r2=0.44; p<0.0001). In comparison, paternally transmitted alleles above 100 GAA mostly decreased in size (-15 GAA (r2=0.63; p<0.0001)), resulting in the transmission bias observed in SCA27B pedigrees. SCA27B diagnosis must consider both the phenotype and GAA expansion size. In carriers of GAA250-299 repeats, the absence of documented familial transmission and a presentation deviating from the key SCA27B phenotype, should prompt the search for an alternative cause. Affected fathers have a reduced risk of having affected children, which has potential implications for genetic counseling. This work was supported by the Fondation pour la Recherche Médicale, grant number 13338 to JLM, the Association Connaître les Syndrome Cérébelleux - France (to GS) and by the European Union's Horizon 2020 research and innovation program under grant agreement No 779257 ("SOLVE-RD" to GS). DP holds a Fellowship award from the Canadian Institutes of Health Research (CIHR). SK received a grant (01GM1905C) from the Federal Ministry of Education and Research, Germany, through the TreatHSP network. This work was supported by the Australian Government National Health and Medical Research Council grants (GNT2001513 and MRFF2007677) to MB and PJL.

STOPPING OLDER PERSON GENDER-BASED VIOLENCE IN WOMEN 55+ THROUGH PROMISING PRACTICES: A SCOPING REVIEW

Abstract Background Intimate partner and family violence (IPFV) disproportionately affect women of all ages, but are often understudied in older populations. Older women also face numerous barriers to reporting these types of abuse. A scoping review was undertaken to: (1) synthesize current knowledge about the utility and suitability of screening and intervention tools for older women (55+) experiencing IPFV; and (2) identify existing policy, practice, and research gaps with regard to current screening and intervention tools. Methods A comprehensive search of the databases Medline, CINAHL, PsychINFO, AgeLine, ASSIA, and Sociological Abstracts was conducted. In addition, grey literature sources were searched using Google Scholar, ISI Social Sciences Citation Index, ISI Conference Proceedings Citation Index-Social Science &amp; Humanities, Dissertations &amp; Theses: Full Text, Canadian Institute for Health Information (CIHI), and National Institute of Health (NIH). After screening and selection, 42 documents were included for data extraction. Results There were five major themes that emerged: (1) older women were not the specific targets of the studies/tools; (2) screening and intervention tools should address health outcomes; (3) tools identified were used or developed for some diverse populations; (4) two or more tools were used in combination; and (5) intervention tools should focus on social support and empowerment. Conclusions Older women, especially those with intersectional identities, are rarely represented in studies of IPFV, and are even less frequently the primary focus. Screening and intervention tools should address health outcomes, social support, and empowerment. Effective screening and intervention may stem from utilizing multiple tools in combination.

Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial

In patients with heart failure and reduced ejection fraction, sleep-disordered breathing, comprising obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is associated with increased morbidity, mortality, and sleep disruption. We hypothesised that treating sleep-disordered breathing with a peak-flow triggered adaptive servo-ventilation (ASV) device would improve cardiovascular outcomes in patients with heart failure and reduced ejection fraction. We conducted a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial of peak-flow triggered ASV in patients aged 18 years or older with heart failure and reduced ejection fraction (left ventricular ejection fraction ≤45%) who were stabilised on optimal medical therapy with co-existing sleep-disordered breathing (apnoea-hypopnoea index [AHI] ≥15 events/h of sleep), with concealed allocation and blinded outcome assessments. The trial was carried out at 49 hospitals in nine countries. Sleep-disordered breathing was stratified into predominantly OSA with an Epworth Sleepiness Scale score of 10 or lower or predominantly CSA. Participants were randomly assigned to standard optimal treatment alone or standard optimal treatment with the addition of ASV (1:1), stratified by study site and sleep apnoea type (ie, CSA or OSA), with permuted blocks of sizes 4 and 6 in random order. Clinical evaluations were performed and Minnesota Living with Heart Failure Questionnaire, Epworth Sleepiness Scale, and New York Heart Association class were assessed at months 1, 3, and 6 following randomisation and every 6 months thereafter to a maximum of 5 years. The primary endpoint was the cumulative incidence of the composite of all-cause mortality, first admission to hospital for a cardiovascular reason, new onset atrial fibrillation or flutter, and delivery of an appropriate cardioverter-defibrillator shock. All-cause mortality was a secondary endpoint. Analysis for the primary outcome was done in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT01128816) and the International Standard Randomised Controlled Trial Number Register (ISRCTN67500535), and the trial is complete. The first and last enrolments were Sept 22, 2010, and March 20, 2021. Enrolments terminated prematurely due to COVID-19-related restrictions. 1127 patients were screened, of whom 731 (65%) patients were randomly assigned to receive standard care (n=375; mean AHI 42·8 events per h of sleep [SD 20·9]) or standard care plus ASV (n=356; 43·3 events per h of sleep [20·5]). Follow-up of all patients ended at the latest on June 15, 2021, when the trial was terminated prematurely due to a recall of the ASV device due to potential disintegration of the motor sound-abatement material. Over the course of the trial, 41 (6%) of participants withdrew consent and 34 (5%) were lost to follow-up. In the ASV group, the mean AHI decreased to 2·8-3·7 events per h over the course of the trial, with associated improvements in sleep quality assessed 1 month following randomisation. Over a mean follow-up period of 3·6 years (SD 1·6), ASV had no effect on the primary composite outcome (180 events in the control group vs 166 in the ASV group; hazard ratio [HR] 0·95, 95% CI 0·77-1·18; p=0·67) or the secondary endpoint of all-cause mortality (88 deaths in the control group vs. 76 in the ASV group; 0·89, 0·66-1·21; p=0·47). For patients with OSA, the HR for all-cause mortality was 1·00 (0·68-1·46; p=0·98) and for CSA was 0·74 (0·44-1·23; p=0·25). No safety issue related to ASV use was identified. In patients with heart failure and reduced ejection fraction and sleep-disordered breathing, ASV had no effect on the primary composite outcome or mortality but eliminated sleep-disordered breathing safely. Canadian Institutes of Health Research and Philips RS North America.

A comprehensive, open-source data model for wastewater-based epidemiology.

The recent SARS-COV-2 pandemic has sparked the adoption of wastewater-based epidemiology (WBE) as a low-cost way to monitor the health of populations. In parallel, the pandemic has encouraged researchers to openly share their data to serve the public better and accelerate science. However, environmental surveillance data are highly dependent on context and are difficult to interpret meaningfully across sites. This paper presents the second iteration of the Public Health Environmental Surveillance Open Data Model (PHES-ODM), an open-source dictionary and set of data tools to enhance the interoperability of environmental surveillance data and enable the storage of contextual (meta)data. The data model describes how to store environmental surveillance program data, metadata about measurements taken on various specimens (water, air, surfaces, sites, populations) and data about measurement protocols. The model provides software tools that support the collection and use of PHES-ODM formatted data, including performing PCR calculations and data validation, recording data into input templates, generating wide tables for analysis, and producing SQL database definitions. Fully open-source and already adopted by institutions in Canada, the European Union, and other countries, the PHES-ODM provides a path forward for creating robust, interoperable, open datasets for environmental public health surveillance for SARS-CoV-2 and beyond.

Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial

Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. Canadian Institutes of Health Research (CIHR, MOP-142448).

Is Ultrahypofractionated Whole Pelvis Radiation Therapy (WPRT) as Well Tolerated as Conventionally Fractionated WPRT in Patients With Prostate Cancer? Early Results From the HOPE Trial

ObjectiveTo evaluate acute toxicity and quality of life (QOL) impact of ultra-hypofractionated whole pelvis radiotherapy (WPRT) compared to conventional WPRT fractionation post high-dose rate (HDR) prostate brachytherapy (BT). MethodsBLINDED FOR REVIEW is a phase 2, multi-institutional randomized controlled trial involving men with prostate-confined disease and NCCN unfavorable intermediate, high, or very-high-risk prostate cancer. Patients were randomly assigned to receive conventionally fractionated WPRT (standard arm) or ultra-hypofractionated WPRT (experimental arm) in a 1:1 ratio. All patients underwent radiotherapy with 15 Gy HDR-BT boost in a single fraction followed by WPRT delivered with conventional fractionation (45 Gy in 25 daily fractions or 46 Gy in 23 fractions) or ultra-hypofractionation (25 Gy in 5 fractions delivered on alternate days). Acute toxicities, measured during radiotherapy and at 6 weeks post-treatment, were assessed using the clinician-reported Common Terminology Criteria for Adverse Events (CTCAE) version 5.0, and QOL was measured using the Expanded Prostate Cancer Index Composite (EPIC-50) and International Prostate Symptom Score (IPSS). ResultsA total of 80 patients were enrolled and treated across three Canadian institutions. A total of 39 and 41 patients received external radiotherapy with conventionally fractionated and ultra-hypofractionated WPRT, respectively. All patients received androgen deprivation therapy, except for 2 patients treated in the ultra-hypofractionated arm. Baseline clinical characteristics were similar between the two arms, with 51 (63.8%) patients having high or very high-risk prostate cancer disease. Treatment was well tolerated with no significant differences in the rate of acute adverse events between arms. No grade 4 adverse events or treatment-related deaths were reported. Ultra-hypofractionated WPRT had a less detrimental impact in the EPIC-50 bowel total, function and bother domain scores when compared to conventional WPRT in the acute setting. On the contrary, more patients treated with ultra-hypofractionated WPRT reached the minimum clinical important difference on EPIC-50 urinary domains. No significant QOL differences between arms were noted in the sexual and hormonal domains. ConclusionUltra-hypofractionated WPRT following HDR-BT is a well-tolerated treatment strategy in the acute setting and leads to less detrimental impact on bowel QOL domains when compared to conventional WPRT.

Treatment of patent ductus arteriosus and short-term outcomes among extremely preterm infants: a multicentre cohort study

The optimal treatment strategy for patent ductus arteriosus (PDA) in extremely preterm infants is currently highly controversial. This study aimed to evaluate the association between PDA treatment and short-term outcomes among extremely preterm infants. This cohort study included all extremely preterm infants (≤27 and 6/7 weeks) who were admitted to hospitals participating in the Chinese Neonatal Network from January 2019 to December 2021, and were diagnosed to have PDA by echocardiogram. PDA treatment was defined as medical treatment and/or surgical ligation of PDA during hospitalization. Short-term outcomes included death, bronchopulmonary dysplasia (BPD), death/BPD, retinopathy of prematurity, necrotizing enterocolitis, and severe brain injury. Multivariate logistic regression was used to evaluate the association between PDA treatment and outcomes. Subgroup analysis were performed among infants with different respiratory support on 3 and 7 days of life. A total of 2494 extremely preterm infants with the diagnosis of PDA were enrolled, of which 1299 (52.1%) received PDA treatment. PDA treatment was significantly associated with lower risk of death (adjusted odds ratio, 0.48; 95% confidence interval, 0.38-0.60). The decreased risk of death was accompanied by increased risk of BPD and death/BPD. In subgroup analysis according to respiratory support, PDA treatment was associated with lower risk of death among infants who required invasive ventilation. However, the beneficial effect on death was not significant among infants who did not require invasive ventilation. PDA treatment was associated with reduced mortality in extremely preterm infants, but this beneficial effect was mainly present among infants who required invasive ventilation. This study was funded by the Shanghai Science and Technology Commission's Scientific and Technological Innovation Action Plan (21Y21900800) and the Canadian Institutes of Health Research (CTP87518).

Generative adversarial deep learning in images using Nash equilibrium game theory

A generative adversarial learning (GAL) algorithm is presented to overcome the manipulations that take place in adversarial data and to result in a secured convolutional neural network (CNN). The main objective of the generative algorithm is to make some changes to initial data with positive and negative class labels in testing, hence the CNN results in misclassified data. An adversarial algorithm is used to manipulate the input data that represents the boundaries of learner’s decision-making process. The algorithm generates adversarial modifications to the test dataset using a multiplayer stochastic game approach, without learning how to manipulate the data during training. Then the manipulated data is passed through a CNN for evaluation. The multi-player game consists of an interaction between adversaries which generates manipulations and retrains the model by the learner. The Nash equilibrium game theory (NEGT) is applied to Canadian Institute for Advance Research (CIFAR) dataset. This was done to produce a secure CNN output that is more robust to adversarial data manipulations. The experimental results show that proposed NEGT-GAL achieved a grater mean value of 7.92 and takes less wall clock time of 25,243 sec. Therefore, the proposed NEGT-GAL outperforms the compared existing methods and achieves greater performance.

Faith-based organisations and their role in supporting vaccine confidence and uptake: a scoping review protocol

IntroductionFaith-based organisations (FBOs) and religious actors increase vaccine confidence and uptake among ethnoracially minoritised communities in low-income and middle-income countries. During the COVID-19 pandemic and the subsequent vaccine rollout, global...

Development and Validation of the CANHEART Population-Based Laboratory Prediction Models for Atherosclerotic Cardiovascular Disease.

Prediction of atherosclerotic cardiovascular disease (ASCVD) in primary prevention assessments exclusively with laboratory results may facilitate automated risk reporting and improve uptake of preventive therapies. To develop and validate sex-specific prediction models for ASCVD using age and routine laboratory tests and compare their performance with that of the pooled cohort equations (PCEs). Derivation and validation of the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) Lab Models. Population-based cohort study in Ontario, Canada. A derivation and internal validation cohort of adults aged 40 to 75 years without cardiovascular disease from April 2009 to December 2015; an external validation cohort of primary care patients from January 2010 to December 2014. Age and laboratory predictors measured in the outpatient setting included serum total cholesterol, high-density lipoprotein cholesterol, triglycerides, hemoglobin, mean corpuscular volume, platelets, leukocytes, estimated glomerular filtration rate, and glucose. The ASCVD outcomes were defined as myocardial infarction, stroke, and death from ischemic heart or cerebrovascular disease within 5 years. Sex-specific models were developed and internally validated in 2 160 497 women and 1 833 147 men. They were well calibrated, with relative differences less than 1% between mean predicted and observed risk for both sexes. The c-statistic was 0.77 in women and 0.71 in men. External validation in 31 697 primary care patients showed a relative difference less than 14% and an absolute difference less than 0.3 percentage points in mean predicted and observed risks for both sexes. The c-statistics for the laboratory models were 0.72 for both sexes and were not statistically significantly different from those for the PCEs in women (change in c-statistic, -0.01 [95% CI, -0.03 to 0.01]) or men (change in c-statistic, -0.01 [CI, -0.04 to 0.02]). Medication use was not available at the population level. The CANHEART Lab Models predict ASCVD with similar accuracy to more complex models, such as the PCEs. Canadian Institutes of Health Research.

P182: Effects of Physical Environment on Quality of Life of Residents in Dementia Facilities in Canada &amp; South Korea: A Longitudinal Observational Study

Approximately 44% of new residents of care facilities in Korea were diagnosed with dementia (Song, Park &amp; Kim, 2013), and in Canada, about one-third of older adults younger than 80 who have been diagnosed with dementia live in long-term care facilities (Canadian Institute for Health Information, 2018). Due to the rapid increase of these figures in the future, continuing to provide assistance services and appropriate environment for residents with dementia could be challenging for both countries.This longitudinal observational study aims to examine whether residents with dementia in long-term care facilities with variability in physical environment attributions in Vancouver (N=11), Canada and Seoul (N=9), South Korea had a distinction in their quality of life (QoL). Physical environmental assessment was conducted using the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) (Sloane et al., 2002). QoL was assessed three times over one year using Dementia Care Mapping tool (DCM) (University of Bradford, 2010). The results of the study demonstrated that the residents with dementia living in an institutional large-scale setting showed statistically more withdrawn behavior and spent more time to be negative mood or affect compared to the ones in a small-scale setting. This study also found that the number of potential positive behaviors of residents in a small-scale setting was three times higher than that of residents in an institutional large-scale setting. When looking at the distinction between two countries in the behavior category with a large average time difference, the residents with dementia in Korea had shorter meal/dessert times compared to those in Canada. The study supports that the small-scale homelike environment is intensely associated with a therapeutic environment for older adults with dementia.

Biologically inspired deep residual networks

&lt;p&gt;Many difficult computer vision issues have been effectively tackled by deep neural networks. Not only that but it was discovered that traditional residual neural networks (ResNet) captures features with high generalizability, rendering it a cutting-edge convolutional neural network (CNN). The images classified by the authors of this research introduce a deep residual neural network that is biologically inspired introduces hexagonal convolutions along the skip connection. With the competitive training techniques, the effectiveness of several ResNet variations using square and hexagonal convolution is assessed. Using the hex-convolution on skip connection, we designed a family of ResNet architecture,hexagonal residual neural network (HexResNet), which achieves the highest testing accuracy of 94.02%, and 55.71% on Canadian Institute For Advanced Research (CIFAR)-10 and TinyImageNet, respectively. We demonstrate that the suggested method improves vanilla ResNet architectures’ baseline image classification accuracy on the CIFAR-10 dataset, and a similar effect was seen on the TinyImageNet dataset. For Tiny- ImageNet and CIFAR-10, we saw an average increase in accuracy of 1.46% and 0.48% in the baseline Top-1 accuracy, respectively. The generalized performance of advancements was reported for the suggested bioinspired deep residual networks. This represents an area that might be explored more extensively in the future to enhance all the discriminative power of image classification systems.&lt;/p&gt;

Distribution and Migration of Recent Healthcare Graduates in Canada.

Although data on new graduates are available and typically included in the health workforce planning (HWP) model, information on their interprovincial migration pattern is less known. This paper aims to understand the mobility pattern of recent healthcare graduates - family physicians and regulated nurses - across the different Canadian jurisdictions. Health workforce data from the Canadian Institute for Health Information (CIHI) were used to identify recent family physician and regulated nurse graduates. We identified new graduates (between 2015 and 2019) in a particular province and distributed them according to the province/territory in which they registered to practise. The jurisdiction where they are trained is a key factor in determining their migration rates. For both professions, Ontario and British Columbia have the lowest rates of new graduate out-migration and the highest rates of in-migration, leaving them with a positive net interprovincial migration. This analysis can be used to inform better HWP at the jurisdictional level in these professions. Working and community conditions matter to keep and attract new graduates.

Future leaders in a learning health system: Exploring the Health System Impact Fellowship.

The Canadian health system is reeling following the COVID-19 pandemic. Strains have become growing cracks, with long emergency department wait times, shortage of human health resources, and growing dissatisfaction from both clinicians and patients. To address long-needed health system reform in Canada, a modernization of training is required for the next generation health leaders. The Canadian Institutes of Health Research Health System Impact Fellowship (HSIF) is an example of a well-funded and connected training program which prioritizes embedded research and embedding technically trained scholars with health system partners. The program has been successful in the scope and impact of its training outcomes as well as providing health system partners with a pool of connected and capable scholars. Looking forward, integrating aspects of evidence synthesis from both domestic and international sources and adapting a general contractor approach to implementation within the HSIF could help catalyze learning health system reform in Canada.

Prognosis after cerebral venous thrombosis: Mortality during initial admission and at 30 days and one year after discharge in a large Canadian population-based cohort

BackgroundPrognosis following cerebral venous thrombosis (CVT) is more favorable than other stroke types, but longer-term literature is limited, and trends over time are under-explored. ObjectiveUsing administrative data, we examined factors associated with mortality in the inpatient setting, at 30 days and at one year following hospital discharge among a large consecutive cohort of Canadian patients with CVT. Design/methodsCVT patients from British Columbia (BC), Canada from 2000 to 2017 were identified using ICD diagnosis codes from the BC subset of the Canadian Institute for Health Information's Discharge Abstract Database. Logistic regression was used to investigate factors associated with inpatient mortality and survival analysis with Cox regression was used to explore factors associated with mortality at 30 days and one year. ResultsOf 554 incident CVT patients identified, 508 (92 %) survived their index admission. Older age (OR 1.04, 95 % CI 1.03–1.06, p < 0.01) and the presence of seizures (OR 2.31, 95 % CI 1.08–4.94, p = 0.03) or intracranial bleeding (OR 2.28, 95 % CI 1.08–4.85, p = 0.03) were associated with increased odds of inpatient mortality. Mortality after hospital discharge was 3.0 % at 30 days and 9.4 % at one year. Older age (HR 1.05, 95 % CI 1.02–1.08, p < 0.01 at 30 days; HR 1.05, 95 % CI 1.04–1.07, p < 0.01 at 1 year) and having recent or active malignancy (HR 4.17, 95 % CI 1.51–11.52, p < 0.01 at 30 days; HR 4.60, 95 % CI 2.60–8.11, p < 0.01 at 1 year) were significantly associated with higher risks of mortality at 30 days and one year after discharge. There were decreases in inpatient mortality over the study period, but this was offset by higher mortality within 30 days after discharge in the later study epochs. ConclusionsAmong patients discharged with a diagnosis of CVT, one-year mortality was high at 9.4 %. Older age and a history of cancer were associated with higher mortality after discharge.

Emergency Department Overcrowding in Canada

What Is the Issue?&#x0D; &#x0D; Emergency departments (EDs) across Canada are under strain and experiencing overcrowding, a situation that arises when the demand for health services in the ED exceeds the capacity of the health system — which includes the ED, hospital, and community — to provide quality care in a reasonable amount of time.&#x0D; ED overcrowding is contributing to a deteriorating standard of care as health care providers and staff become overworked and burned out, is putting health and lives at risk, and is placing additional strain on an already overwhelmed health care system.&#x0D; &#x0D; What Did We Do?&#x0D; &#x0D; The CADTH Health Technology Expert Review Panel (HTERP) convened to develop objective, impartial, trusted pan-Canadian guidance to inform decisions about which evidence-informed solutions should be considered to help alleviate ED overcrowding in Canada.&#x0D; &#x0D; What Is HTERP’s Position on ED Overcrowding?&#x0D; &#x0D; ED overcrowding is a complex health system issue. EDs operate within hospitals and broader health and social systems, which means that accountability for causes, impacts, and solutions do not lie solely within the ED and its operations.&#x0D; Output factors (e.g., misalignment between acute care bed capacity within the hospital and population needs) and input factors (e.g., misalignment between care available in the community and population needs, including care outside of regular business hours) respectively, are the main contributors to ED overcrowding in Canada. Health system capacity is not aligned with, nor has kept pace with, the growing and changing health care needs of the population, which results in overcrowded EDs.&#x0D; Health systems will observe better results by implementing strategies that improve patient flow and focus on output and input factors relative to throughput factors.&#x0D; &#x0D; What Is HTERP’s Guidance to Help Alleviate ED Overcrowding?&#x0D; &#x0D; Interventions to alleviate overcrowding need to align with the main contributing factors to ED overcrowding in the particular context in which they will be implemented.&#x0D; Understanding the context in which ED overcrowding is occurring, with attention to bottlenecks to patient flow, should be the first step to identify evidence-informed solutions.&#x0D; Transparency and accountability should be key principles in ED, hospital, and health system operations. HTERP recommends identifying and ensuring clear roles, responsibilities, and reporting relationships embedded within an accountability framework for ED overcrowding across health system partners, including a commitment to act on data.&#x0D; Each province and territory should mandate consistent and comprehensive reporting by all hospitals to the Canadian Institute of Health Information’s National Ambulatory Care Reporting System (NACRS) database.&#x0D; HTERP’s guidance includes an Evidence Navigation Guide to support identification of evidence-informed interventions to help alleviate ED overcrowding.&#x0D;