An Implementation Science Laboratory as One Approach to Whole System Improvement: A Canadian Healthcare Perspective

Implementation science (IS) has emerged as an integral component for evidence-based whole system improvement. IS studies the best methods to promote the systematic uptake of evidence-based interventions into routine practice to improve the quality and effectiveness of health service delivery and patient care. IS laboratories (IS labs) are one mechanism to integrate implementation science as an evidence-based approach to whole system improvement and to support a learning health system. This paper aims to examine if IS labs are a suitable approach to whole system improvement. We retrospectively analyzed an existing IS lab (Alberta, Canada’s Implementation Science Collaborative) to assess the potential of IS labs to perform as a whole system approach to improvement and to identify key activities and considerations for designing IS labs specifically to support learning health systems. Results from our evaluation show the extent to which IS labs support learning health systems through enabling infrastructures for system-wide improvement and research.

Development and Evaluation of a Novel Fast Broad-Range ITS/LSU DNA PCR and Sequencing Assay (FBR-PCR/S) for Rapid Diagnosis of Invasive Fungal Diseases: Multi-Year Experience in a Large Canadian Healthcare Zone and a Literature Review

BackgroundThis study evaluated the performance of a novel fast broad range PCR and sequencing (FBR-PCR/S) assay for the improved diagnosis of invasive fungal disease (IFD) in high-risk patients in a large Canadian healthcare region.MethodsA total of 114 clinical specimens (CS) including bronchoalveolar lavages (BALs) were prospectively tested from 107 patients over a 2-year period. Contrived BALs (n=33) inoculated with known fungi pathogens were also tested to increase diversity. Patient characteristics, fungal stain and culture results were collected from the laboratory information system. Dual-priming oligonucleotide (DPO) primers targeted to the ITS (~350 bp) and LSU (~550 bp) gene regions were used to perform FBR-PCR/S assays on extracted BALs/CS. The performance of the molecular test was evaluated against results of fungal stains and culture, and where available, histopathology, and clinical review for the presence of IFD.ResultsThe 107 patients were predominantly male (67, 62.6%%) with a mean age of 59 yrs. (range = 0 to 85 yrs.): 74 (69.2%) patients had at least one underlying comorbidity: 19 (34.5%) had confirmed and 12 (21.8%) had probable IFD. Culture recovered 66 fungal isolates from 55 BALs/CS with Candida spp. and Aspergillus spp. being most common. For BALs, the molecular assay vs. fungal culture had sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), and efficiency of 88.5% vs.100%, 100% vs. 61.1%, 100% vs. 88.5%, 61.1% vs. 100%, and 90.2% for both. For other CS, the molecular assay had similar performance to fungal culture with sensitivity, specificity, PPV, NPV and efficiency of 66.7%, 87.0%, 66.7%, 87.0% and 81.3% for both methods. Both methods also performed similarly, regardless of whether CS stain/microscopy showed yeast/fungal elements. FBR-PCR/S assays results were reported in ~8h compared to fungal cultures that took between 4 to 6 weeks.ConclusionsRapid molecular testing compared to culture has equivalent diagnostic efficiency but improves clinical utility by reporting a rapid species-level identification the same dayshift (~8h).

Fidaxomicin as first line: What will it cost in the USA and Canada?

Importance: Recent changes in the Infectious Diseases and Healthcare Epidemiology Societies of America (IDSA-SHEA) guidelines for managing Clostridioides difficile infections (CDI) have placed fidaxomicin as first-line treatment for CDI. Objective: To estimate the net cost of first line fidaxomicin as compared to vancomycin in the American and Canadian healthcare systems and to estimate the price points at which fidaxomicin would become cost saving. Data sources: We identified all randomized controlled trials comparing fidaxomicin with vancomycin through the 2021 IDSA-SHEA guideline update. Medication costs were obtained from wholesale prices (US) and the Quebec drug formulary (Canada). The average cost of a CDI recurrence was established through two systematic reviews using PubMed. Study selection: For fidaxomicin efficacy, we included double-blind and placebo-controlled trials. For the systematic review of recurrence costs, studies were included if they were primary research articles, had a cost-analysis of CDI, included cases of recurrent CDI, and were calculated with cost parameters from American or Canadian healthcare systems. Studies were excluded if the population was solely pediatric or hospitalized. Data extraction and Synthesis: For the efficacy meta-analysis, data was pooled using a random effects model. For the costs review, literature screening was performed by 2 independent reviewers. The mean cost across identified studies was adjusted to 2021 dollars. Main Outcomes and Measures: The primary outcome of the meta-analysis was CDI recurrence at day 40. The primary outcome of the systematic review was the average cost of a CDI recurrence in the American and Canadian healthcare systems. The objective was to estimate the net cost per recurrence prevented and the price point below which fidaxomicin would be cost saving. Results: At current drug pricing, the estimated additional cost of a 10-day course of fidaxomicin compared to vancomycin in order to prevent one recurrence was $46,178USD (95%CI $36,942-$69,267) and $13,760CAD (95%CI $11,008-$20,640), respectively. The estimated mean systemic cost of a CDI recurrence was $14,506USD and $8,588CAD, respectively. When priced below $1550USD and $800CAD, fidaxomicin was likely to become cost saving. Conclusions and Relevance: The increased drug expenditure on fidaxomicin will not be offset through recurrence prevention unless fidaxomicin price is re-negotiated.

Proceedings of the inaugural Canadian Healthcare Navigation Conference: a forum for sharing innovations and best practices in navigation services

Background Individuals experiencing chronic illnesses face many physical, emotional, and social strains as a result of their illnesses, all the while trying to navigate unfamiliar territory in the healthcare system. Navigation is a strategy that can help people facing complex care needs and barriers to care in finding and accessing needed supports in the health care system. Navigators provide a patient-centred service, guiding individuals through their care plans and overcoming barriers to care. Navigation supports for individuals experiencing complex care needs have shown significant promise and have been gaining traction across Canada. Methods The Canadian Healthcare Navigation Conference was the first event of its kind in Canada to bring together navigation researchers, service providers, students, decision makers, and individuals with lived experience to share lessons learned, promising practices, and research findings. This event was co-hosted by the Family Navigation Project at Sunnybrook Health Sciences Centre and NaviCare/SoinsNavi at the University of New Brunswick, and took place virtually on April 15–16, 2021. Results This event spanned two days, which both began with a keynote address, one from a researcher and medical professional in navigation, and another from an individual with lived experience involved in advocacy in Canadian healthcare. Concurrent oral presentations by a variety of presenters were held following each keynote presentation. A poster session was held at the end of the first day, and a panel presentation rounded out the second day. Concurrent and poster presentations covered a range of topics pertaining to approaches to navigation, navigator roles, evaluation and quality improvement, lived experience in navigation, and navigation in the context of the COVID-19 pandemic. The panel presentation focused on identifying how the navigation field has progressed in Canada and identifying crucial next steps in navigation. These next steps were determined to be: 1) agreement on navigation-related definitions, 2) regulation and training, 3) equity, diversity, inclusion, and accessibility, 4) integrating lived experience, and 5) regional coordination. Conclusion This conference was an important first step to creating a shared national conversation about navigation services so that we can continue to develop, implement, and share best evidence and practices in the field.

Inclusion, diversity, equity, and accessibility: From organizational responsibility to leadership competency

An awakening to systemic anti-black racism, anti-Indigenous racism, and harmful colonial structures in the context of a pandemic that has made health inequities and injustices impossible to ignore, is driving healthcare organizations to establish and strengthen approaches to inclusion, diversity, equity, and accessibility (IDEA). Health research and care organizations, which are shaping the future of healthcare, have a responsibility to make IDEA central to their missions. Many organizations are taking concrete action critically important to embedding IDEA principles, but durable change will not be achieved until IDEA becomes a core leadership competency. Drawing from the literature and consultation with individuals recognized for excellence in IDEA-informed leadership, this study will help Canadian healthcare and health research leaders—particularly those without lived experience—understand what it means to embed IDEA within traditional leadership competencies and propose opportunities to achieve durable change by rethinking governance, mentorship, and performance management through an IDEA lens.

Disrupting the paradigm of oncology care in Canada: the triumphs, challenges and future implications of telemedicine

Medicine has long been one of the lingering aspects of society yet to be fully disrupted by technological advances. Unlike media, banking and commerce which have adapted to the growing demand for convenience and accessibility from the public, the practice of medicine in many ways remains much unchanged from decades prior. The 2019 novel coronavirus (COVID-19) demanded an immediate shift in the way Canadian healthcare was delivered to reduce the risk of viral transmission from in person patient encounters. Cancer poses a large and ever-increasing impact on the Canadian population and healthcare resources. Brenner et al. (2020) estimated nearly half of the Canadian population will develop cancer in their lifetime in addition to the recent increasing yearly number of new diagnoses and deaths as the population grows and ages [1]. Cancer patients were initially an ideal population for telemedicine encounters during the pandemic. These patients often have additional comorbidities association with COVID-19 mortality and a diagnosis of cancer may further increase this risk [2]. As healthcare enters a second year within the new paradigm of virtual medicine, it is important to consider the impact and future of telemedicine on Canada’s ever-growing oncology patients.

Bayesian inference for continuous-time hidden Markov models with an unknown number of states

We consider the modeling of data generated by a latent continuous-time Markov jump process with a state space of finite but unknown dimensions. Typically in such models, the number of states has to be pre-specified, and Bayesian inference for a fixed number of states has not been studied until recently. In addition, although approaches to address the problem for discrete-time models have been developed, no method has been successfully implemented for the continuous-time case. We focus on reversible jump Markov chain Monte Carlo which allows the trans-dimensional move among different numbers of states in order to perform Bayesian inference for the unknown number of states. Specifically, we propose an efficient split-combine move which can facilitate the exploration of the parameter space, and demonstrate that it can be implemented effectively at scale. Subsequently, we extend this algorithm to the context of model-based clustering, allowing numbers of states and clusters both determined during the analysis. The model formulation, inference methodology, and associated algorithm are illustrated by simulation studies. Finally, we apply this method to real data from a Canadian healthcare system in Quebec.

Decision Making Surrounding IT Outsourcing within Ontario Hospitals

With the increases to healthcare expenditures and with technology playing a more critical role in hospitals, IT outsourcing has become an important topic for hospital executives. There has been a lack of research in Canadian healthcare on IT outsourcing within hospitals. This research explores the several factors associated with hospital CIOs and Managers in outsourcing their IT systems. Additionally, this research looks to identify the benefits, risks and alternatives to IT outsourcing within Canada, specifically within the province of Ontario. While transaction, agency and knowledge-based theories are discussed, they are not tested. They provide more of a guide and confirmation of these decision factors. Hospital CIOs and Managers were interviewed and recorded to determine the decision factors. Lacity et al (2010) IT Outsourcing decision model was used as a starting point for the decision factors and a Canadian model was developed from an adaption of Lacity et al work. This research provides a starting point for IT outsourcing research within the Ontario hospital sector.

Decision Making Surrounding IT Outsourcing within Ontario Hospitals

With the increases to healthcare expenditures and with technology playing a more critical role in hospitals, IT outsourcing has become an important topic for hospital executives. There has been a lack of research in Canadian healthcare on IT outsourcing within hospitals. This research explores the several factors associated with hospital CIOs and Managers in outsourcing their IT systems. Additionally, this research looks to identify the benefits, risks and alternatives to IT outsourcing within Canada, specifically within the province of Ontario. While transaction, agency and knowledge-based theories are discussed, they are not tested. They provide more of a guide and confirmation of these decision factors. Hospital CIOs and Managers were interviewed and recorded to determine the decision factors. Lacity et al (2010) IT Outsourcing decision model was used as a starting point for the decision factors and a Canadian model was developed from an adaption of Lacity et al work. This research provides a starting point for IT outsourcing research within the Ontario hospital sector.