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Background: Decision aids can help patients set realistic expectations. In this study, we explored alternative presentations to visualise patient-reported outcomes (EQ-5D-5L) data within an online, individualized patient decision aid for total knee arthroplasty (TKA) that, in part, generates individualized comparisons based on age, sex and body mass index, to enhance usability prior to implementation into routine clinical practice., Methods: We used data visualization techniques to modify the presentation of EQ-5D-5L outcomes data within the decision aid. The EQ-5D-5L data was divided into two parts allowing patients to compare themselves to similar individuals (1) pre-surgery and (2) 1-year post-surgery. We created 2 versions for each part and sought patient feedback on comprehension, usefulness, and visual appeal. Patients from an urban orthopedic clinic were recruited and their ratings and comments were recorded using a researcher-administered checklist. Data were managed using Microsoft Excel, R version 3.6.1 and ATLAS.ti V8 and analyzed using descriptive statistics and directed content analysis., Results: A total of 24 and 25 patients participated in Parts 1 and 2, respectively. Overall, there was a slight preference for Version 1 in Part 1 (58.3%) and Version 2 in Part 2 (64%). Most participants demonstrated adequate comprehension for all versions (range 50-72%) and commented that the instructions were clear. While 50-60% of participants rated the content as useful, including knowing the possible outcomes of surgery, some participants found the information interesting only, were unsure how to use the information, or did not find it useful because they had already decided on a treatment. Participants rated visual appeal for all versions favorably but suggested improvements for readability, mainly larger font and image sizes and enhanced contrast between elements., Conclusions: Based on the results, we will produce an enhanced presentation of EQ-5D-5L data within the decision aid. These improvements, along with further usability testing of the entire decision aid, will be made before implementation of the decision aid in routine clinical practice. Our results on patients' perspectives on the presentation of EQ-5D-5L data to support decision making for TKA treatments contributes to the knowledge on EQ-5D-5L applications within healthcare systems for clinical care., (© 2024. The Author(s).)

The epidemic of type-2 diabetes in First Nations communities is tragic. Culturally-appropriate approaches addressing multiple components, focusing beyond glycemic control, are urgently needed. Using an intention-to-treat framework, 13 processes of care indicators were assessed to compare proportions of patients who received care at baseline relative to 2-year follow-up. Clinical improvements were demonstrated across major process of care indicators (e.g. screening, education, and vaccination activities). We found RADAR improved reporting for most diabetes processes of care across seven FN communities and was effective in supporting diabetes care for FN communities, in Alberta Canada., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Challenges exist for the management of diabetes care in First Nations populations. RADAR (Reorganizing the Approach to Diabetes through the Application of Registries) is a culturally appropriate, innovative care model that incorporates a disease registry and electronic health record for local care provision with remote coordination, tailored for First Nations people. This study assessed the effectiveness of RADAR on patient outcomes and diabetes care organization in participating communities in Alberta, Canada. It revealed significant improvements in outcomes after 2 years, with 91% of patients achieving a primary combined end point of a 10% improvement in or persistence at target for A1C, systolic blood pressure, and/or LDL cholesterol. Qualitative assessment showed that diabetes care organization also improved. These multimethod findings support tailored diabetes care practices in First Nations populations., Competing Interests: No potential conflicts of interest relevant to this article were reported., (© 2023 by the American Diabetes Association.)

Background and Objectives: Patient-reported outcome measures invite patients to self-report aspects of their quality of life and have been reported to enhance communication with clinicians. We aimed to examine how routine use of patient-reported outcome measures in in-center hemodialysis units influenced patient-clinician communication., Design, Setting, Participants, & Measurements: A concurrent, longitudinal, mixed-methods approach was used. We used data from a cluster randomized controlled trial of 17 hemodialysis units in northern Alberta that introduced a patient-reported outcome measures intervention. Patient-clinician communication was assessed using a modified Communication Assessment Tool. Using interpretive description, we explored patients' and nurses' perceptions of communication pertaining to routine patient-reported outcome measure use. Through purposeful sampling, we interviewed ten patients and eight nurses and conducted six observations in the dialysis units, which were documented in field notes. We reviewed 779 patient responses to open-ended survey questions from randomized controlled trial data. Qualitative data were thematically analyzed., Results: Overall, patient-reported outcome measure use did not substantively improve patient-clinician communication. There was a small positive change in mean total Communication Assessment Tool scores (range, 1-5) from baseline to 12 months in patient-reported outcome measure use units (0.25) but little difference from control group units that did not use patient-reported outcome measures (0.21). The qualitative findings provide in-depth insights into why patient-reported outcome measure use did not improve patient-clinician communication. The purpose of patient-reported outcome measure use was not always understood by patients and clinicians; patient-reported outcome measures were not implemented as originally intended in the trial, despite clinician training; there were challenges using patient-reported outcome measures as a means to communicate; and patient-reported outcome measure use was perceived to have limited value., Conclusions: While patient-reported outcome measures use did not improve patient-clinician communication, qualitative data suggest implementation challenges, including limited clarity of purpose and perceived limited value, that may have limited the effectiveness of the intervention., (Copyright © 2022 by the American Society of Nephrology.)

Background: First Nations (FN) people of Canada experience health, social, and systemic inequities due to colonization. Consequently, COVID-19 has placed further mental health stress on people related to personal finances, employment security and worry over infection, resulting in exacerbated effects of unresolved past medical and physical traumas. This study aims to understand the experiences related to mental health in an Alberta FN community during the early stages of the pandemic., Methods: In partnership with FN leadership, the study implemented an online cross-sectional survey. Adults from a large FN community in Alberta, Canada, were asked to complete a survey, including two mental health-related screening questionnaires: (1) Generalized Anxiety Disorder-2 item; and (2) Patient Health Questionnaire-2 item. In addition, respondents could provide responses to open-ended questions about their experiences., Results: Among 106 respondents, 95 (89.6%) finished the survey; 18% of adults screened positive for depressive symptoms (score of 3 or greater) and reported difficulty following public health advice for using hand sanitizer, maintaining social distancing, or self-isolating. 21% of adults screened positive for symptoms of anxiety (score of 3 or greater) and reported difficulty maintaining social distance, self-isolating, obtaining food and clothing, or meeting other basic living requirements., Conclusions: FN communities may be disproportionately affected by COVID-19, and may experience exacerbated symptoms of anxiety, depression and overall poor mental health and well-being. Additional supports and services, including for mental health, should be considered for FN in the context of COVID-19 public health measures., Highlights: The COVID-19 pandemic has brought upon increased stress and accompanying symptoms of anxiety and depression for a First Nations community in Alberta. Studies, such as this one, that characterize the influence of the COVID-19 pandemic on mental health among First Nations people, are urgently needed because of increasing demands on healthcare systems due to the pandemic and potential delays in the care of patients living with pre-existing mental health conditions. There is an opportunity to capitalize on First Nations people's experiences of post-traumatic growth proactively supporting/maintaining their well-being and possibly the development of community-based mental health interventions and supports., (© 2022. The Author(s).)

Objective: The purpose of this qualitative study was to explore working men's perspectives about sleep health and the intersecting influences of gender and work, describing participant's views on current and potential programming and organizational support to promote sleep health., Methods: Twenty men employed in male-dominated industries in the north-central region of Alberta, Canada, participated in 4 consultation group discussions addressing motivators, facilitators and barriers to sleep health., Results: Participants reported sleeping an average of 6.36 (SD ±1.1) hours per night, and the majority worked more than 40 hours per week. Data were analyzed using an inductive approach. The findings provided important insights. In normalizing sleep deprivation and prioritizing the need to "just keep going" on six or less hours of sleep, the men subscribed to masculine ideals related to workplace perseverance, stamina and resilience. Workplace cultures and practices were implicated including normative dimensions of overtime and high productivity and output, amid masculine cultures constraining emotions and conversations about sleep, the sum of which muted avenues for discussing, let alone promoting sleep. Challenges to good sleep were primarily constructed around time constraints, and worry about meeting work and home responsibilities. Men's preferences for workplace support included providing and incentivizing the use of sleep health resources, designing work for sleep health (e.g., shift schedules, overtime policies) and getting advice from experienced coworkers and experts external to the workplace organization., Conclusion: These findings hold potential for informing future gender-sensitive programming and organizational practices to support sleep health among working men.

Objectives: The First Nations people experience significant challenges that may influence the ability to follow COVID-19 public health directives on-reserve. This study aimed to describe experiences, perceptions and circumstances of an Alberta First Nations community, related to COVID-19 public health advice. We hypothesized that many challenges ensued when following and implementing advice from public health experts., Methods: With First Nations leadership and staff, an online cross-sectional survey was deployed between April 24 and June 25, 2020. It assessed the appropriateness of public health advice to curb COVID-19 within this large First Nations community. Both quantitative and qualitative data were captured and described., Results: A total of 106 adults living on-reserve responded; over 80% were female. Difficulty accessing food was significant by employment status (p = 0.0004). Those people with lower income found accessing food (p = 0.0190) and getting essential medical care (p = 0.0060), clothing (p = 0.0280) and transportation (p = 0.0027) more difficult. Some respondents described lost income associated with COVID-19 experiences, as well as difficulties accessing essential supplies. Respondents found "proper handwashing" most easy (98%) and "keeping a distance of 2 m from others" most difficult (23%). Many respondents found following public health advice within their personal domain easy and put "family safety" first but experienced some difficulties when navigating social aspects and obligations, particularly when unable to control the actions of others. People stated wanting clear information, but were sometimes critical of the COVID-19 response., Conclusion: First Nations people face many additional challenges within the COVID-19 response, driven in part by ongoing issues related to significant societal, economic, and systemic factors., (© 2021. The Author(s), under exclusive licence to The Author(s) under exclusive license to The Canadian Public Health Association.)

Background: We aimed to describe (1) depressive and anxiety symptom burdens reported by adults on in-centre hemodialysis in Northern Alberta, Canada and (2) patients' and nurses' perceptions of managing such symptoms using routine patient-reported outcome measures (PROMs)., Methods: A longitudinal mixed methods approach was employed. Cluster randomized controlled trial data exposed the prevalence of positive screens (scores ≥ 3) for depressive (PHQ-2) and anxiety (GAD-2) symptoms. A descriptive qualitative approach was used to understand patients' and nurses' perceptions of managing these symptoms using the ESAS-r: Renal and EQ-5D-5L. Using purposeful sampling, patients and nurses were invited for interviews. Field notes were documented from 6 dialysis unit observations. Patients' responses to open-ended survey questions and nurses' electronic chart notes related to mental health were compiled. Thematic and content analyses were used., Results: Average age of patients (n = 408) was 64.0 years (SD 15.4), 57% were male, and 87% were not working; 29% screened positive for depressive symptoms, 21% for anxiety symptoms, and 16% for both. From patient (n = 10) and nurse (n = 8) interviews, unit observations, patient survey responses (n = 779) and nurses' chart notes (n = 84), we discerned that PROMs (ESAS-r: Renal/EQ-5D-5L) had the potential to identify and prompt management of mental health concerns. However, opinions differed about whether mental health was within kidney care scope. Nonetheless, participants agreed there was a lack of mental health resources., Conclusions: Prevalence of depressive and anxiety symptoms aligned with existing literature. Tensions regarding mental health management highlight the need for systemic decisions about how routine PROM use, including mental health assessment, may be optimized to meet patients' needs., (© 2021. The Author(s).)

Background: Diabetes care remains suboptimal in First Nations populations. Innovative and culturally relevant approaches are needed to promote systematic and proactive organization of diabetes care for people living with diabetes on-reserve in Canada. The RADAR model is one strategy to improve care: an integrated disease registry paired with an electronic health record for local community healthcare providers with remote care coordination. We qualitatively assessed adoption and implementation of RADAR in First Nations communities in Alberta to inform its potential spread in the province., Methods: We used the RE-AIM framework to evaluate adoption and implementation of RADAR in 6 First Nations communities. Using purposeful sampling, we recruited local healthcare providers and remote care coordinators involved in delivering RADAR to participate in telephone or in-person interviews at 6- and 24-months post-implementation. Interviews were digitally recorded, transcribed, and verified for accuracy. Data was analyzed using content analysis and managed using ATLAS.ti 8., Results: In total, we conducted 21 semi-structured interviews (6 at 6-months; 15 at 24-months) with 11 participants. Participants included 3 care coordinators and 8 local healthcare providers, including registered nurses, licensed practical nurses, and registered dietitians. We found that adoption of RADAR was influenced by leadership as well as appropriateness, acceptability, and perceived value of the model. In addition, we found that implementation of RADAR was variable across communities regardless of implementation supports and appropriate community-specific adaptations., Conclusions: The variable adoption and implementation of RADAR has implications for how likely it will achieve its anticipated outcomes. RADAR is well positioned for spread through continued appropriate community-based adaptations and by expanding the existing implementation supports, including dedicated human resources to support the delivery of RADAR and the provision of levels of RADAR based on existing or developed capacity among local HCPs., Trial Registration: Not applicable to this qualitative assessment.  ISRCTN14359671 .

Background: Osteoporosis is a chronic condition that is often left untreated. Nurse case-managers can double rates of appropriate treatment in those with new fractures. However, little is known about patients' experiences of a nurse case-managed approach to osteoporosis care., Objective: Our aim was to describe patients' experiences of nurse case-managed osteoporosis care., Methods: A qualitative, descriptive design was used. We recruited patients enrolled in a randomized controlled trial of a nurse case-management approach. Individual semi-structured interviews were conducted which were transcribed and analyzed using content analysis. Data were managed with ATLAS.ti version 7., Results: We interviewed 15 female case-managed patients. Most (60%) were 60-years or older, 27% had previous fracture, 80% had low bone mineral density tests, and 87% had good osteoporosis knowledge. Three major themes emerged from our analysis: acceptable information to inform decision-making; reasonable and accessible care provided; and appropriate information to meet patient needs., Conclusions: This study provides important insights about older female patients' experiences with nurse case-managed care for osteoporosis. Our findings suggest that this model to osteoporosis clinical care should be sustained and expanded in this setting, if proven effective. In addition, our findings point to the importance of applying patient-centered care across all dimensions of quality to better enhance the patients' experience of their health care., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2019.)

We assessed the context in which a hip Fracture Liaison Service was implemented. We conducted semi-structured interviews with 21 key informants at two time points to understand organizational readiness, facilitators, and barriers to change. We identified strategies important to successful implementation, particularly in the context of change fatigue., Purpose: Fracture Liaison Service (FLS) is effective for secondary fracture prevention. Two hospital sites implemented FLS for hip fracture patients, 50 + years, in Alberta, Canada. We assessed organizational readiness, facilitators, and barriers to change to better understand the context in which the FLS was implemented to inform its potential spread provincially., Methods: We recruited individuals involved in FLS implementation at provincial and site levels to participate in telephone interviews at baseline and 16 months post-implementation. Interviews were transcribed and analyzed using thematic content analysis. In addition, site-level participants were invited to complete the Organizational Readiness to Implement Change tool at baseline., Results: We conducted 33 semi-structured interviews (20 at baseline; 13 at post-implementation) with 21 key informants. Participants included managers (24%), FLS physicians/clinical nurses (19%), operational/leadership roles (19%), physicians/surgeons (14%), pharmacists (10%), nurse practitioners (10%), and social work (5%). Seventeen site-level participants completed the ORIC tool at baseline; all participants scored high (71%) or neutral (29%). We found that the use of several strategies, including demonstrating value, providing resources, and selecting appropriate sites, were important to implementation, particularly in the context of change fatigue. Participants perceived the FLS as acceptable and there was evidence of facilitated learning rather than simply monitoring implementation as intended., Conclusions: An effective change management approach neutralized change fatigue. This approach, if maintained, bodes well for the potential spread of the FLS provincially if proven effective and cost effective. Change readiness assessment tools could be used strategically to inform the spread of the FLS to early adopter sites.

Background: Diabetes care is suboptimal in First Nations populations. Innovative and culturally-relevant approaches are needed to promote proactive organization of diabetes care for diabetes patients on-reserve in Canada. The Reorganizing the Approach to Diabetes care through the Application of Registries ( RADAR ) model is one strategy to improve care: an integrated disease registry and electronic health record for community healthcare workers with centralized care coordination. The aim of this study was to qualitatively assess the organization of type 2 diabetes care in participating communities in Alberta, Canada, at baseline prior to implementing RADAR., Methods: Using qualitative description, we purposefully sampled healthcare workers involved in diabetes care at each health center. We used the 5Rs framework (i.e., Recognize, Register, Resource, Relay, Recall) to inform the baseline assessment and conducted group interviews in 6 communities with 16 healthcare workers. Detailed notes were taken and validated by participants. Data was managed using ATLAS.ti 8 and analyzed using content analysis., Results: We found strong commitment and effort by local healthcare workers to support people living with type 2 diabetes in their communities. However, healthcare workers were limited in their ability to identify (i.e., recognize), track (i.e., register and relay) and manage (i.e., resource and recall) people with type 2 diabetes as proposed by the 5Rs framework. The organization of diabetes care was often reactive and dependent on patients' abilities to navigate the health system. Interestingly, participants talked about the 5Rs in relationship to one another, not in a linear or isolated manner., Conclusions: Overall, the organization of diabetes care in participating communities did not align with the recommended approach of the 5Rs framework. In addition, we propose "reimagining" the 5Rs to reflect the interdependence and mediation of components situated within human and financial resources. This will better equip healthcare workers to assess, plan and execute organized and proactive diabetes care. However, the onus on people living with type 2 diabetes to engage with healthcare services remains a concern., Trial Registration: ISRCTN.com, ISRCTN14359671., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2020.)

Purpose: Women who are diagnosed with gestational diabetes mellitus have an increased risk of developing type 2 diabetes, but most receive little guidance regarding disease prevention. This study examined the role and usefulness of social support, including peer counselling in facilitating behaviour change as a part of a healthy eating and physical activity intervention among women with a previous gestational diabetes mellitus pregnancy., Methods: We used a qualitative descriptive approach to investigate participants' experiences with the social support they received during the intervention. We used purposeful sampling and invited women and peer counsellors to participate in semi-structured interviews. Data were analyzed using content analysis., Results: We interviewed nine women and two peer counsellors. Participants received emotional, appraisal, and informational types of social support from the peer counsellor and exercise specialist that they reported as useful. Additionally, participants' received informal emotional and instrumental support from family, friends, and colleagues that they found useful in supporting behaviour change., Conclusions: Different types of social support are important to encourage behaviour change. These findings provide insight into the types of social support women with previous gestational diabetes mellitus find useful, in addition to practical ways that social support can be incorporated into future interventions., Competing Interests: No potential conflict of interest was reported by the authors., (© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Type-2 diabetes rates in First Nations communities are 3-5 times higher than the general Canadian population, resulting in a high burden of disease, complications and comorbidity. Limited community nursing capacity, isolated environments and a lack of electronic health records (EHR)/registries lead to a reactive, disorganized approach to diabetes care for many First Nations people. The Reorganizing the Approach to Diabetes through the Application of Registries (RADAR) project was developed in alignments with federal calls for innovative, culturally relevant, community-specific programs for people with type-2 diabetes developed and delivered in partnership with target communities., Methods: RADAR applies both an integrated diabetes EHR/registry system (CARE platform) and centralized care coordinator (CC) service that will support local healthcare. The CC will work with local healthcare workers to support patient and community health needs (using the CARE platform) and build capacity in best practices for type-2 diabetes management. A modified stepped wedge controlled trial design will be used to evaluate the model. During the baseline phase, the CC will work with local healthcare workers to identify patients with type-2 diabetes and register them into the CARE platform, but not make any management recommendations. During the intervention phase, the CC will work with local healthcare workers to proactively manage patients with type-2 diabetes, including monitoring and recall of patients, relaying clinical information and coordinating care, facilitated through the shared use of the CARE platform. The RE-AIM framework will provide a comprehensive assessment of the model. The primary outcome measure will be a 10% improvement in any one of A1c, BP, or cholesterol over the baseline values. Secondary endpoints will address other diabetes care indicators including: the proportion of clinical measures completed in accordance with guidelines (e.g., foot and eye examination, receipt of vaccinations, smoking cessation counseling); the number of patients registered in CARE; and the proportion of patients linked to a health services provider. The cost-effectiveness of RADAR specific to these communities will be assessed. Concurrent qualitative assessments will provide contextual information, such as the quality/usability of the CARE platform and the impact/satisfaction with the model., Discussion: RADAR combines innovative technology with personalized support to deliver organized diabetes care in remote First Nations communities in Alberta. By improving the ability of First Nations to systematically identify and track diabetes patients and share information seamlessly an overall improvement in the quality of clinical care of First Nations people living with type-2 diabetes on reserve is anticipated., Trial Registration: ISRCTN study ID ISRCTN14359671 , retrospectively registered October 7, 2016.

Background: Primary care reforms should be supported by high-quality evidence across the entire life cycle of research. Front-line healthcare providers play an increasing role in implementation research. We recently evaluated two interventions for people with type 2 diabetes (T2D) in partnership with four Primary Care Networks (PCNs) in Alberta, Canada. Here, we report healthcare professionals perspectives on participating in primary care implementation research., Methods: Guided by the RE-AIM framework, we collected qualitative data before, during, and after both interventions. We conducted 34 in-person or telephone interviews with 17 individual PCN professionals. We used content analysis to identify emerging codes and concepts., Results: Two major themes emerged from the data. First, healthcare managers were eager to conduct implementation research in a primary care setting. Second, regardless of willingness to conduct research, there were challenges to implementing experimental study designs for both interventions. PCN professionals presumed the interventions were better than usual care, expressed role conflict, and reported administrative burdens related to research participation. Perceptions of patient vulnerability and an obligation to intervene exacerbated these issues., Conclusions: Healthcare professionals with limited practical research experience might not foresee the challenges in implementing experimental study designs in primary care settings to generate high-quality evidence. These issues are intensified when healthcare professionals perceive target patient populations as vulnerable and in need of intervention based on the presenting illness. Possible solutions include further research training, involving healthcare professionals in study design development, and using non-clinical staff to conduct research activities, particularly among acutely unwell patient populations.

Background: Randomized controlled trials are considered the "gold standard" for scientific rigor in the assessment of benefits and harms of interventions in healthcare. They may not always be feasible, however, when evaluating quality improvement interventions in real-world healthcare settings. Non-randomized controlled trials (NCTs) are designed to answer questions of effectiveness of interventions in routine clinical practice to inform a decision or process. The on-off NCT design is a relatively new design where participant allocation is by alternation. In alternation, eligible patients are allocated to the intervention "on" or control "off " groups in time series dependent sequential clusters., Methods: We used two quality improvement studies undertaken in a Canadian primary care setting to illustrate the features of the on-off design. We also explored the perceptions and experiences of healthcare providers tasked with implementing the on-off study design., Results and Discussion: The on-off design successfully allocated patients to intervention and control groups. Imbalances between baseline variables were attributed to chance, with no detectable biases. However, healthcare providers' perspectives and experiences with the design in practice reveal some conflict. Specifically, providers described the process of allocating patients to the off group as unethical and immoral, feeling it was in direct conflict with their professional principle of providing care for all. The degree of dissatisfaction seemed exacerbated by: 1) the patient population involved (e.g., patient population viewed as high-risk (e.g., depressed or suicidal)), 2) conducting assessments without taking action (e.g., administering the PHQ-9 and not acting on the results), and 3) the (non-blinded) allocation process., Conclusions: Alternation, as in the on-off design, is a credible form of allocation. The conflict reported by healthcare providers in implementing the design, while not unique to the on-off design, may be alleviated by greater emphasis on the purpose of the research and having research assistants allocate patients and collect data instead of the healthcare providers implementing the trial. In addition, consultation with front-line staff implementing the trials with an on-off design on appropriateness to the setting (e.g., alignment with professional values and the patient population served) may be beneficial., Trial Registration: Health Eating and Active Living with Diabetes: ClinicalTrials.gov identifier: NCT00991380. Date registered: 7 October 2009. Controlled trial of a collaborative primary care team model for patients with diabetes and depression: Clintrials.gov Identifier: NCT01328639 Date registered: 30 March 2011.