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Objective To evaluate the effectiveness of person-centred quality improvement strategies on the management and control of adults with hypertension in primary care. Methods A systematic review and meta-analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person-centred quality improvement strategies for the management and control of essential hypertension among adults ( ≥ 18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes. Results Eight studies were included (total of 5654 patients). Findings favour use of person-centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self-management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration. Conclusion Person-centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person-centred quality improvement intervention most effective in improving hypertension outcomes.

The International Classification of Diseases, Ninth Revision (ICD-9) was released in the 1970s and adopted in Canada for physician billing claims in 1979 (CIHI n.d.b.; WHOamp; International Conference for the Ninth Revision of the International Classification of Diseases 1977). ICD-9 is no longer adequate for representing our modern healthcare environment and patient needs. We summarize the findings from a small survey of ICD-9 users across Canada - such as family physicians, researchers and decision makers - who describe the limitations of ICD-9 and the features that they would desire in a new or updated classification system.

Author(s): Tomfohr-Madsen, Lianne; Cameron, Emily E; Dunkel Schetter, Christine; Campbell, Tavis; O'Beirne, Maeve; Letourneau, Nicole; Giesbrecht, Gerald F | Abstract: ObjectivePreterm birth (PTB) is a prevalent public health concern. Pregnancy anxiety, poor sleep quality, and short sleep duration have been associated with an increased risk of PTB. Theoretically, sleep variables could moderate the strength of the relationship between pregnancy anxiety and PTB; investigating this question was the primary aim of this study.MethodThe sample consisted of 290 pregnant women who were assessed at 2 time points in pregnancy: Time 1 (l 22 weeks gestational age [GA]; MGA = 15.04, SD = 3.55) and Time 2 (32 weeks GA; MGA = 32.44, SD = 0.99). Pregnancy anxiety was assessed with the Pregnancy-Related Anxiety Scale, sleep quality was assessed by the Pittsburgh Sleep Quality Index, and sleep duration was assessed via actigraphy. Data on gestational age at birth were obtained from the electronic medical record.ResultsAfter adjustment for relevant covariates, higher levels of pregnancy anxiety were associated with shorter gestational length and an increased risk of PTB. There were no direct associations between sleep quality or sleep duration and gestational length or PTB. Pregnancy anxiety interacted with sleep duration such that pregnancy anxiety was significantly associated with shorter gestational length and PTB only when women had relatively shorter sleep duration (approximately l 8.3 hr).ConclusionsThis study reveals new evidence of an interaction between pregnancy anxiety and sleep duration in the prediction of the timing of delivery. The findings point to avenues to better understand and potentially ameliorate risk for PTB. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The risk of pregnancy loss in von Willebrand disease (VWD) has been inconsistently reported. Von Willebrand factor (VWF) is a known regulator of angiogenesis, so has the potential to affect placental function. We sought to determine the risk of pregnancy loss and placenta-mediated pregnancy complications in women with VWD, compared with women without VWD. Women with VWD followed in the Southern Alberta Rare Blood and Bleeding Disorders Clinic were invited to participate in a questionnaire (February-June 2014). The same questionnaire was sent to women without VWD identified in a low-risk obstetrical clinic in Calgary, Alberta, Canada. The primary outcome was the proportion of pregnancies that ended in pregnancy loss. Secondary outcomes were preeclampsia, fetal growth restriction, placental abruption, and preterm labor less than 37 weeks gestation. Of the 30 (31.6%) VWD participants that responded, 26 (86.7%) were diagnosed with Type 1 VWD, of which 11 (42.3%) had VWF antigen or activity levels less than 30%. In women with VWD, there were 20 pregnancy losses out of 80 pregnancies [25.0%, 95% confidence interval (CI), 16.81-35.48], compared with eight losses out of 50 pregnancies in the control group (16.0%, 95% CI, 8.34-28.51; P = 0.28). There was no difference in the risk of preeclampsia (1.7 versus 0%, P = 1.00) or preterm labor (16.7 versus 7.1%, P = 0.23) among VWD and control groups. There were no other placenta-mediated pregnancy complications reported. There is no significant difference in pregnancy loss between women with and without VWD; however, a large multicenter study is needed to clarify the risk of pregnancy loss in women with VWD.

Introduction Practice-based research networks (PBRNs) conduct research in community settings, which poses quality control challenges to the integrity of research, such as study implementation and data collection. A foundation for improving research processes within PBRNs is needed to ensure research integrity. Methods Network directors and coordinators from seven U.S.-based PBRNs worked with a professional team facilitator during semiannual in-person meetings and monthly conference calls to produce content for a compendium of recommended research practices specific to the context of PBRNs. Participants were assigned to contribute content congruent with their expertise. Feedback on the draft document was obtained from attendees at the preconference workshop at the annual PBRN meeting in 2013. A revised document was circulated to additional PBRN peers prior to finalization. Results The PBRN Research Good Practices (PRGPs) document is organized into four chapters: (1) Building PBRN Infrastructure; (2) Study Development and Implementation; (3) Data Management, and (4) Dissemination Policies. Each chapter contains an introduction, detailed procedures for each section, and example resources with information links. Conclusion The PRGPs is a PBRN-specific resource to facilitate PBRN management and staff training, to promote adherence to study protocols, and to increase validity and generalizability of study findings.

Introduction Spinal manipulation therapy (SMT) is used throughout the world by chiropractors, osteopaths, physiotherapists and other manual therapists, yet there are no systematic data collection mechanisms in place to monitor and evaluate adverse events (AE) that occur after SMT. We established a reporting and learning system (“SafetyNet”) to fill this void and to address several aims, one of which is a prospective population-based active surveillance study to (a) document AE after SMT, (b) identify potential risk factors, and (c) develop potential strategies to mitigate risk. The purpose of this paper is to describe the development and validation of provider and patient measurement instruments to identify potential SMT AE in provider offices. Methods Instrument development and validation occurred in a step-wise fashion: (1) definition of terms (e.g. adverse event, seriousness); (2) identification and development of key domains, items, and sub-items; and (3) assessment of relevant measurement properties. Results Two provider short instruments, a provider long instrument, and a pre and post treatment patient comment instruments were developed, refined, and pilot tested with 12 providers and 300 patients. Conclusions The development and validation of instruments to evaluate SMT AEs may benefit the SMT research community as well as clinicians and their patients by providing rigorous prospective assessment of potential SMT-related AEs and their risk factors, thus enhancing patient safety and the promotion of a safety culture. Placing the instruments in providers’ offices for use on consecutive patients is next on the SafetyNet research agenda.

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.

Background The cost of implementing safety systems in primary care has not been examined. One type of safety system is a safety learning system (SLS). An SLS has 2 components: a reporting that monitors patient safety incidents and a learning component that facilitated the development and implementation of improvement strategies. It is important to understand the costs of an SLS to determine if the improvement program is financially sustainable. Objective To determine the costs of the development, implementation, and operation of the community-based SLS. Methods Nineteen participating family physician clinics in Calgary, Alberta, were included (15 urban and 4 rural) consisting of 47 physicians, 53 office staff, 18 nurses, and 6 clinic managers. Costs of the SLS were determined by the ingredient method using micro-costing. The costs were divided into 3 stages: development, implementation, and operational. Development costs were processes required to create and initiate the SLS. Implementation costs were accrued as a result of establishing, running, and refining the SLS. Finally, operational costs were those related to maintaining the SLS. Costs were further broken down into fixed, marginal, and in kind; this approach will allow policy and decision makers to apply the appropriate costs to their own settings. Results The total development, implementation, and operational costs for the SLS in Canadian dollars were $77,011, $19,941, and $166,727, respectively, with a total cost of $263,679 over approximately a 4-year period. During this time, 270 incident reports were submitted, and 54 improvement cycles were implemented. Conclusions The results provide quantitative data, which could be useful to legislators, policy makers, and other private and public sector payers of patient safety programs in determining the overall sustainability of an SLS.

Objective To discuss the characteristics of incidents reported to the Medical Safety in Community Practice (MSCP) safety learning system. Methods Members of family physician offices in the Alberta Health Services—Calgary zone, confidentially reported patient safety incidents via web or fax from September 2007 to August 2010. The incident reporting form contained both open-ended and closed questions. Incidents were reviewed for their characteristics. Results A total of 19 family practices participated in MSCP. A total of 264 useable reports were collected. Reporting was higher when practices first joined and then decreased. There was an average of 1.4 reports per month. Physicians submitted the majority of reports. Physicians and nurses were more likely to report an incident than office staff. The vast majority of reported incidents were judged to have ‘ virtually certain evidence of preventability’ (93%). Harm was associated with 50% of incidents. Only 1% of the incidents had a severe impact. The top four types of incidents reported were documentation (41.4%), medication (29.7%), clinical administration (18.7%) and clinical process (17.5%). Conclusion MSCP has developed and implemented the first safety learning system in Canada for family practice. All clinic members were encouraged to submit reports, but most of the incidents were reported by physicians. The vast majority of incidents reported were preventable with limited severity. The most frequently reported types of incidents fell into the categories of documentation and medication. The low reporting rates suggest that for family practices incident reporting may not be the most effective method to determine the types and frequency of incidents in family medicine.

Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.

Objective To assess the effect of 25-hydroxyvitamin D (25-OHD) levels on pregnancy outcomes and birth variables. Design Systematic review and meta-analysis. Data sources Medline (1966 to August 2012), PubMed (2008 to August 2012), Embase (1980 to August 2012), CINAHL (1981 to August 2012), the Cochrane database of systematic reviews, and the Cochrane database of registered clinical trials. Study selection Studies reporting on the association between serum 25-OHD levels during pregnancy and the outcomes of interest (pre-eclampsia, gestational diabetes, bacterial vaginosis, caesarean section, small for gestational age infants, birth weight, birth length, and head circumference). Data extraction Two authors independently extracted data from original research articles, including key indicators of study quality. We pooled the most adjusted odds ratios and weighted mean differences. Associations were tested in subgroups representing different patient characteristics and study quality. Results 3357 studies were identified and reviewed for eligibility. 31 eligible studies were included in the final analysis. Insufficient serum levels of 25-OHD were associated with gestational diabetes (pooled odds ratio 1.49, 95% confidence interval 1.18 to 1.89), pre-eclampsia (1.79, 1.25 to 2.58), and small for gestational age infants (1.85, 1.52 to 2.26). Pregnant women with low serum 25-OHD levels had an increased risk of bacterial vaginosis and low birthweight infants but not delivery by caesarean section. Conclusion Vitamin D insufficiency is associated with an increased risk of gestational diabetes, pre-eclampsia, and small for gestational age infants. Pregnant women with low 25-OHD levels had an increased risk of bacterial vaginosis and lower birth weight infants, but not delivery by caesarean section.

IntroductionA team of interdisciplinary research leaders have taken a novel approach to support a patient safety culture for spinal manipulation therapy (SMT) providers. The aim was to devise a team-based approach to identify modifiable and non-modifiable patient and provider risk factors.MethodsSafetyNET has four main areas of inquiry, led by five principal investigators. The SafetyNET initiative began with qualitative research regarding patient safety, including identification of potential facilitators and barriers to patient safety research. Simultaneously, a health law team is conducting research to identify potential barriers to patient safety research, including the risk of litigation.ResultsFeedback from both the qualitative and health law team is informing the development and implementation of an active surveillance reporting and learning system. This information in turn, helps inform our basic science team toward investigation of the potential mechanism of action for SMT-related adverse events.ConclusionOne outcome of the SafetyNET initiative is to provide a model for other disciplines and jurisdictions with respect to improving safety in procedures common to several regulated health disciplines.This article belongs to the Special Issue: Ensuring and Improving Patients Safety in Integrative Health Care.

Background Home care (HC) is a critical component of the ongoing restructuring of healthcare in Canada. It impacts three dimensions of healthcare delivery: primary healthcare, chronic disease management, and aging at home strategies. The purpose of our study is to investigate a significant safety dimension of HC, the occurrence of adverse events and their related outcomes. The study reports on the incidence of HC adverse events, the magnitude of the events, the types of events that occur, and the consequences experienced by HC clients in the province of Ontario. Methods A retrospective cohort design was used, utilizing comprehensive secondary databases available for Ontario HC clients from the years 2008 and 2009. The data were derived from the Canadian Home Care Reporting System, the Hospital Discharge Abstract Database, the National Ambulatory Care Reporting System, the Ontario Mental Health Reporting System, and the Continuing Care Reporting System. Descriptive analysis was used to identify the type and frequency of the adverse events recorded and the consequences of the events. Logistic regression analysis was used to examine the association between the events and their consequences. Results The study found that the incident rate for adverse events for the HC clients included in the cohort was 13%. The most frequent adverse events identified in the databases were injurious falls, injuries from other than a fall, and medication-related incidents. With respect to outcomes, we determined that an injurious fall was associated with a significant increase in the odds of a client requiring long-term-care facility admission and of client death. We further determined that three types of events, delirium, sepsis, and medication-related incidents were associated directly with an increase in the odds of client death. Conclusions Our study concludes that 13% of clients in homecare experience an adverse event annually. We also determined that an injurious fall was the most frequent of the adverse events and was associated with increased admission to long-term care or death. We recommend the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols, for assessing and mitigating the risk of an adverse event occurring.