Background As of May 2022, Ontario has seen more than 1.3 million cases of COVID-19. While the majority of individuals will recover from infection within 4 weeks, a significant subset experience persistent and often debilitating symptoms, known as “post-COVID syndrome” or “Long COVID.” Those with Long COVID experience a wide array of symptoms, with variable severity, including fatigue, cognitive impairment, and shortness of breath. Further, the prevalence and duration of Long COVID is not clear, nor is there evidence on the best course of rehabilitation for individuals to return to their desired level of function. Previous work with chronic conditions has suggested that the addition of electronic case management (ECM) may help to improve outcomes. These platforms provide enhanced connection with care providers, detailed symptom tracking and goal setting, and access to relevant resources. In this study, our primary aim is to determine if the addition of ECM with health coaching improves Long COVID outcomes at 3 months compared to health coaching alone. Methods The trial is an open-label, single-site, randomized controlled trial of ECM with health coaching (ECM+) compared to health coaching alone (HC). Both groups will continue to receive usual care. Participants will be randomized equally to receive health coaching (± ECM) for a period of 8 weeks and a 12-week follow-up. Our primary outcome is the WHO Disability Assessment Scale (WHODAS), 36-item self-report total score. Participants will also complete measures of cognition, fatigue, breathlessness, and mental health. Participants and care providers will be asked to complete a brief qualitative interview at the end of the study to evaluate acceptability and implementation of the intervention. Discussion There is currently little evidence about the optimal treatment of Long COVID patients or the use of digital health platforms in this population. The results of this trial could result in rapid, scalable, and personalized care for people with Long COVID which will decrease morbidity after an acute infection. Results from this study will also inform decision making in Long COVID and treatment guidelines at provincial and national levels. Trial registration ClinicalTrials.gov NCT05019963. Registered on 25 August 2021.
Background Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population. Methods Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted. Results Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was “critically low.” Interventional studies were scant. Conclusion While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.
Background: Mobile technology interventions present opportunities for enhanced patient engagement and outcomes. Aims: To assess the feasibility and patient attitudes toward using mobile technology in HCV care. Methods: Cross-sectional survey data were collected from HCV patients (N=115) at two sites, an academic hospital-based outpatient viral HCV program (n= 92) and a mostly low SES communitybased site (n = 23). Measures included demographics, HCV disease status and risk factors, and mobile technology access and preferences. Differences in mobile technology access, use, and preferences by treatment site, treatment experience, ethnicity, gender, education level, and income level were assessed by Mann-Whitney and chi-square tests. Results: 78% owned a mobile device. Of these, 69% reported having Internet access and 72% unlimited text plans. 66% reported comfort in texting. Half liked the idea of using a cell phone for HCV clinical care; others expressed dislike/uncertainty. Poorer access to mobile technology was reported by treatment naïve, community site, and non-White participants (p values ranging from 0.02 to 0.01). Respondents from the community rated lower comfort in texting (p = 0.01). A similar trend was noted for respondents with incomes below $30,000 as compared to higher income (p = 0.09). Yet, groups similarly liked the idea of using mobile technology in HCV care. Conclusion: Mobile technology is an alternative model to augment existing HCV care. Variability in acceptability and accessibility of this approach was highlighted. Tailoring care delivery to individual patients with a particular focus on patients being served in community-based programs with low SES will be critical.
Background Healthcare resources are limited and unnecessary, and inappropriate emergency department use is now a highly visible healthcare priority. Individuals visiting the emergency department for mental health-related reasons are often amongst the most frequent presenters. In response, researchers and clinicians have created interventions to streamline emergency department use and several primary studies describe the effects of these interventions. Yet, no consensus exists on the optimal approach, and information on the quality of development, effectiveness, acceptability, and economic considerations is hard to find. The purpose of this study is to systematically review interventions designed to improve appropriate use of the emergency department for mental health reasons. Method A mixed-method systematic review using Joanna Briggs Methodology. Search combining electronic databases (EMBASE, MEDLINE, PsycINFO, CINAHL, HealthSTAR, PROQUEST, Cumulative Index to Nursing and Allied Health) and secondary searches (grey literature and hand search with consultation). Two independent reviewers will screen titles and abstracts using predetermined eligibility criteria and a third reviewer will resolve conflicts. Full texts will also be screened by two independent reviews and conflicts resolved in a consensus meeting with a third reviewer. A pilot-tested data extraction form will be used to retrieve data relevant to the study objectives. We will assess the quality and of all included studies. Data describing interventions will be summarized using logic models and reported narratively. Quality of development will be assessed using the Oxford Implementation Index. For data on intervention effectiveness, we will assess statistical heterogeneity and conduct a meta-analysis using a random effects method, if appropriate. For interventions that cannot be pooled, we will report outcomes narratively and descriptively. Qualitative data on acceptability will be synthesized using meta-aggregation and an economic evaluation of interventions will be done. The reporting of this protocol follows the PRISMA-P statement. Discussion Using a combined systematic review methodology and integrated knowledge translation plan, the project will provide decision makers with concrete evidence to support the implementation and evaluation of interventions to improve emergency department use for mental health reasons. These interventions reflect widespread priorities in the area of mental health care. Systematic review registration PROSPERO CRD42018087430
Background: Although hepatitis C virus (HCV) treatment has improved dramatically, decision making related to treatment continues to be complex and challenging. Little data exists regarding patient information needs and preferences in the direct-acting antiviral (DAA) era. Methods: We evaluated patient-perceived information needs and preferences when making HCV treatment decisions. A cross-sectional survey was conducted at two Ottawa-based sites: a hospital-located outpatient viral hepatitis clinic, and a community-based HCV patient support program. Results: One hundred and seventeen patients completed the survey: the mean age was 52.1 years (range 23 to 78), and 64% were male, 81.5% were White, 48.6% were on disability support or leave, and 60.3% had a high school education or less. Although traditional sources of health information (e.g., direct communication with health care providers) remain preferred by most, a range of preferences were reported including utilization of newer technologies (e.g., emails, text messages). The telephone was rated as the preferred method of contact for medication reminders, with daily or weekly communication reported as most helpful. White participants, those more highly educated, and those with a higher income all indicated a greater acceptability for e-mail and/or text message communication for medication and appointment reminders. Conclusions: There is no single preferred source or method of communicating with patients. These findings indicate that a tailored multi-pronged approach, including newer technologies, is more likely to effectively educate and communicate with the heterogeneous population of individuals living with HCV.
IntroductionPeople with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI?Methods and analysisWe will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting.Ethics and disseminationThis study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.
BackgroundDramatic increases in acute hepatitis C (HCV) incidence is linked to the opioid epidemic and increased injection drug use. Over 50% of people with HCV also have a mental illness. IDSA/HIVMA calls for the integration of infectious diseases, addiction medicine, and mental health as key to addressing the opioid epidemic. Barriers identified include limited physician education and stigma. This study examined medical trainees’ gaps in training and attitudes toward HCV, drug use, and mental illness.MethodsMedical students and residents (N = 98) at a large Canadian University completed questionnaires assessing stigma, attitudes, knowledge, and training related to HCV, drug use, and mental illness.ResultsMost participants were medical residents (71%). Within-subjects ANOVAs showed that trainees worked with more patients with mental illness (71%) than drug use (55%) or HCV (21%) (P’s < 0.001). Trainees reported less positive experiences with patients with drug use (34%) and HCV (36%) compared with those with mental illness (55%) (p’s < 0.05). They reported that injection drug use (68%), prescription opioids (66%), and heroin use (59%) were the most challenging substance use problems to treat (P < 0.001). They were less satisfied working with patients with drug use (40%) or HCV (40%) than mental illness (59%) (P’s < 0.01). Trainees reported they were more able to help patients with mental illness (83%) than HCV (65%) or drug use (73%) (P’s < 0.01). Only 34% saw HCV treatment as central to their professional role. Their training better prepared them to treat mental illness (58%) than drug use (41%) or HCV (19%) (P’s < 0.001). They were more interested in training in drug use (76%) and mental health (71%) than HCV (62%) (P’s < 0.01).ConclusionMedical trainees report being ill-equipped to treat patients with HCV and drug use (specifically opioids) and are less satisfied with this work. Many report attitudes that may be viewed by patients as stigmatizing. There is a large knowledge gap related to the effectiveness of HCV treatment. Addressing the opioid crisis requires a physician workforce that is prepared to integrate treatment for HCV, drug use, and mental illness. Infectious disease specialists can take a leadership role in building capacity to foster integration.Disclosures All authors: No reported disclosures.
Background: As of May 2022, Ontario has seen more than 1.3 million cases of COVID-19. While the majority of individuals will recover from infection within four weeks, a significant subset experience persistent and often debilitating symptoms, known as “post-COVID syndrome” or “Long COVID”. Those with Long COVID experience a wide array of symptoms, with variable severity, including fatigue, cognitive impairment, and shortness of breath. Further, the prevalence and duration of Long COVID is unclear, nor is there evidence on the best course of rehabilitation for individuals to return to their desired level of function. Previous work with chronic conditions has suggested that the addition of electronic case management (ECM) may help to improve outcomes. These platforms provide enhanced connection with care providers, detailed symptom tracking and goal setting, and access to relevant resources. In this study, our primary aim is to determine if the addition of ECM with health coaching improves Long COVID outcomes at three months compared to health coaching alone.Methods: The trial is an open-label, single site, randomized controlled trial of ECM with health coaching (ECM+) compared to health coaching alone (HC). Both groups will continue to receive usual care. Participants will be randomized equally to receive health coaching (+/- ECM) for a period of 8 weeks and a 12-week follow-up. Our primary outcome is the WHO Disability Assessment Scale (WHODAS), 36-item self-report total score. Participants will also complete measures of cognition, fatigue, breathlessness, and mental health. Participants and care providers will be asked to complete a brief qualitative interview at the end of the study to evaluate acceptability and implementation of the intervention.Discussion: There is currently little evidence about the optimal treatment of Long COVID patients or the use of digital health platforms in this population. The results of this trial could result in rapid, scalable, and personalized care for people with Long COVID which will decrease morbidity after an acute infection. Results from this study will also inform decision making in Long COVID and treatment guidelines at provincial and national levels.Trial registration: ClinicalTrials.gov, NCT05019963, Registered on 25 August 2021, https://clinicaltrials.gov/ct2/show/NCT05019963
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