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The Evidence Speaks

The Evidence Speaks (October 2018)

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The Evidence Speaks Series is a recurring feature highlighting the latest in CHÉOS research. This series features summaries of select publications as well as in-depth features on the latest work from our investigators.
In the early days of CHÉOS, the Centre had a series known as “The Evidence Speaks,” a monograph series to keep media and the research community up-to-date with CHÉOS’ current research results in the health outcomes field.

Sawatzky R, Laforest E, Schick-Makaroff K, Stajduhar K, Reimer Kirkham S, et al. Design and introduction of a quality of life assessment and practice support system: Perspectives from palliative care settings. J Patient Rep Outcomes. 2018 Aug 22;2:36.

Dr. Rick Sawatzky, CHÉOS Scientist and Patient-Reported Outcomes Program Head, led a study on the development and implementation of a Quality of Life and Practice Support System (QPSS) in palliative inpatient and home care settings. CHÉOS Scientists Drs. Anne GadermannSandra Lauck, and Peter Dodek also contributed to the project. Integrating quality of life (QOL) assessments into routine care has the potential to make care more patient-centred by increasing the visibility of perceived health care needs so that they may be addressed. There have been efforts to use handheld electronic systems, like tablets, to incorporate such assessments into care, but the best means of doing so is not yet clear. The study took an integrated knowledge translation approach and unfolded in two stages to create, contextualize, and implement knowledge into the study’s particular practice settings. Stage I consisted of focus groups to ascertain the features clinicians desired in a QPSS prototype while Stage II gathered information on the experiences of clinicians, patients, and family caregivers relating to the initial introduction of the QPSS prototype. In total, 71 clinicians, 18 patients, and 17 family caregivers were involved in the study. Twelve focus groups with clinicians were held in Stage I and 5 focus groups, 24 interviews with clinicians, and 35 interviews with patients or family caregivers were held in Stage II. The data gathered during the focus groups and interviews were analyzed using qualitative methodology to identify central themes. In Stage I, the clinicians expressed preferences for design features relating to hardware (lightweight, durable, easy to disinfect), software (simple, accessible, integrated into health system), and types of assessments included. Five assessments were chosen for the QPSS prototype to meet requests for a holistic assessment, greater focus on patient and family-caregiver experiences, and to assess satisfaction and experiences with care, specifically end-of-life care. Patients and caregivers were generally receptive to the QPSS prototype in Stage II, while clinicians expressed concerns regarding the clinical value of the assessments and how they would be integrating into existing practices. Other considerations emerged relating to logistical, technical, and aesthetic components of the system and the need to understand organizational context and priorities to guide use of QOL assessment data. Amidst the enthusiasm towards using electronic systems to integrate QOL assessment instruments into clinical practice, this study illustrates the need to engage with health care providers, patients, and family caregivers to optimize integration.

Shankar S, Gogosis E, Palepu A, Gadermann AM, Hwang SW. “I Haven’t Given Up and I’m Not Gonna”: A phenomenographic exploration of resilience among individuals experiencing homelessness. Qual Health Res. 2018 Sep 26 epub ahead of print.

Resilience is an elusive and complex concept but is generally understood as the ability to adapt to adversity and has been found to be related to positive health outcomes. Researchers from UBC and Toronto,including CHÉOS Scientists Drs. Anita Palepu and Anne Gadermann, sought to explore the concept of resilience among adults experiencing homelessness, an endeavour that had not been previously undertaken. The researchers took a phenomenographic inquiry approach in order to understand how resilience is collectively conceptualized and experienced. Phenomenography is used to describe how people make sense of phenomena and how these phenomena can be described by conceptions. Using semi-structured interviews from a 2011 study assessing the impact of housing transitions on health (The Health and Housing in Transition Study), a sample of 22 adults living in Vancouver were analyzed. Eight conceptions were identified and categorized as relating to Staying Strongand Sustaining Positive Beliefs. Both positive conceptions, including “I’m looking to live” and “Feeling gratitude and appreciation”, and negative conceptions, such as “Where I go negative things happen”, were noted. By situating these conceptions into an outcome space, the researchers were able to understand how these concepts are tied to temporal elements and contextual factors. The researchers found that rather than being an all-or-nothing trait, resilience is a process and a multidimensional construct consisting of both positive and negative aspects. The findings regarding resilience suggest that it is detectable during adversity and that there is potential for it to be strengthened through interventions. The researchers highlight that by identifying resilience there is potential to mitigate some risks related to adversity, develop more effective services, and contribute to positive health outcomes. Future research may look at generalizability of the study’s findings to other populations and developing a better understanding of how contextual factors influence resilience.

Holowachuk S, Zhang W, Gandhi SK, Anis AH, Potts JE, Harris KC. Cost savings analysis of early extubation following congenital heart surgeryPediatr Cardiol. 2018 Sep 10 epub ahead of print.

Previous research has shown that early extubation, the removal of the endotracheal ventilation tube, is effective in shortening patients’ length of stay (LOS) following congenital heart surgery with no effects on morbidity or mortality. While preceding studies have proven the benefits of early extubation through reduced resource utilization, they have not examined the associated economic implications. Dr. Aslam Anis, CHÉOS Director, and CHÉOS Health Economics Program Head Dr. Wei Zhang, along with researchers from the Children’s Heart Centre at BC Children’s Hospital (BCCH), aimed to characterize cost savings of early extubation in children. They conducted a cost savings analysis comparing BCCH, where the established protocols encourage early extubation, with data from the Society of Thoracic Surgeons (STS) database. Among the sites included in the STS database is no consistent set of protocols regarding extubation timing. Patients that underwent any of STS’ eight benchmark operations, atrial septal defect repair, or bidirectional cavopulmonary anastomosis between 2010 and 2012 were included in the analysis. Length of stay data was collected for 370 patients from BCCCH and 19,947 patients from the STS cohort. Early extubation was defined as extubation occurring within 24 hours of arrival to the ICU after surgery. The researchers estimated both direct and indirect costs associated with a reduction in length of stay from early extubation. Direct costs were estimated based on data obtained from the Decision Support Services Department at BCCH. They calculated the average cost per day in the ICU or on the ward including costs of diagnostic testing, medications, and allied health professionals. Indirect costs included family travel costs, accommodations, food, and lost wages. The estimates were run through multiple simulations in order to assess and account for uncertainty. LOS varied by procedure, but the patients from BCCH had on average shorter LOS than patients from the STS database. There was a 49% reduction in total post-operative costs and an overall cost savings of $12,976 per patient, which resulted mostly from reductions to direct costs — total estimated cost savings at BCCH over the study period was $4.8 million, 91% of which from reductions in direct costs. Though actual cost savings will differ between health centres, the reduction to direct costs means greater savings for the health care system which can improve health care resource utilization and any savings to indirect costs is an additional benefit to patient families.

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