Jayna Holroyd-Leduc’s research while affiliated with University of Calgary and other places

Objective Care partners play a vital role in supporting persons living with dementia (PLWD) in using medical services. We conducted a meta-synthesis to explore care partner perspectives of ED care for PLWD, as well as healthcare provider (HCP) perceptions of care partner roles within the ED, to identify care gaps and facilitators across the ED continuum. Methods MEDLINE, PsycINFO and Embase databases were searched from inception to 8 May 2023. Grey literature was also searched. Articles were included if they reported on care partner roles or experiences regarding care delivery for PLWD in the ED, either from the perspective of care partners or HCPs. A charting exercise was used to categorise the primary focus and outcomes of the articles selected for inclusion. A second charting exercise was used to derive overarching themes based on care partner roles in ED care for PLWD, and care partner perspectives surrounding barriers and facilitators to care. Results 16 articles were included. Important barriers and facilitators to care for PLWD were identified and organised according to the timepoint of the visit (pre-ED, during a visit and post-ED). Key care gaps and barriers to care included: gaps in primary care access and care planning, ED environment and organisational processes, deficits in communication regarding patient care, lack of care partner involvement in clinical decisions, and difficulties with discharge transitions and follow-up care. Key facilitators to care included: clinical information provided by care partners, care coordination, and care partner support and engagement. Conclusion These findings can aid in developing dementia-friendly EDs by informing policy and practices, as well as environmental modifications. Future studies should focus on the feasibility and effectiveness of interventions targeted towards EDs and primary care settings. Engagement of care partners in these intervention studies will be critical to their success.

Falls and hip fractures are a major health concern among older adults in long term care (LTC) with almost 50% of residents experiencing a fall annually. Hip fractures are one of the most important and frequent fall-related injuries in LTC. There is moderate to strong certainty evidence that multifactorial interventions may reduce the risk of falls and fractures; however, there is little evidence to support its implementation. The purpose of this study was to determine the feasibility (recruitment rate and adaptations) with a subobjective to understand facilitators to and barriers of implementing the PREVENT (Person-centred Routine Fracture PreEVENTion) model in practice. The model includes a multifactorial intervention on diet, exercise, environmental adaptations, hip protectors, medications (including calcium and vitamin D), and medication reviews to treat residents at high risk of fracture. Our secondary outcomes were to determine if there was a change in knowledge uptake of the guidelines among healthcare providers and in the proportion of fracture prevention prescriptions post-intervention. We conducted a mixed-methods longitudinal cohort study in three LTC homes across southern Ontario. A local champion was selected to help guide the implementation of the model and promote best practices. We reported recruitment rates using descriptive statistics and challenges to implementation using content analysis. We reported changes in knowledge uptake and in the proportion of fracture prevention medications using the McNemar’s test. We recruited three LTC homes and identified one local champion for each home. We required two months to identify and train the local champion over three, 1.5-hour train-the-trainer sessions, and the local champion required three months to deliver the intervention to a team of healthcare professionals. We identified several facilitators, barriers, and adaptations to PREVENT. Benefits of the model include easy access to the Fracture Risk Scale (FRS), clear and succinct educational material catered to each healthcare professional, and an accredited Continuing Medical Educational module for physicians and nurses. Challenges included misperceptions between the differences in fall and fracture prevention strategies, fear of perceived side effects associated with fracture prevention medications, and time barriers with completing the audit report. Our study found an increase knowledge uptake of the guidelines and an increase in the proportion of fracture prevention prescriptions post-intervention.

Background Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. Methods We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2–3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. Discussion The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. Trial Registration This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic.clinicaltrials.gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1

Background The impact of social frailty on older adults is profound including mortality risk, functional decline, falls, and disability. However, effective strategies that respond to the needs of socially frail older adults are lacking and few studies have unpacked how social determinants operate or how interventions can be adapted during periods requiring social distancing and isolation such as the COVID-19 pandemic. To address these gaps, we conducted a scoping review using JBI methodology to identify interventions that have the best potential to help socially frail older adults (age ≥65 years). Methods We searched MEDLINE, CINAHL (EPSCO), EMBASE and COVID-19 databases and the grey literature. Eligibility criteria were developed using the PICOS framework. Our results were summarized descriptively according to study, patient, intervention and outcome characteristics. Data synthesis involved charting and categorizing identified interventions using a social frailty framework. Results Of 263 included studies, we identified 495 interventions involving ~124,498 older adults who were mostly female. The largest proportion of older adults (40.5%) had a mean age range of 70-79 years. The 495 interventions were spread across four social frailty domains: social resource (40%), self-management (32%), social behavioural activity (28%), and general resource (0.4%). Of these, 189 interventions were effective for improving loneliness, social and health and wellbeing outcomes across psychological self-management, self-management education, leisure activity, physical activity, Information Communication Technology and socially assistive robot interventions. Sixty-three interventions were identified as feasible to be adapted during infectious disease outbreaks (e.g., COVID-19, flu) to help socially frail older adults. Conclusions Our scoping review identified promising interventions with the best potential to help older adults living with social frailty.

Background Despite decades of anti-racism and equity, diversity, and inclusion (EDI) interventions in academic medicine, medical racism continues to harm patients and healthcare providers. We sought to deeply explore experiences and beliefs about medical racism among academic clinicians to understand the drivers of persistent medical racism and to inform intervention design. Methods We interviewed academically-affiliated clinicians with any racial identity from the Departments of Family Medicine, Cardiac Sciences, Emergency Medicine, and Medicine to understand their experiences and perceptions of medical racism. We performed thematic content analysis of semi-structured interview data to understand the barriers and facilitators of ongoing medical racism. Based on participant narratives, we developed a logic framework that demonstrates the necessary steps in the process of addressing racism using if/then logic. This framework was then applied to all narratives and the barriers to addressing medical racism were aligned with each step in the logic framework. Proposed interventions, as suggested by participants or study team members and/or identified in the literature, were matched to these identified barriers to addressing racism. Results Participant narratives of their experiences of medical racism demonstrated multiple barriers to addressing racism, such as a perceived lack of empathy from white colleagues. Few potential facilitators to addressing racism were also identified, including shared language to understand racism. The logic framework suggested that addressing racism requires individuals to understand, recognize, name, and confront medical racism. Conclusions Organizations can use this logic framework to understand their local context and select targeted anti-racism or EDI interventions. Theory-informed approaches to medical racism may be more effective than interventions that do not address local barriers or facilitators for persistent medical racism.

Background Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups. Methods This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis. Results Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions. Conclusions This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.

Falls and hip fractures are a major health concern among older adults in long term care (LTC) with almost 50% of residents experiencing a fall annually. Hip fractures are one of the most important and frequent fall-related injuries in LTC. The purpose of this study was to determine the feasibility (recruitment rate and adaptations) of implementing the PREVENT (Person-centred Routine Fracture PreEVENTion) model in practice, with a subobjective to understand facilitators and barriers. The model includes a multifactorial intervention on diet, exercise, environmental adaptations, hip protectors, medications (including calcium and vitamin D), and medication reviews to treat residents at high risk of fracture. Our secondary outcomes aimed to assess change in knowledge uptake of the guidelines among healthcare providers and in the proportion of fracture prevention prescriptions post-intervention. We conducted a mixed-methods non-experimental design study in three LTC homes across southern Ontario. A local champion was selected to guide the implementation. We reported recruitment rates using descriptive statistics and adaptations using content analysis. We reported changes in knowledge uptake using the paired sample t-test and the percentage of osteoporosis medications prescriptions using absolute change. Within five months, we recruited three LTC homes. We required two months to identify and train the local champion over three 1.5-hour train-the-trainer sessions, and the champion required three months to deliver the intervention to the healthcare team. We identified several facilitators, barriers, and adaptations. Benefits of the model include easy access to the Fracture Risk Scale, clear and succinct educational material catered to each healthcare professional, and an accredited educational module for physicians and nurses. Challenges included misperceptions between the differences in fall and fracture prevention strategies, fear of perceived side effects associated with fracture prevention medications, and time barriers with completing the audit report. Our study did not increase knowledge uptake of the guidelines, but there was an increase in the proportion of osteoporosis medication post-intervention.

Background Substitute decision‐makers (SDMs) make decisions that honor medical, personal, and end‐of‐life wishes for older adults who have lost capacity, including those with dementia. However, SDMs often lack support, information, and problem‐solving tools required to make decisions and can suffer with negative emotional, relationship, and financial impacts. The need for adaptable supports has been identified in prior meta‐analyses. This scoping review identifies evidence‐based decision‐making resources/tools for SDMs, outlines domains of support, and determines resource/tool effectiveness and/or efficacy. Methods The scoping review used the search strategy: Population—SDMs for older adults who have lost decision‐making capacity; Concept—supports, resources, tools, and interventions; Context—any context where a decision is made on behalf of an adult (>25 years). Databases included MEDLINE, Embase, CINAHL, PsycINFO, and Abstracts in Social Gerontology and SocIndex. Tools were scored by members on the research team, including patient partners, based on domains of need previously identified in prior meta‐analyses. Results Two reviewers independently screened 5279 citations. Articles included studies that evaluated a resource/tool that helped a family/friend/caregiver SDMs outside of an ICU setting. 828 articles proceeded onto full‐text screening, and 25 articles were included for data extraction. The seventeen tools identified focused on different time points/decisions in the dementia trajectory, and no single tool encompassed all the domains of caregiver decision‐making needs. Conclusion Existing tools may not comprehensively support caregiver needs. However, combining tools into a toolkit and considering their application relevant to the caregiver's journey may start to address the gap in current supports.

Background Long-term care (LTC) was overwhelmingly impacted by COVID-19 and unnecessary transfer to emergency departments (ED) can have negative health outcomes. This study aimed to explore how the COVID-19 pandemic impacted LTC to ED transfers and hospitalizations, utilization of community paramedics and facilitated conversations between LTC and ED physicians during the first four waves of the pandemic in Alberta, Canada. Methods In this retrospective population-based study, administrative databases were linked to identify episodes of care for LTC residents who resided in facilities in Alberta, Canada. This study included data from January 1, 2018 to December 31, 2021 to capture outcomes prior to the onset of the pandemic and across the first four waves. Individuals were included if they visited an emergency department, received care from a community paramedic or whose care involved a facilitated conversation between LTC and ED physicians during this time period. Results Transfers to ED and hospitalizations from LTC have been gradually declining since 2018 with a sharp decline seen during wave 1 of the pandemic that was greatest in the lowest-priority triage classification (CTAS 5). Community paramedic visits were highest during the first two waves of the pandemic before declining in subsequent waves; facilitated calls between LTC and ED physicians increased during the waves. Conclusions There was a reduction in number of transfers from LTC to EDs and in hospitalizations during the first four waves of the pandemic. This was supported by increased conversations between LTC and ED physicians, but was not associated with increased community paramedic visits. Additional work is needed to explore how programs such as community paramedics and facilitated conversations between LTC and ED providers can help to reduce unnecessary transfers to hospital.