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      Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study

      , MSc, MD, FRCPC 1 , 2 , 3 , 4 , 5 , , , BSc, M Adm 2 , , PhD 5 , , MD, DPhil, FRCPC 6 , 7 , 8 , , MD, FRCPC 2 , 5 , 9 , , PhD 1 , 3 , , PhD 10 , , MSc 2 , 5 , , MD, PhD 3 , 5 , 11 , , MD, PhD 1 , 3 , 12 , 13 , , PhD, MRSC, FCAHS 14 , , MSc, MD, CCFP(EM)(COE) 15 , 16 , , MBA 2 , , BSc, M Adm 2 , , MSc 2 , , BSc, MSc 5 , 17 , , BScSoc, M Adm 5 , 18 , , PhD 1 , 3 , 19 , 20 , , MSc, MD, FRCPC 21 , , PhD, RN 5 , 18 , , PhD 3 , 22 , 23 , , MSc, MD, FRCPC 1 , 3 , 20 , , MD, PhD, CCFP (EM) 1 , 3 , 5 , , BSc 5 , Network Of Canadian Emergency Researchers 24
      JMIR Research Protocols
      JMIR Publications
      implementation science, knowledge translation, context adaptation, interrupted time series, care transitions, elderly, older persons, health care utilization, frailty, learning health systems, Wiki, collaborative writing applications

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          Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a “Wiki-suite” (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders.


          The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools.


          Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools.


          Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit.


          This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada.

          Trial Registration

          ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245.

          International Registered Report Identifier (IRRID)


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          Most cited references67

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          Post-hospital syndrome--an acquired, transient condition of generalized risk.

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            Recovery of activities of daily living in older adults after hospitalization for acute medical illness.

            To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. Observational. Tertiary care hospital, community teaching hospital. Older (aged >or=70) patients nonelectively admitted to general medical services (1993-1998). Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.
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              Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies.

              In an interrupted time series (ITS) design, data are collected at multiple instances over time before and after an intervention to detect whether the intervention has an effect significantly greater than the underlying secular trend. We critically reviewed the methodological quality of ITS designs using studies included in two systematic reviews (a review of mass media interventions and a review of guideline dissemination and implementation strategies). Quality criteria were developed, and data were abstracted from each study. If the primary study analyzed the ITS design inappropriately, we reanalyzed the results by using time series regression. Twenty mass media studies and thirty-eight guideline studies were included. A total of 66% of ITS studies did not rule out the threat that another event could have occurred at the point of intervention. Thirty-three studies were reanalyzed, of which eight had significant preintervention trends. All of the studies were considered "effective" in the original report, but approximately half of the reanalyzed studies showed no statistically significant differences. We demonstrated that ITS designs are often analyzed inappropriately, underpowered, and poorly reported in implementation research. We have illustrated a framework for appraising ITS designs, and more widespread adoption of this framework would strengthen reviews that use ITS designs.

                Author and article information

                JMIR Res Protoc
                JMIR Res Protoc
                JMIR Research Protocols
                JMIR Publications (Toronto, Canada )
                August 2020
                5 August 2020
                : 9
                : 8
                : e17363
                [1 ] Department of Family and Emergency Medicine Université Laval Québec, QC Canada
                [2 ] Centre intégré de santé et de services sociaux de Chaudière-Appalaches Ste-Marie, QC Canada
                [3 ] VITAM - Centre de recherche en santé durable Québec, QC Canada
                [4 ] Department of Anesthesiology and Critical Care Medicine Division of Critical Care Medicine Université Laval Québec, QC Canada
                [5 ] Centre de recherche intégrée pour un système apprenant en santé et services sociaux Centre intégré de santé et de services sociaux de Chaudière-Appalaches Lévis, QC Canada
                [6 ] Department of Medicine Sinai Health System Toronto, ON Canada
                [7 ] Department of Medicine University Health Network Toronto, QC Canada
                [8 ] Department of Medicine University of Toronto Toronto, QC Canada
                [9 ] Department of Medicine Faculty of Medicine Université Laval Québec, QC Canada
                [10 ] Department of Social Work University of Sherbrooke Sherbrooke, QC Canada
                [11 ] Institut national d'excellence en sante et en services sociaux Québec, QC Canada
                [12 ] Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN) Québec, QC Canada
                [13 ] Canada Research Chair in Shared Decision Making and Knowledge Translation Université Laval Québec, QC Canada
                [14 ] Département de gestion, d’évaluation et de politique de santé École de santé publique Université de Montréal Montreal, QC Canada
                [15 ] Schwartz-Reisman Emergency Medicine Institute Mount Sinai Hospital Toronto, ON Canada
                [16 ] Department of Family and Community Medicine University of Toronto Toronto, ON Canada
                [17 ] Faculty of Medicine Université Laval Québec, QC Canada
                [18 ] Faculty of Nursing Université Laval Québec, QC Canada
                [19 ] Office of Education and Professional Development Faculty of Medicine Université Laval Québec, QC Canada
                [20 ] CHU de Québec-Université Laval Québec, QC Canada
                [21 ] Centre intégré universitaire de santé et de services sociaux de l'Estrie - CHUS Sherbrooke, QC Canada
                [22 ] Centre d'excellence sur le vieillissement du Québec Hôpital du Saint-Sacrement Québec, QC Canada
                [23 ] Département de réadaptation Faculté de médecine Université Laval Québec, QC Canada
                [24 ] Network of Canadian Emergency Researchers Ottawa, ON Canada
                Author notes
                Corresponding Author: Patrick Michel Archambault patrick.archambault@ 123456fmed.ulaval.ca
                Author information
                ©Patrick Michel Archambault, Josée Rivard, Pascal Y Smith, Samir Sinha, Michèle Morin, Annie LeBlanc, Yves Couturier, Isabelle Pelletier, El Kebir Ghandour, France Légaré, Jean-Louis Denis, Don Melady, Daniel Paré, Josée Chouinard, Chantal Kroon, Maxime Huot-Lavoie, Laetitia Bert, Holly O Witteman, Audrey-Anne Brousseau, Clémence Dallaire, Marie-Josée Sirois, Marcel Émond, Richard Fleet, Sam Chandavong, Network Of Canadian Emergency Researchers. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 05.08.2020.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.

                : 11 December 2019
                : 15 January 2020
                : 17 March 2020

                implementation science,knowledge translation,context adaptation,interrupted time series,care transitions,elderly,older persons,health care utilization,frailty,learning health systems,wiki,collaborative writing applications


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