“PSI funding was important to our study, and it allowed us to achieve our goals. We could work with vendors to create the interventions and hire a research assistant to do data collection, which made the study more robust.” – Dr. Jennifer Tsang

Dr. Jennifer Tsang, an intensivist at Niagara Health, would like to see more community hospitals in Ontario increase their research capacity, and as a researcher herself, she understands the importance of dedicated funding allocated to community research.

She says that programs like PSI’s Healthcare Research by Community Physicians Grant are essential. “It’s challenging for community hospitals to apply for funding and compete against an academic centre. The academic hospital and staff often have better track records of research that give them an advantage,” she says. “Having separate community health research grants really helps individuals like myself who are leading research in a community setting.”

Dr. Tsang received a Healthcare Research by Community Physicians Grant from PSI Foundation to develop interventions to improve adherence to pain, agitation and delirium (PAD) guidelines, specifically the frequency of assessing patients for PAD, in the intensive care unit at Niagara Health.

PAD clinical guidelines recommend screening for pain and agitation four times per 12-hour shift, and once per 12-hour shift for delirium. But Dr. Tsang saw that community centres are often behind in adopting guidelines.

She and her team developed an e-learning module targeting nurses and laminated reminder tools placed at each bedside, and they reminded physicians to talk about PAD during multi-disciplinary rounds with a note left on the computer on wheels. They also developed interventions targeting family members: a team of volunteers interviewed family members about the patient to develop a personalized approach to managing PAD, and pamphlets and a video provided information about delirium for family members. Finally, they displayed posters in the ICU about delirium, its importance and the team approach to managing it.

Together, the interventions increased the number of patients who were screened according to the guidelines for pain and agitation, though the delirium assessment did not change. The study did not examine why delirium assessments did not change, but it could be due to the greater time required for delirium screening or the belief that screening will not change how the condition is managed.

“Sometimes we try complicated interventions, but sometimes simple things like these reminders have the biggest impact,” she says. “Also, in my community hospital, I don’t have the resources of an academic hospital. We had to be very practical.”

Dr. Tsang notes that while there may be challenges in adopting guidelines at a community hospital, the study shows that it is possible using practical, low-cost interventions. Involving frontline staff in the design of the interventions and as “local champions” to encourage and support staff during implementation, as well as approaching the interventions through the lens of quality improvement, all seemed to be important in increasing adherence to PAD guidelines in a community setting.

Dr. Tsang says that her grant is just one example of important, relevant research done in a community setting, and she would encourage more centres to pursue projects relevant to their community.

“Most community centres have primarily focused on delivery of clinical services rather than conduct of research programs or projects, but I think this is starting to change,” she says. “We need more community hospitals embarking on research, and PSI funding is critical for making that happen.”

“PSI has a good reputation of supporting studies that have impact on daily practice. It supports practicing physicians’ research that will have immediate impact on the practice of their colleagues.” – Dr. Marcel Ruzicka

New automated blood pressure monitors have significant advantages over older monitors. One such advantage is the ability to take blood pressure measurements without medical personnel in the room, eliminating the possibility of “white coat phenomenon,” which is thought to result in higher readings when medical personnel are present. New PSI-funded research suggests that different ways of taking automated measurements may need interpretation if they are to be used to accurately diagnose and manage hypertension.

“The circumstance under which blood pressure measurement is taken, more so than the technique, is crucial for estimating blood pressure,” says Dr. Marcel Ruzicka, a nephrologist specializing in kidney-related hypertension at The Ottawa Hospital Research Institute. The differences in measurements among techniques can be large enough that they may affect a physician’s decision about whether a patient needs to be treated for hypertension.

“It’s not a question of which method is best,” says Dr. Ruzicka. “Our study provides evidence that different blood pressure targets might be appropriate if you use a different measurement method from the technique used for the published blood pressure target.”

With a PSI Foundation Clinical Research Grant, Dr. Ruzicka and his team compared different ways of measuring blood pressure to look for differences in the measurements. A total of 78 patients completed the study, during which their blood pressure was measured on two consecutive days using different methods: using automated devices both attended and unattended by a nurse, and using an ambulatory blood pressure measurement device that took measurements every 20-30 minutes over a 24-hour period.

Their results suggest that resting blood pressure readings were not significantly different whether the measurement was fully or partially attended, or even unattended. Most importantly, they found that resting blood pressure – regardless of whether medical personnel were in the room or not – was significantly lower compared to the 24-hour average, suggesting that the ambulatory measurement may be crucial for hypertension diagnosis and management.

“The ambulatory measurement includes everything in your life, and for most people, there aren’t many times when you sit alone and quiet, as you do with resting blood pressure,” says Dr. Ruzicka. “In a way, this result is not surprising.”

The study is not meant to discourage practices from using any particular technique. Instead, Dr. Ruzicka says that it’s more important to understand that the techniques yield different results, and physicians need to understand these differences when diagnosing hypertension.

“This information is crucial for family physicians and specialists in order to provide them with a guide of how to interpret these measurements,” he says. “We hope that eventually these results will be reflected in the guidelines [for diagnosis and management of hypertension].”

“Because PSI is geared toward physicians, there’s almost an unwritten understanding of why you’re doing the research and that it’s for the end goal of treating our patients better. We don’t have to prove that our research has clinical relevance.” – Dr. Kim Wong

Total knee replacement is a common procedure done in many hospitals, and it is known to be associated with a significant amount of post-operative pain. Many interventions exist to address this pain, but since a myriad of techniques can be used, choosing the optimal technique can be a source of much discussion in the operating room. Local practices vary based on the location and time of team members’ training, and orthopedic and anesthesia teams may have different views of the best approach to use.

“Everyone seems to have differing opinions about which analgesic intervention to use perioperatively,” says Dr. Kim Wong, an anesthesiologist at Health Sciences North in Sudbury. “But at the end of the day, everyone wants the patient to go home with as little pain as possible and as soon as possible.”

Evidence on the subject has been definitively inconclusive so far, with mostly small, comparative single intervention studies. Dr. Wong saw the need for a larger interdisciplinary study that compared different combinations of interventions used in real world practice on patient outcomes, with the goal of providing clarity on the best approach to use.

She received a grant from PSI Foundation to lead a five-arm randomized blinded trial that involved both the orthopedic and anesthesia departments at Health Sciences North. They compared different combinations of three pain management interventions used before and during total knee replacement surgery: intrathecal morphine, femoral nerve block (a regional anesthetic injected into the upper thigh) and periarticular infiltration (local anesthetic and anti-inflammatory injected around the knee joint). They evaluated whether intrathecal morphine alone, different pairs of the interventions or a combination of all three affected time for patients to reach discharge criteria, their pain scores and their narcotics needs after surgery to control pain.

The study team found that all of the arms of the study met discharge criteria, with patients being discharged by the afternoon of the second day. But further analysis showed that any combination of two interventions had better pain outcomes than intrathecal morphine alone, though the combination without intrathecal morphine resulted in less itchiness. Surprisingly, the combination of three interventions did not result in significantly better outcomes.

“I hope the study gives surgeons and anesthesiologists comfort that they can choose the interventions that they do best, as long as they provide two,” says Dr. Wong. “In my own clinical practice, I can tailor my approach to accommodate a patient’s individual medical history with the comfort of knowing that I’m not placing them at a disadvantage of getting out of the hospital faster or with less pain.”

Dr. Wong says that it was ambitious to lead a five-arm trial with enough statistical power to be clinically relevant, and the study team did have challenges with recruitment. As a result, PSI Foundation funding was essential to the study’s success. “It allowed us to address the challenges without having to worry about stopping the study or not having a powered study that would lend less credibility to the results,” she says. “The funding allowed the financial buffer to reflect the realities of clinical research.”

Research from a PSI Foundation–funded team has led to the development of a first-of-its-kind assessment of seniors’ biomedical and social vulnerability. The Frailty and Vulnerability Evaluation (FAVE) tool, developed by Dr. Ross Upshur and his team at Bridgepoint Active Healthcare and the Department of Family and Community Medicine in Toronto with funding from PSI Foundation, is a step towards higher quality care for seniors.

Dr. Upshur’s career has largely been focused on senior care, starting with electives as an undergraduate in medical school, followed by several years as a primary care physician in a rural area with a large senior population. In recent years of his research career, he and his team have been interested in developing tools to help physicians in family practice manage the complex health care needs of seniors.

They identified that while certain aspects of seniors’ health were becoming better understood, there was still a significant gap – social isolation. “There’s growing interest and recognition from the health system around frailty,” says Dr. Upshur. “Frailty is important, but not the whole story.” Yet, no clinical tools in primary care looked at both frailty and social vulnerability, so he and his team, with input from an expert advisory committee, developed one.

The new tool, FAVE, asks seniors about their health and functional abilities, but importantly, also asks about their social wellbeing, including their loneliness, living arrangements, feeling of safety and economic insecurity. “People are now talking about loneliness and isolation as an issue,” says Dr. Upshur. “A primary care physician might notice that a patient might have issues with loneliness and vulnerability, but collecting this information has not been systematic.”

With funding from PSI Foundation, the team validated FAVE and compared the performance to existing measures, such as the frailty score and physician judgment, to determine if it is a reliable predictor of an individual’s health and wellbeing.

More than 260 patients from 10 Family Health Teams from urban, suburban and rural practices completed the tool. Seniors completed the FAVE assessment on paper or electronically prior to an appointment with their family physician. The team also asked the family physician for an assessment of the individual’s frailty and wellbeing, blinded from the patient’s score on the tool.

They found that patients thought the survey was user friendly, and importantly, that FAVE scores correlated well with seniors’ self-reported health, as well as physician assessments and frailty scores.

To understand whether FAVE is a good predictor of an individual’s future health, the team is now looking at patients’ charts one year after they complete the tool, particularly to examine the patient’s total number of health care transitions (such as being admitted to the emergency department, long-term care or a return home), and the total number of days spent at home. The analysis is currently underway but will help determine whether FAVE, physician judgment, the frailty score, or a combination is the best predictor of a patient’s future health care transitions.

Dr. Upshur notes that PSI Foundation plays an important role in this type of research. “It can be difficult to get funding for small-scale projects that engage local partners, but PSI Foundation is a strong supporter of this type of research,” says Dr. Upshur. “They focus on research that is meaningful to clinical practice.”

As Ontario includes an already large and growing population of seniors, Dr. Upshur hopes that FAVE will help primary care physicians care for both the health and social needs of seniors. “The tool is just one component of a systematic approach for seniors in the community by primary care physicians,” he says. “It’s an important step towards more comprehensive, appropriate, compassionate and high quality care for seniors.”

A potentially practice-changing study led by a PSI Foundation-funded surgical resident has challenged long-held beliefs about care for small bowel obstructions (SBOs).

SBO, a blockage in the intestine often cause by scar tissue (or “adhesions”) from previous surgery, is a common condition, representing about 20% of all hospital admissions for abdominal pain. A small number of patients whose conditions don’t resolve with usual treatment receive surgery, but most patients, about 80%, recover from SBO through treatment with bowel rest, IV fluids and gastric decompression. These patients are considered to be successfully treated and released from hospital, yet many of them will return – sometimes as often as every few months – with a recurrence.

Dr. Ramy Behman, a surgical resident with the University of Toronto, wanted to study the long-term natural history of SBO and potentially improve treatment. “We’ve been treating SBO the same way for a long time. Some people bounce back from an SBO, but then they’re dealing with it every few months,” says Dr. Behman. “SBOs aren’t very well studied, so a better understanding of the natural history could be helpful to improve treatment.”

Dr. Behman applied for and received PSI Foundation funding, which he says was crucial to the research, especially so early in his career. “I don’t know how we would have done the study without the funding,” he says. “And having people outside of your research committee think that the research is worthwhile is very encouraging when you’re just starting off.”

With a Resident Research Grant, Dr. Behman looked at 10 years of health administrative data, identifying nearly 40,000 patients in Ontario admitted to hospital for their first SBO during that time period. They then followed how the patients were treated on that occasion and any following recurrences and tracked the outcomes. The large dataset allowed them to examine the different ways that SBOs are managed and how outcomes are affected.

“We were one of the first groups to really step back and look at the long-term disease course,” he says. “And what we found was challenging to the dogma.”

Physicians have long believed that surgery for SBO would increase the risk of recurrence by creating new adhesions and usually don’t recommended surgery for SBO unless other treatments are unsuccessful. But Dr. Behman’s research suggested that this actually isn’t the case – in fact, surgery could reduce the risk of recurrence. According to their results, patients with SBO treated with surgery – whether on the first or subsequent occurrences – cut the risk of recurrence by about half.

“Operating can take patients off the recurrence cycle. It can really change the trajectory of disease for patients,” says Dr. Behman.

Surgery does have its own risks, namely the risk of complications that could potentially have been avoided, as well as a greater upfront cost than standard treatment. Dr. Behman and his team are analyzing the cost-utility to examine whether the greater upfront costs are offset by fewer hospital readmissions due to recurrences, and he is hoping to publish the results soon.

He notes that the study may influence guidelines for SBO management and help physicians make informed decisions about how the condition can be managed.

“This isn’t a uniform prescription for every patient with SBO, but it adds to our understanding of the disease and facilitates informed decision making,” he says. “The optimal practice will be the right intervention for the right patient.”