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The Evidence Speaks (July 2017)

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We’re proud to introduce our Evidence Speaks series, 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.

Henrich NJ, Dodek PM, Gladstone E, Alden L, Keenan SP, Reynolds S, Rodney P. Consequences of moral distress in the intensive care unit: A qualitative study. Am J Crit Care. 2017 Jul;26(4):e48-57.

Moral distress in the intensive care unit (ICU) is the negative emotion experienced by health care providers resulting from dissonance between the care they think should be provided and the care that is actually delivered. CHÉOS Scientist Dr. Peter Dodek, along with former CHÉOS Scientist Natalie Henrich and others, qualitatively evaluated the impact of moral distress in ICU professionals. Clinical staff in the three ICUs in Vancouver first completed a survey and then participated in focus groups, organized by profession. In total, 56 professionals participated, including nurses, physicians, physiotherapists, social workers, and others. After transcription and coding of the audio recordings from the focus groups, the research team identified themes and subthemes. A feeling of frustration was the most common result of experiencing moral distress. Some study participants felt that moral distress reduces the quality of care by distracting care providers while others felt that an increase in vigilance resulting from moral distress increased the quality of care. Nurses and other health professionals coped by seeking support from their colleagues while physicians used coping mechanisms external to the workplace, like exercise. Based on the results of the focus groups, the researchers suggested that team discussions following distressing situations could help providers cope. They also suggested that burnout could be avoided by giving health care professionals a short break from the ICU, either by performing nonclinical duties or working outside the ICU.

Trenaman L, Stacey D, Bryan S, Taljaard M, Hawker G, Dervin G, Tugwell P, Bansback N. Patient decision aids for patients considering total joint replacement: A cost-effectiveness analysis alongside a randomised controlled trial. Osteoarthritis Cartilage. 2017 Jun 15 epub ahead of print.

Total joint replacement in those with end-state hip and knee osteoarthritis is effective, economical, and is performed roughly 100,000 times per year in Canada. However, benefit is not seen in all patients and there are inherent risks related to surgery; it can be difficult for patients to be fully informed about treatment options during their brief contact with a surgeon. Interventions to encourage shared decision making (SDM), which can improve the communication of patient values and preferences in these situations, can be costly but may also lower future costs by modifying treatment decisions and resource utilization. CHÉOS’ Dr. Nick Bansback and PhD trainee Logan Trenaman used data from a previous Canadian study to identify patient outcomes and estimate the cost effectiveness of a decision aid for total joint replacement over a 2-year time period. By calculating costs, resource utilization, and quality of life information, the research team showed that the patient decision aid, along with a surgeon preference report, is cost effective without impacting health outcomes. Cost savings were $560 per patient, driven by a decrease in the number of surgeries. This, however, did not impact quality of life, which was increased, relative to baseline, in both those who delayed surgery and those who underwent surgery. Although the researchers suggested that a longer-term follow up analysis is necessary, decision aids to improve SDM could be a valuable addition to the health care system in this context.

Urbanoski K, Veldhuizen S, Krausz M, Schütz C, Somers JM, Kirst M, Fleury MJ, Stergiopoulos V, Patterson M, Strehlau V, Goering P. Effects of comorbid substance use disorders on outcomes in a Housing First intervention for homeless people with mental illness. Addiction. 2017 Jul 1 epub ahead of print.

The At Home/Chez Soi (AHCS) study, funded by the Mental Health Commission of Canada and taking place in Vancouver, Winnipeg, Toronto, Montreal, and Moncton, examined the effectiveness of a Housing First approach, combined with appropriate health care and supports, as a way to combat homelessness. Housing First, a strategy that provides individuals with stable housing and supports with no housing readiness conditions, has been questioned when it comes to people with active substance-related disorders. Because abstinence or treatment is not mandatory to receive housing, some have suggested that it may enable continued substance use and harm. In response to these potential shortcomings, the AHCS team, led by Principal Investigators Drs. Michael Krausz and Christian Schütz, with co-investigator Dr. Verena Strehlau, assessed the impact of substance use disorder (SUD) on the effectiveness of the housing first strategy. The researchers found that, although people with SUD in both the housing first and usual treatment groups spent less time in stable housing, SUD status did not impact the effectiveness of the housing first approach. The housing first strategy was as effective in improving community functioning, quality of life, health-related quality of life, and mental health symptoms in those with and without SUD, compared to people who did not receive housing first care. This secondary analysis shows that abstinence or treatment for SUD is not necessary prior to provision of housing in homeless Canadians with mental illness.

Health research in the heart of Vancouver