McMaster University

McMaster University

  • 2015 Program
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Symposium Program 2015

Symposium Program 2015


Time Description Location
12:00 Check-In, Poster Setup and Lunch

Lecture Theatre (2018), Second Floor

Poster set-up on the 3rd Floor

12:30 Welcome, Introduction and Overview Lecture Theatre (2018), Second Floor
12:45 Plenary Session Keynote Address Lecture Theatre (2018), Second Floor
1:30 Concurrent Breakout Session; Oral Presentations Lecture Theatre (2018), Second Floor
1:30 Concurrent Breakout Session; Family Medicine Resident QA Presentations PHR 1008 (Pharmacy building)
2:30 Poster Viewing & Coffee Break Great Room, Third Floor
3:30 Concurrent Breakout Session; Oral Presentations Lecture Theatre (2018), Second Floor
3:30 Concurrent Breakout Session; Family Medicine Resident QA Presentations PHR 1008 (Pharmacy building)
4:30 Social Break Great Room, Second Floor
4:45 Closing Ceremony and Presentation of Awards Lecture Theatre (2018), Second Floor
5:00 Symposium Adjourned


Awards will be given for top ranked oral and poster presentations.

Keynote Presentation

Schlegel Centre of Excellence for Innovation in Aging

Josie d’Avernas, MSc.Josie d'Avernas

In September of 2015, the Schlegel Centre of Excellence for Innovation in Aging will open its doors. Josie will describe the many unique features of this innovation centre which is designed to enhance care and living for older adults through co-location of research, training and practice. This centre, located on the University of Waterloo north-west campus, is specifically designed to encourage co-mingling of seniors, students, educators and researchers. It will be home to 192 long-term care residents as well as to University of Waterloo and Conestoga College programs for learning and applied research related to seniors care and living. Future phases are planned to expand to retirement and independent living for seniors, as well as expansion of learning and research spaces.

Josie is Vice President of the Schlegel-University of Waterloo Research Institute for Aging (RIA).  The RIA partners with the University of Waterloo, Conestoga College and 14 continuum of care Schlegel Villages to promote research generation, research transfer to practice, and improved gerontology content in college and university courses.  She is also actively involved in the Schlegel Centre for Learning, Research and Innovation in Long-Term Care. 

Josie has a Master’s degree in Health Studies and Gerontology from the University of Waterloo. 

Abstract Listing


Session 1: 1:30 – 2:30pm

O-1: A Comparison of the Greater Trochanter and Piriformis Fossa Entry Points for Antegrade Nailing of Femoral Shaft Fractures: A Systematic Review & Quantitative Synthesis

Sheth, Ujash; Gohal, Chetan*; Chahal, Jaskarndip; Dwyer, Tim

*Michael G. DeGroote School of Medicine Waterloo Regional Campus

Objectives: The optimal entry point for antegrade intramedullary nailing of femoral shaft fractures remains controversial. The purpose of this systematic review and quantitative synthesis was to determine if there is a difference in operative parameters, healing and functional outcome when comparing the greater trochanter (GT) and piriformis fossa (PF) entry points.

Methods: A systematic literature search was conducted using multiple databases from inception to October 2014. All randomized trials, prospective and retrospective cohort studies comparing GT and PF entry points for antegrade nailing of femoral shaft fractures in adults were included. Study quality was assessed independently by two reviewers.

Results: Four studies (570 patients) met the inclusion criteria. A quantitative synthesis using a random-effects model found that the GT entry point was associated with significantly shorter operative (mean difference [MD], – 20.05 [95% confidence interval (CI), – 23.09 to –17.02]; P < 0.00001) and fluoroscopy times (MD, – 24.55 [95% CI, – 43.23 to –5.86]; P = 0.01). There was no significant difference in nonunion (risk ratio [RR], 0.74 [95% CI, 0.35 to 1.58]; P = 0.44) and delayed union rates (RR, 0.94 [95% CI, 0.41 to 2.14]; P = 0.88) between the two entry points. Heterogeneity in outcome measures used prevented pooled analysis of functional outcomes.

Conclusions: This review supports the use of the GT entry during antegrade nailing of femoral shaft fractures over the PF entry. Further study is required to determine the effect of each entry point on the surrounding soft tissue structures and ultimately its impact on postoperative function.

O-2: Formative Evaluation of the Canadian Mental Health Association- Waterloo, Wellington, Dufferin Geriatric Addictions Project

Rios, Sebastian*

University of Waterloo- School of Public Health and Health Systems

Objective: The Geriatric Addictions Project supports the planning, development, and implementation of an integrated and inter-professional approach to geriatric addictions and mental health in the Waterloo Wellington Local Health Integrated Network (WWLHIN). The aim of this presentation is to discuss the results of a recent formative evaluation of this project.

Methods: The evaluation was designed with the purpose of assessing how project planning and implementation is proceeding, identify if there are any problems, and gather feedback from the target population. As such, a logic model and an evaluation matrix were developed to help design and guide this evaluation, and illustrate the relationships between inputs, activities, outputs and outcomes for the project. Additionally, an online questionnaire distributed to service providers in the region was employed to gather feedback on the education, training and consultations provided by this initiative. While interviews and a focus group were utilized to gather the perspective of older adults with mental health and addictions issues.

Conclusion: The results indicate that the project is meeting the intended initial outcomes in the areas of increasing exposure, capacity, and awareness of geriatric addictions. The client perspective piece identifies attractive features of the project, as well as needs and barriers for the target population.

O-3: At the intersection of CHESS and MAPLe: Changing the course for high-risk home care clients?

Sinn, C. J.*, Hogeveen, S.*, Chang, B. W., Turcotte, L., Betini, R. S. D., Hirdes, J. H.

*University of Waterloo- School of Public Health and Health Systems

In Ontario, home care agencies complete the Resident Assessment Instrument–Home Care (RAI-HC) for clients on admission and every six months thereafter. The RAI-HC outputs many useful scales and algorithms to guide care planning—including the Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) scale and Method for Assigning Priority Levels (MAPLe) algorithm. CHESS is a measure of health instability and has been shown to predict death in community and institutional care. MAPLe predicts long-term care placement and caregiver distress. These two outputs identify clients at risk for different adverse events.

The purpose of this study is to identify a subset of home care clients at high risk for death or long-term care placement at one year and whose trajectory may be changed by clinical intervention. We defined a target group of clients with high CHESS and high MAPLe, accounting for 8.8% of the population. Using a series of survival analyses, we found that clients in the target group experience death or long-term care placement 2.6 times faster than the general home care population.

The RAI-HC also outputs Clinical Assessment Protocols (CAPs) that flag key clinical areas where there is potential for improvement or prevention of a decline. Clients in the target group are more likely to trigger the following CAPs: activities of daily living, cardiorespiratory conditions, communication, and appropriate medication, among others. By identifying a subset of high-risk clients and addressing modifiable areas of risk, home care agencies may potentially reduce rates of adverse events.

O-4: Quality assurance at Grand River Regional Cancer Centre: Investigating the risks and benefits of the adoption of dose-escalated radiotherapy for prostate cancer 

Stephens, Robert*; Xu, Samuel; Costa, Andrew; Hill, Brianne; Gopaul, Darindra

Grand River Regional Cancer Centre

Purpose: To evaluate the freedom from biochemical failure (FFF) and acute toxicity for patients with prostate cancer treated with curative intent radiotherapy (RT) at Grand River Regional Cancer Centre (GRRCC) from 2007 to 2012 inclusive.

Methods and Materials: A retrospective review of electronic patient charts at GRRCC was conducted, and 246 prostate cancer patients were included. The median follow-up was 24 months (2007-2012). Contingency tables, logistic regression, and actuarial analysis were used to compare the incidence of biochemical failure (BF = prostate specific antigen [PSA] of nadir + 2 ng/ml) and the incidence of combined gastrointestinal (GI) and genitourinary (GU) acute toxicity symptoms ≥ Radiation Therapy Oncology Group (RTOG) grade 2 in low-dose (<78 Gy) and high-dose (78 Gy) groups.

Results: Contingency tables showed no significant association between dose group and acute toxicity symptoms ≥ RTOG grade 2, but there was a significant association between dose and BF (P = 0.03), with 11.5% in the <78 Gy group and 4.2% of patients in the 78 Gy group experiencing BF. Logistic regression supported these conclusions: the patients in the <78 Gy group had 5.8 greater odds of experiencing BF compared to the 78 Gy group (P = 0.04). Actuarial analysis for the rate of BF revealed a non-significant difference between the <78 Gy and 78 Gy groups.

Conclusion: Analysis of biochemical failure rates and rates of toxicity suggests a moderate improvement in biochemical failure corresponding to dose escalation, without any increase in the incidence of acute GU or GI toxicity.

KW & Area Family Medicine Resident Quality Assurance Project Presentations: 1:30 – 2:30pm

O-1: Screening for Post Partum Depression in Primary Care

Drs. Lindsey Sutherland and Claire Harlick

Description of Project: To assess documentation of screening for post partum depression (PPD) in the primary care setting.

Background: PPD is the onset of depressive symptoms, unipolar major depressive disorder, or mood disorder in the postpartum period1. The incidence is approximately 20% in the first three months postpartum and 10.4% within the first 49 weeks postpartum, indicating a higher risk earlier in the postpartum period2,3. PPD can result in poor mother-infant bonding, marital distress, family conflict, loss of income, and in extreme cases, harm to self or infant1,4. Primary care offers an excellent opportunity to screen women during the postpartum period for depression during prenatal, postpartum, and well baby visits.

Methods: A chart review of postpartum women was conducted at the Centre for Family Medicine (CFFM) in Kitchener, Ontario. Charts were reviewed for the one year postpartum period to assess for documentation of screening and diagnosis of PPD.

Results: 136 charts were reviewed, 14 (10.3%) patients were diagnosed with a mental illness during the one-year postpartum, of which 4 (2.9%) were diagnosed with PPD. None were diagnosed using a screening tool. Other diagnoses included: ‘postpartum anxiety’, ‘some symptoms of PPD’ or ‘anxiety.’ Of the 4 with PPD, diagnosis was by their family physician (2), PGY1 family medicine resident (1), and a clinical clerk (1).

Conclusion: The rate of PPD documented in postpartum CFFM patients was lower than the national average with 2.9% versus an expected 16%. A standardized screening and documentation method could ensure adequate screening of women for PPD.

O-2:Prescribing Patterns and Resistance Rates for UTI within a Kitchener Family Health Team

Drs. Urooj Chaudry, Stephanie Spadotto, Alex Mee and Meredith Pope

Background: Urinary tract infections (UTIs) account for a high volume of family practice visits and frequently result in antibiotic therapy. Significant variations in physician practice with regards to the role of empiric treatment, and antibiotic selection was frequently observed by co-investigators during training. We designed this study to investigate whether the practices at our study centre are in keeping with guidelines, and furthermore, to deduce our local resistance patterns to better direct our choice of antibiotic prescribed.

Methods: Electronic medical record search parameters included patient encounters as follows: i) female patients ii) over the age of 5 years iii) that presented for a concern regarding a “UTI “ iv) with a “culture report” available v) between January 1st, 2014 and September 15th, 2014 at the Kitchener based study centre. Following application of appropriate exclusions, relevant data from remaining charts was collected.

Results: Of the 303 patient encounters included in our study, 156 (51.5%) patients were treated appropriately (either prescribed a ‘sensitive’ antibiotic to a culture proven UTI or refrained from treating a culture negative UTI). Resistance rates to TMP-SMX at our study centre were 18.8%. Nitrofurantoin, the most commonly prescribed empiric therapy (66%), also had the highest culture sensitivity at 92.7%.

Conclusion: Over half (54.5%) of patients presenting with symptoms consistent with acute uncomplicated cystitis will have culture-proven diagnosis. Of these cultures, 49.1% will have resistance to one or more class of antibiotic. Our site-based resistance rates support the first line use of nitrofurantoin and TMP-SMX, as per guideline recommendations.

O-3: Screening for osteoporosis in Males over 65: How well are we doing?

Drs. Carla Loureiro and Jamie McMurrich

Background: Osteoporosis is a disease characterized by low bone mass and increased fracture risk. Osteoporotic-related fractures are a significant source of morbidity and mortality. Specifically, post-fracture mortality and institutionalization rates are higher in men than women. Despite this, osteoporosis in men remains underdiagnosed and inadequately treated. Given the impact of fractures in males, screening is central to osteoporosis diagnosis and its treatment. The purpose of this study was to determine the bone mineral densitometry (BMD) screening rates in men older than 65 years of age as recommended by the 2010 Clinical Practice Guidelines.

Methods: A chart review was conducted from February to March 2015 on 4 family practices to assess BMD screening rates among males over 65 years of age. Secondary outcomes included whether screening was up-to-date and whether patients were managed appropriately according to their calculated fracture risk.

Results: Among 193 men eligible for screening, 73 (37.8%) were offered or underwent screening. Only 43 (22.3%) were considered up-to-date with regards to screening as per the most recent guidelines. Among those who were screened, only 33 (45.2%) patients had documented evidence of calcium and/or vitamin D supplementation. Pharmacologic treatment was appropriately initiated in all 18 patients considered high risk for fracture.

Conclusions: Low BMD screening rates among primary care physicians may be central to the under diagnosis and inadequate treatment of osteoporosis in men. Interventions aimed at improving screening rates may improve osteoporosis diagnosis and prevention of fractures in males.

O-4: Residency Education on Over-the-counter Medications

Drs. Lucas Spicer and Ellyas Omar

Background: Over-the-counter (OTC) medications are frequently recommended and yet residents receive minimal formal training regarding these medications. The purpose of this quality assurance project is to assess family medicine residents' comfort level or prior learning experience with OTC medications and offer recommendations on improving the family medicine curriculum.

Methods: We invited all residents from the Kitchener-Waterloo Family Medicine Residency Program to attend a three-hour educational session at a local pharmacy where the most commonly prescribed or recommended OTC medications were reviewed by a local family physician. We presented residents with a pre-intervention questionnaire to complete prior to the session and a post-intervention questionnaire after the session.

Results: The pre-intervention questionnaire was completed by 31 residents. Of these, 84% noted that they never received any formal training on OTC medications in medical school or residency. The effectiveness of the educational session was assessed by two knowledge-based questions in the questionnaire. Prior to the educational session, only 16% of residents got question one correct and 35% got question two correct; during post-intervention, 90% of residents answered both questions correctly. All residents rated the session as very helpful and they expressed their interest to have this type of educational session incorporated into their academic days at least once per year.

Conclusions: Conducting a half-day educational session on OTC medications in a pharmacy is a worthwhile and rewarding experience for family medicine residents. Similar educational intervention should be integrated into our family medicine curriculum.

Session 2: 3:30-4:30pm

O-5: Towards Consensus on Quality Assurance Indicators for Primary Care Memory Clinics

Heckman G*, Boscart VM, Hillier LM, Lee L, Molnar F, Seitz D, Stolee P

Schlegel-UW Research Institute for Aging / University of Waterloo- School of Public Health and Health Systems

Objective: Primary care memory clinics (PCMCs) are being established to provide system capacity for dementia care. There is a need for routine integration of standardized quality indicators (QI) into PCMC care processes to ensure high quality care. The purpose of this project was to develop consensus on the most relevant QIs for PCMCs.

Methods: A Delphi survey of PCMC clinicians and specialists was used to develop consensus on QIs for use in PCMCs. A list of QIs was identified through a systematic literature review. Survey participants were asked to rate the QIs according to importance and feasibility. Mean ratings determined relative rankings of importance. Two survey rounds were conducted involving 179 and 88 participants, respectively. QIs ranked below a pre-specified threshold or not easily measured were eliminated.

Results: Consensus was reached on 18 QIs. These included criteria for referrals to specialists; assessment, reassessment, and documentation requirements for diagnoses of mild cognitive impairment and dementia; criteria for diagnostic testing; medication reviews; discussing risks and benefits of cholinesterase inhibitors and of antipsychotics; stroke prophylaxis in the presence of vascular risk factors; assessment for safety risks; counselling on driving risks and fitness to drive assessment; and advanced care planning, including identification of substitute-decision makers.
Conclusions: A set of QIs for PCMCs has been identified. These indicators will form the basis of a quality assurance framework to enhance primary and collaborative care and that can be used in further studies to evaluate the quality of dementia care models in primary care.

O-6: Overwhelming Diagnosis: Preliminary Findings of a Scoping Review of Technologies for Supporting Mental Healthcare Decision Making

Perlman, Christopher*; Martin, Lynn; Bieling, Peter; Lee, Joon; Lee, Minho; Stapleton, Jackie

*University of Waterloo- School of Public Health and Health Systems

Objectives: Due to the complexity of mental health conditions and the incremental advances in the availability of data there is a need to link research on the use of technologies to mental healthcare practice. This study explores the scope of technologies that have been designed to assist with clinical decision making related to mental illness.

Methods: A scoping review captured the existent literature related to the use of technologies for mental healthcare decision making. A search for relevant studies was conducted using the following databases: MEDLINE, EMBASE, PsycINFO and Web of Knowledge including Science Citation Index, Social Sciences Citation Index, and Arts and Humanities Citation Index. The search was limited to English language materials published between January 1, 2000 and June, 2013.

Results: Of the 3,917 articles identified in the databases searched, 215 references were deemed relevant. Of those, 170 dealt with diagnostic and symptom screening decisions, 36 dealt with treatment monitoring, 6 dealt with guideline reminder support, and 3 dealt with shared-decision making. A number of target mental health conditions and care settings were identified, although the vast majority were indented for use with a select few conditions.

Conclusions: An array of technologies have been envisioned to support decision making related to mental healthcare. However, the primary focus of these technologies tends to be related to diagnostic and classification decisions related to a select few conditions. This leaves questions about the extent to which decision support technologies have been underutilized in the care of persons with mental health conditions.

Included in Judging:

O-7: Implementation of a Modified Surgical Safety Checklist in the Waterloo-Wellington Local Health Integrated Network (LHIN)

Chahal, Vick*

Grand River Hospital/St. Mary's General Hospital: Division of Plastic & Reconstructive Surgery

Since 2008, many hospitals have introduced a surgical safety checklist into the main operating room using the guidelines set forth by the World Health Organization (WHO). These surgical safety checklists have reduced perioperative complications and mortality. While being an important component to patient safety and quality improvement in our institutions, the current surgical safety checklist is not applicable to all surgical settings. A literature search reveals there is no such checklist for minor surgical procedures done under local anaesthesia in the minor out-patient procedure room. The purpose of this project was to develop a modified surgical safety checklist for the minor out-patient procedure (MOP) room. A new 11 item surgical safety checklist was created focusing on patient participation and discharge planning. The next step will be to implement the modified surgical safety checklist in a pilot program. Our anticipation is that the modified surgical safety checklist will improve patient and health care provider satisfaction, increase patient safety awareness, and improve surgical team communication and interaction.

KW & Area Family Medicine Resident Quality Assurance Project Presentations: 3:30-4:30pm

O-5: Beside Ultrasound for the Family Practice- Ready of Not?

Drs. John McCuaig, Jeff Jonusaitis and Mark Schwindt

Background:Point-of-Care-Ultrasound (POCUS) is well-established in several medical specialties. Within family medicine, however, POCUS remains in infancy. Our project adds to the early groundwork in family practice POCUS by gauging awareness and interest in it among local office-based practitioners.

Methods:An online survey was completed by willing physicians and residents– mostly around Kitchener-Waterloo, Hamilton, London, and Toronto. Responders self-rated their comfort level with POCUS, and their interest in potential utilities within the office.

Results:86 participants completed the survey – 36% practicing exclusively in-office. 60% had no experience with POCUS, with only 2 responders using in-office POCUS routinely. 95% did not have access to POCUS in the office, while 11% had sought out POCUS outside the office for diagnostic or therapeutic purposes. 78% identified POCUS as having potential use in their office. Modalities felt to be of the greatest potential use included 1st trimester obstetrical, abdominal aortic, and soft tissue scanning, as well as POCUS guided injections. Cost, plus lack of knowledge and resources were identified as the largest barriers to incorporating POCUS into the office.

Conclusion:Among family physicians and residents, there appears a substantial level of interest into pursuing POCUS as an office tool. However, certain barriers keep those interested from following through – while comfort and competency can be developed through feasibly created courses, current costs of POCUS devices and training itself remain principal obstacles.

O-6: Change in Average Pain Score versus Change in Interference Score in Patients Managed by a Primary Care Pain Team

Drs. Jason Zhu, Colin Yardley and Helen Davis-Herdman

Background: Chronic pain accounts for a large number of primary care patient visits. The brief pain inventory is an efficient tool for evaluating response to treatment. Anecdotally, it was observed in the Center for Family Medicine’s pain clinic that some patients would rate their pain scores consistently high throughout their management, while on patient interview overall function seemed to improve significantly. We sought to determine whether interference score would improve independent of average pain scores over time.

Methods: A retrospective chart review was performed on patients seen within a primary care pain clinic between February 2008 and Apr 12 2014. Patients over the age of 18 with any form of ongoing pain were included . Patients were excluded if they had only one BPI recorded, or if they only had one visit to the pain clinic.

Results: The average pain and interference scores were 6.6 and 5.1 at visit one compared to 5.8 and 5.4 respectively at visit two. Results of a student T-Test showed a significant difference in pain but not in the interference score from time one to time two

 Conclusion: BPI average pain scores show a significant difference between visit one and visit two while no such difference was found with interference scores.

O-7: Identifying Barriers to Biopsy for Suspicious Skin Lesions in Primary Care: A Resident Perspective

Drs. Mercedes Rodriguez, Sarah Leonard and Carla Geurtjens

Background: Skin cancer remains the most prevalent type of Cancer and it contributes to significant morbidity and mortality. In Canada, family doctors remain the gatekeepers for specialist referrals for treatment of cancers. Since biopsy proven lesions receive expedited referrals, we sought to determine the preparedness and intention of residents for performing skin biopsies in their future family practices.

Methods: Residents who attended academic half day at the Kitchener-Waterloo site were recruited to participate. Written surveys were completed before and after a resident-led educational session designed to address potential barriers to performing biopsies and provide strategies to overcome these barriers. Analysis was completed to assess overall population preparedness and assess our intervention’s effectiveness.

Results: Most residents (85.2%) feel the program has prepared them to perform skin biopsies and no graduating residents feel uncomfortable performing biopsies independently. Discomfort with cosmetically sensitive areas is the most pressing concern for residents (66.7%), which persists following an educational session (48.1%). Residents are also concerned that they will not receive adequate remuneration for performing biopsy procedures. Residents respond well to teachable points in an educational session, specifically points addressing how to appropriately bill for the procedure and the safety of performing biopsies on pigmented lesions.

Conclusion:Residents in the family medicine residency program in Kitchener-Waterloo feel technically prepared and comfortable performing skin biopsies, however there are persistent barriers that may prevent residents from performing biopsies in their future practice. Educational sessions may effectively address some of these barriers.



P-1: Participatory action research and the role of consumer networks to improve primary care for persons with spinal cord injury

Lee J., Milligan J., Wolfe D., McMillan C., Hillier L., & Bauman C

The Centre for Family Medicine Family Health Team

A Consumer Network (CN) was developed in Ontario, Canada using a Participatory Action Research (PAR) model to provide consumer input into health care planning with the aim of improving primary care for persons with spinal cord injury (SCI). The creation of the CN is guided by a PAR model, which is well suited for SCI population/consumer as it is based upon the premise that health services informed by participants’ lived experience may result in multiple positive outcomes, collaborative relationships between providers and users, and fosters self-management. Twenty-two SCI participants included are receiving care at The Centre for Family Medicine.

An interprofessional primary care clinic was developed aimed at improving access to quality care for persons with SCI and two network participants became SCI Patient Advisors. These Advisors have contributed consumer perspectives on the provision of primary health care, the development of research projects, and the development of education sessions.

This has demonstrated the beneficial role of a CN model based on a PAR approach to positively impact practice improvements through both program enhancements and development of research projects aimed at improving care and QoL for persons with SCI. This exemplifies the possibilities of collaborative health care for SCI consumers.

P-2: Quality Assurance in the Diagnosis of Dementia: Essential Physical Examination Components

Heckman G*, Boscart VM, Hillier LM, Lee L, Molnar F, Seitz D, Stolee P

*Schlegel-UW Research Institute for Aging / University of Waterloo

Objectives: Primary care memory clinics (PCMCs) are being established in Ontario to enhance system capacity for dementia care. Variability in documentation of the physical examination (PE) suggests the need for Quality Indicators (QI) specific to this domain. The purpose of this study is to achieve consensus on essential PE manoeuvres.

Methods: PCMC physicians and affiliated specialists were surveyed to rate the importance of PE manoeuvres as essential, discretionary, or unnecessary to the diagnostic process. Participants were asked to identify who should perform specific PE manoeuvres

Results: Ninety surveys were completed. Most considered the assessment of orthostatic vital signs as essential and the responsibility of allied health professionals. Nutrition and hygiene assessments were deemed essential and the responsibility of referring or PCMC physicians. General PE manoeuvers were considered discretionary or unnecessary, and the responsibility of referring physicians. Gait assessments was considered essential. Specialists were significantly more likely than PCMC physicians to consider examination for facial asymmetry, extra-ocular movements, and pyramidal and extrapyramidal signs as essential. General PE was considered the purview of the referring physician. Specialists considered most neurological examination manoeuvres the purview of PCMC physicians, who generally considered these the responsibility of referring physicians. Time constraints were cited as important barriers to PE.

Conclusions: This study identified PE manoeuvers considered important to the assessment of patients referred to a PCMC. A tiered approach to the PE of patients seen in PCMCs may be warranted, based on a shared understanding of roles and responsibilities of clinicians involved, and considering potential training requirements.

P-3: Transitional Care for Stroke Survivors” has been accepted as a poster presentation

Afzal, Arsalan*; Fage, Maria. Khan, Dana. Weir, Julie. Breaton, Jennifer

*Waterloo Wellington Community Care Access Centre

Adults with an acute stroke event have a unique risk because of ineffective transitional care and poor inter-provider communication when transitioning to different care settings . Supported and coordinated patient transition from hospital to home is a Canadian Stroke Best Practice . Providing this seamless transition improves continuity of care after discharge, resulting in positive outcomes and an improved patient experience.

As part of the Waterloo Wellington Integrated Stroke System, the Community Stroke Program includes a “Discharge Link Meeting (DLM)” to facilitate patient transition from hospital to home. This novel concept was built on the work piloted by the Stroke Network of Southeastern Ontario. The DLM is an in-hospital meeting involving the stroke survivor, caregiver, community therapist and hospital interdisciplinary stroke care team. Patient status, goals and plan of care are established. The community therapist who attends the DLM sees the patient at home within 48 hours of discharge.

The DLMs were implemented in a phased approach starting with in-patient rehabilitation sites followed by acute sites. As of March 1, 2015, 81 of the 109 eligible stroke survivors participated in a DLM. Early results suggest that a DLM supports patient transition from hospital to home, improves communication and trust between hospital and community providers. Evaluation activities are underway to understand the impact on patient experience and outcomes.

The DLM is a successful transition management model. The model should be considered for community stroke programs across Canada to improve patient transitions from hospital, improve communication and build trust between hospital and community providers.

P-4: Mobile Qi Gong Wellness App- Improving Physical and Cognitive Resiliency in Older Adults

Mr. Tony Tin, Colleen McMillan

University of Waterloo- School of Social Work

Objectives: To explore the physical and cognitive merits of a mobile wellness app for older adults with minimal exercise levels.

Methods: The authors developed a mobile app featuring a series of QiGong video exercises augmented by a mood charting to baseline the relationship between non impact exercises and mood. QiGong is a centuries old Chinese exercise that incorporates gentle breathing and non strenuous stretching and holding exercises for older adults who have minimal to nil fitness levels. The mobile Qi Gong exercise app was downloaded to Apple iPads with the exercise videos delivered through five different, four minute training videos as demonstrated by a Qi Gong master. There was an embedded audio reminder that was adapted to individual time and exercises preferences and schedules.

Results: Over 82% responded favourably to the use of the QiGong Wellness app. The simplicity and user friendliness of the app resulted in participants using the app several times a week. The feature of charting their mood pre and post the exercises was a preferred feature by the participants.

Conclusions: The piloting of a health and wellness self management tool through a mobile app featuring the Chinese exercise of Qi Gong represents an innovative, visual and accessible self management tool that supports daily physical activity while fostering a sense of personal empowerment and enhancing the quality of life. Contrary to public perception and previous studies, this sample of older adults were interested in digital literary and wanted to be active stakeholders in the self monitoring of their health.

P-5: System Integration of Specialized Geriatric Services

Jane McKinnon Wilson*, Audrey Devitt, Maria Boyes, Cathy Sturdy-Smith, Sheli O'Connor, Julie Wheeler, Sharon Stap, Marilyn White-Campbell Susie Gregg

Canadian Mental Health Association Waterloo Wellington Dufferin

In response to the Living Longer, Living Well, Senior Strategy Report: Dr. Samir Sinha, and the Waterloo Wellington Geriatric Services Network’s commitment to system integration the local Specialized Geriatric Services (SGS) have developed a foundation of integration that is responsive to the voice of the senior while maximizing opportunities across the continuum.  The system integration positions the community for the future by building capacity today.

The SGS integration development and implementation strives to address the senior’s voice by addressing the five principles of the Senior Strategy: access; equity; choice; value and quality health care. The key areas of quality improvement are aligned with the provincial pillars:. Creating effective system management processes to provide reliable and equitable delivery of care: Ensuring intersectoral service delivery to enable system efficiency and equitable access to comprehensive, quality best practice services and increasing capacity and creating knowledgeable care teams.

  • Operational Management and Program Lead for SGS facilitates a system integration.
  • Geriatric Clinical Intake Clinical Intake leverages technology to better utilize existing resources and build on information that honours the voice of the senior.
  • Inter-professional Teams Communities of Practice aligned with geographic communities provide an improved foundation to implement best practices that drive quality improvements; enhanced seamless transitions.
  • Knowledge Transfer: Cross sectoral opportunities for knowledge transfer results in building capacity; standardization of core competencies across the continuum of care.

Additional quality Improvements include: effective utilization of specialty resources; service at ‘right time and right place’; decrease in duplication of assessments.

P-6: Waterloo Wellington Frail Elderly Report Identifies Learning Needs Across the Continuum and Creates ‘Unique’ Knowledge Transfer Opportunities

Audrey Devitt* Jane McKinnon Wilson* Cathy Sturdy Smith* Sharon Stap* Marilyn White-Campbell, Waterloo Wellington Geriatric Services Network, Frail Eldlery Medically Complex Stream Rehabilitation Committee

St. Joseph's Health Centre Guelph and Canadian Mental Health Association Waterloo Wellington Dufferin

The Waterloo Wellington Geriatric Services Network – Frail Elderly Seniors Report recommended a learning needs survey to be implemented with a goal of identifying priorities for knowledge exchange across the continuum. The survey was circulated to agencies serving seniors presenting with frailty concerns. There were 201 respondents; total number of individuals invited to participate in the survey is not known as overlapping distribution lists were accessed. The information in the Learning Needs Report was utilized to inform quality improvement and knowledge transfer work of the following: Geriatric Services Network (GSN);Frail Elderly Medically Complex Stream Rehabilitation Committee; Specialized Geriatric Community of Practice (CoPs); HealthLinks committees/working groups. The priority learning needs identified by the respondents includes the following geriatric syndromes: delirium, cognitive impairment, mood, polypharmacy, falls/gait changes, elder abuse, functional decline, incontinence, frailty, pain, malnutrition, Respondents selected from a list, those knowledge resources or tools that they find helpful in supporting the transfer of knowledge from theory into practice. Case based discussion and knowledge exchange events such as workshops were seen most helpful and were selected by almost 70% of respondents. The development of case based modules developed from the Regional Geriatric Program’s Geriatric interprofessional interorganizational collaboration (Gii Cii) tool kit were developed to assist with addressing some of the geriatric syndromes. The learning needs assessment provided the foundation to develop and implement a tool that is easily accessible and provides onsite learning that is interactive and allows for successful knowledge transfer across the continuum of care.

P-7: Barriers to Antenatal Care in the Kenyan District of Bondo- A Qualitative Interview Study

Xu, Samuel; Meyer, Christopher; McKim, Blaire; Rastin, Julianne; Scott, Sylvia

Michael G. DeGroote School of Medicine Waterloo Regional Campus

Objective: The aim of this study is to identify potential barriers to accessing antenatal care at Matangwe Hospital in the Bondo District of Kenya, a hospital operated by local NGO group Caring Partners Global.

Methods: Participants were selected at random from patients attending postnatal care at the Matangwe Clinic in Bondo, Kenya and had given verbal consent to participate in the study. Participants were interviewed by 2 researchers in the study in private with a translator. Core questions asked to the participants were standardized amongst the researchers. Exclusion criteria threshold was low so as to include a diverse group of individuals from the community and gather a range of responses. Interview notes were compiled following the interviews and data extracted from the statements of the patients to identify barriers to care.

Results: 26 individual participants were interviewed. The age of the participants ranged from 15 to 32 and the number of pregnancies ranged from 1 to 6. Participants came from 15 unique villages from around the clinic. The most commonly found barrier was financial (69.2%). The second most prominent barrier that individuals identified was education (38.5%). Other barriers included stigma, transportation difficulties, religion, and martial issues.

Conclusions: With the barriers identified, Caring Partner Global can initiate projects to address easing the financial burden and educating the villages to hopefully increase antenatal care access along with improving mother/infant mortality. This can be further studied with appropriate retrospective cohort or case-series studies.

P-8: Evolution of campus preference in medical students at the Michael G. DeGroote School of Medicine

Tong, Lili*; Khairullah, Ammar; Edge, Wendy; Trinh, Kien; Morris, Cathy; Costa, Andrew

*Michael G. DeGroote School of Medicine Waterloo Regional Campus

Objectives: Michael G. DeGroote School of Medicine has three campuses – Main Campus (Hamilton – 150 students), and two Regional Campuses (Waterloo and Niagara – 28 students each). The demand for the Main Campus outnumbers the number of seats available. This study aims to quantify the difference in campus preference prior to and after entry into the medical program with the goal of optimizing supply and demand for each campus.

Methods: A web-based survey was disseminated in October 2014 to current students across all classes and sites. Students were asked their rankings of the three campuses prior to entry into the program, and asked to re-rank according to current preference. A cross-sectional demographic profile of the student responses was obtained including assigned campus, campus perceptions and exposure to other campuses.

Results: The initial strong preference for the Main Campus (Main Campus – 85.55%, Regional Campuses – 12.06%, No preference – 2.36%) shifted towards a higher re-ranking of regional campuses (Main Campus – 67.85%, Regional Campuses – 31.52%, No Preference – 0.59%). One factor may be a perceived difference in reputation (Main Campus superior – 74.26%, No difference – 19.82%, Regional Campuses are better – 5.92%) which has now changed (Main Campus superior – 42.90%, No difference – 36.39%, Regional Campuses are better – 20.71%).

Conclusions: Preference and perceptions of campus sites changes dramatically after entry into the program – shifting to a more optimal distribution of seats. An important factor was exposure to a regional campus. Next steps: This data was presented to applicants and their preferences for campus and their acceptance rate will be tracked.

P-9: Integration of HDR brachytherapy and hypo-fractionated external beam radiation therapy for prostate cancer patients

Sharma, Sakshi*, Gopaul, Darin, Stephens, Robert, Kitor, Monika, Osei, Ernest, Morton, Gerard

St. Joseph's Health Centre Guelph and Canadian Mental Health Association Waterloo Wellington Dufferin

Background and Purpose: High Dose Rate (HDR) brachytherapy adjuvant to hypo-fractionated external beam (XRT) radiation therapy provides durable long-term biochemical disease free survival for intermediate risk prostate cancer patients. The purpose of this quality review project was to examine the integration and results of prostate HDR Brachytherapy for patients treated with HDR brachytherapy at a specialized academic center with hypo-fractionated XRT coordinated closer to home at the Grand River Regional Cancer Center.

Material Methods: 12 prostate HDR patients receiving hypo-fractionated XRT at Grand River Regional Cancer were identified. Patients’ records were examined using the EMR, Clinician Portal. Each patient received 15 Gy HDR brachytherapy in one fraction then underwent 37.5 Gy in 15 fractions of hypo-fractionated external beam radiation therapy. The XRT plan was compared to the Sunnybrook guidelines. Biochemical failure was then determined using the Phoenix definition.

Results: All patient started XRT within the prescribed two weeks of HDR. All XRT plans were considered acceptable. Eight of 12 patients were considered ideal (met all criteria). In 4 patients the 105% hotspot was >1%. All 12 patients remain in Biochemical (PSA) control at this time. The mean follow up was 32 months. The mean time to nadir was 30 months.

Conclusion: HDR brachytherapy and hypo-fractionated XRT can be seamlessly delivered in two different centers. This results in the patients receiving HDR brachytherapy at a high volume center, and receiving XRT closer to home. Early results are excellent with no biochemical failures reported to date. Longer follow up is needed.

P-10: Examining Referral Patterns to Specialized Geriatric Services in a Community Hospital

Osborne, Alyson N.*, Magennis, Paul*, Costa, Andrew, & Didyk, Nicole

Michael G. DeGroote School of Medicine Waterloo Regional Campus

Objectives: The authors present an exploratory prospective cohort study that examines referral patters to specialized geriatric services in a community hospital in the hopes of improving case finding services for older adults.

Methods: Thirty older adults (age 65 or older) were screened in the Emergency Department (ED) at St. Mary’s General Hospital (SMGH) using the interRAI ED screener for identifying frail older adults. A chart review was then completed 60 days later to review patient outcomes and identify patterns in referral to geriatric services.

Results: Six patients were identified as frail on the screening tool (3 patients were admitted to hospital, 3 patients were sent home from the ED) however only one patient was referred for specialized geriatric services. The authors present possible barriers/reasons why certain patients were not referred to specialized geriatric services. The characteristics of patients that were referred and those that were not referred for specialized geriatric services are summarized by using case descriptions.

Conclusions: The study identifies that barriers continue to exist for frail older adults to receive specialized geriatric services they would surely benefit from.

P-11: Alternate Level of Care: Clinical Predictors and Barriers to Discharge

Turcotte, Luke*; Hirdes, John

School of Public Health and Health Systems Waterloo University

Although the number of Alternate Level of Care (ALC) patients occupying beds in Complex Continuing Care (CCC) facilities remains stable, a group of difficult to place patients continue to consume a significant proportion of total patient days. Using a linked dataset of Continuing Care Reporting System (CCRS) and Wait Time Information System (WTIS) records, an analysis of the clinical predictors of ALC patient status and barriers to CCC discharge was completed. This work describes the relationships between functional capacity, cognitive impairment, aggressive behaviours and other patient characteristics as they relate to delayed CCC discharge. In addition, the odds of delayed discharge for patients with identified discharge barriers was calculated. This work provides evidence for funding, policy and practice changes to reduce ALC patient days in post-acute care settings and will serve as the basis for a predictive algorithm to identify patients at risk of delayed discharge.

P-12: Synoptic Radiology Reports Improve the Quality and Clarity of Rectal Cancer Imaging Reports

Hussein, Mohamed*, Gopaul, Darin MD

Michael G. DeGroote School of Medicine Waterloo Regional Campus

Radiology reports provide clinicians with key information with regards to the management of many pathological processes. However, the majority of radiology reports do not follow a standardized approach for reporting clinical findings. As such, important findings that may be of importance to the ordering clinician may be omitted from the radiology report. We conducted a chart review of 38 patients undergoing short-course radiation therapy at Grand River Regional Cancer Centre for rectal cancer. The tumor staging MRI reports were then analyzed in order to determine whether the circumferential radial margin (CRM), a key prognostic indicator in rectal cancer, was reported in the MRI reports. It was found that 44.7% (n=17) of the MRI reports were reported in a synoptic fashion, whereas 55.3% (n=21) were not. The CRM was reported in 94% (n=16) of the synoptic reports, whereas it was reported in only 62% (n=13) of the conventional radiology reports. These findings indicate that synoptic radiology reports convey important radiological findings more effectively than conventional radiology reports.

P-13: The Clerkship Guide to Emergency Medicine

Marcus Lai*, Joshua Penslar*

Michael G. DeGroote School of Medicine Waterloo Regional Campus

Several barriers face medical teaching in the ER. Research has shown that bedside teaching in the ER is restricted by large patient volumes and limited time. However, there exists many strategies to supplement ED teaching and learning. Studies show that readily available clinical resources are important for a learner centered approach to medicine. Furthermore, it has been shown that exposure to facts without context are not the best ways to facilitate learner growth. Rather, it is learning with actual experience, with relevant information supplied as needed, that allows for the learner to build upon and modify their pre-existing concepts. Therefore, we aim to create a non-comprehensive guide that focuses on teaching the core principals of ER medicine.

P-14: The Impact of burst exercise on cardiometabolic status of newly diagnosed type 2 diabetics

Pandey, Avinash*

Waterloo Collegiate Institute

Physical activity is an integral part of diabetes rehabilitation. Historically, diabetes rehabilitation has employed low intensity, sustained exercise. Recent studies have demonstrated short-term cardiometabolic benefits of high intensity burst exercise in healthy volunteers. The impacts of burst exercise in diabetics have yet to be assessed. This study compared the impacts of burst and sustained exercises on cardiometabolic factors including: BMI, exercise adherence, cardiopulmonary fitness, blood sugar levels and lipid profiles in newly diagnosed diabetics. 76 patients were recruited from a local diabetes rehabilitation center. Patients were randomized into a control group prescribed routine sustained exercise and an intervention group prescribed a high intensity burst exercise regimen. All patients underwent routine blood tests, stress tests and logged exercise duration in logbooks. Data is still in the process of collection; this report represents the data from 40 of the 76 patients. Patients prescribed the burst regimen exercised 27% more than the control group (p<0.01). Burst exercise patients also showed a 2.3 fold greater improvement in HbA1c, a marker of blood sugar control (p<0.01). The intervention group also improved more in their lipid profile, BMI and cardiopulmonary fitness (as measured by stress testing). Even among patients who exercised similar amounts, greater improvements in biochemical parameters were noted in those randomized to burst exercise. In conclusion, the burst exercise regimen appeared to significantly improve the cardiometabolic status of newly diagnosed diabetic patients. This regimen may represent a simple and effective way to improve diabetes rehabilitation but requires longer-term validation of clinical outcomes.

P-15: AREST CAD: Adherence effects of a comprehensive reminder system on medication adherence in Cardiac patients

Pandey, Avinash*; Choudhry, Niteesh

Waterloo Collegiate Institute

Background: Non-adherence to evidence-based cardiovascular therapies is common. By one year, only half of coronary artery disease patients (CAD) take their medications as prescribed. With the proliferation of cell phones, text message could be a cost-effective method to remind patients to take their medications.

Methods: We recruited 30 CAD patients from a single cardiac center. This study aimed to determine if automated text message reminders could be effective at addressing medication non-adherence. Eligible patients were randomized to receive text message reminders up to 4 times daily at times of their prescribed medications for one month and cross over to usual care (without reminders) for a second month. Patients were instructed to take their medications according to their prescribed regimen. Adherence was assessed through logbooks.

Results: We randomized 30 cardiac patients with an average age of 65 years; 60% were male. Over the course of the 2 months, 100% of patients improved adherence with text message reminders. There was a relative risk reduction for non-adherence of 64% (p<0.01). In all subgroups analyzed, text message reminders significantly improved adherence. Pre-specified subgroups exhibited lower rates of adherence with usual care (elderly, depression, and the less educated). However, these sub-groups showed greater improvements with the text message intervention.

Conclusions: This study demonstrates the effectiveness of a text message reminder system to improve adherence to medications in CAD patients. While the impact of this intervention on clinical outcomes was not assessed, it represents a potentially simple and scalable method for improving adherence to evidence-based therapies.

P-16: An Investigation of non-invasive juglar venous pressure point-of-care devide to diagnose and assess heart failure in a long term and primary care: a qualitative approach

Chetram, Vishaka*; Boscart, Veronique; Heckman, George

School of Public Health and Health Systems Waterloo University

1. To explore nurses and physicians perceived knowledge of, skill and confidence in assessing jugular venous pressure (JVP) in suspected or established heart failure (HF) patients in long term (LTC) and primary care

2. To explore the acceptability of a non-invasive point of care device to measure JVP in diagnosing and managing heart failure in LTC and primary care

3. To test the preliminary usability of the device by nurses and physicians in primary and long term care

Methods: An exploratory, descriptive design was utilized and data was collected through four focus group interviews. All 29 participants were presented with a training module and had an opportunity to use the device on a test subject.

Results: Initial results indicate a high degree of acceptability and usability in long term care despite difficulty in locating the fourth intercostal and interpreting the JVP waveform. Barriers include resident behavior, perceived adequacy with current clinical skills and a belief that HF patients were appropriately diagnosed despite rarely measuring JVP.

Discussion: There is an evident lack of utility of JVP despite having a role in the Canadian Cardiovascular Society Guidelines for diagnosing Heart Failure. The device appears best suited for long term care as oppose to primary care. This may be the result of differing perceptions of time constraints and the role of the emergency department.

Conclusion: This device has tremendous potential to help establish new onset or worsening Heart Failure and can help direct development of future technological devices and their implementation in these settings.

P-17: Squamous Cell Carcinoma of the Anal Canal: 10 Year Experience at Grand River Regional Cancer Centre

Urban, Ryan*; Ling, Justin; Ng, Alex; Hill, Brianne; Gopaul, Darin

Michael G. DeGroote School of Medicine Waterloo Regional Campus

Objective: To evaluate patient outcomes according to different treatment modalities.

Methods: A retrospective chart review was conducted of all patients treated for non-metastatic squamous cell carcinomas of the anal canal from 2004 to 2014.

Results: A total of 73 patients were identified, 60 females (82%) and 13 males (18%). The average age of diagnosis was 62 years (range 39‐91). 29% of the patients were T1 stage, 41% T2, 19% T3 and 7% T4. T stage was unknown in 4%. 63% of patients were N0, 16% N1, 14% N2, 7% N3.
Six patients were treated with primary surgery, 10 with radiation only and 57 with curative intent chemoradiotherapy. Radiation was typically 50-54Gy in 28-30 fractions over 6 weeks. Chemotherapy was 5FU / mitomycin C in 49 patients, 5‐FU / Cisplatinum in 6 patients and 2 patients received 5‐FU alone.
The average follow-up was 40 (2-109) months. There were 11 local recurrences. Local recurrences: 2/6 patients that received surgery only, 2/10 patients that received radiation only, 7/57 patients that received chemoradiotherapy. 4 patients had salvage surgery. Colostomy free survival was 84%. There were 5 nodal recurrences. 3 patients experienced distant metastases (1 brain, 2 liver). 13 patients died – 8 due to anal cancer. Cancer specific survival was 91%, 90%, and 60% and overall survival was 88%, 60%, and 67% for chemoradiotherapy, radiation only, and surgery, respectively.

Conclusion: Chemoradiotherapy is an effective (non-surgical) cure for squamous cell carcinoma of the anal canal with preservation of the anus in the majority of cases.

P-18: Understanding the Role of Allied Health Professionals in Medical Education at a Satellite Medical School

Ladha, Zamin; Merrifield, Kaylyn; Roeper, Rhiana; Kays Sommer, Jennifer*; Bite, Alexandra*

Michael G. DeGroote School of Medicine Waterloo Regional Campus

As medical schools introduce satellite campuses, smaller communities are now being introduced to medical learners. Health professionals of various disciplines in these regional hospitals may have had little to no exposure to medical learners, and may be unaware of the medical student’s role in patient care, or the extent and limitations of their scope of practice. Lack of clarity about these roles is identified as one barrier that hinders interprofessional collaboration and education. The purpose of this project is to assess and optimize the relationships between medical students and various health care professionals. An online survey was distributed to health care professionals at Cambridge Memorial and Grand River Hospitals. Of 141 healthcare professionals surveyed, 90% had encountered medical students in their work; however, 100% of respondents stated they had never received formal training regarding their role when encountering medical students. The majority of healthcare professionals indicated that it would be beneficial to have the roles and responsibilities of medical students clarified. Participants strongly indicated a desire to teach medical students, despite identifying potential barriers to engaging in medical education such as time constraints (48%), student attitudes (21%) and the perception of increased workload (11%). Ultimately, this project will serve to inform policies and lead to the development of effective strategies to improve the relationship between medical students and allied health professionals and optimize opportunities for interprofessional education and collaboration.

P-19: Knowledge confidence and desire for further diabetes management education among nurses and personal support workers in long-term care

Corita Vincent*, Peter Hall, Ph.D, Lynn Hayes-Cardinal, Scott Hannay, Sally Ebsary, Nadira Husein, MD

*School of Public Health and Health Systems Waterloo University

Type 2 diabetes is present in approximately 30% of long-term care home residents and places a large burden on health care practitioners. Additionally, treatment is often further complicated by presence of comorbid conditions, age-related changes, and/or frailty. This study aims to assess the knowledge and confidence of health care practitioners (RNs, RPNs, and PSWs) on a variety of diabetes management areas (glycemic excursions, nutrition, insulin, oral medications, and sick day management), and the need for additional diabetes management education in the LTC setting. RNs, RPNs, and PSWs at two LTC facilities were surveyed about their knowledge, confidence and interest in further diabetes management education. Across domains, knowledge levels reported by practitioners were generally moderate, but some variability existed depending on topic. Knowledge and confidence was highest for nutrition and glycemic excursions and lower for sick day management, oral medications and insulin. Among the whole sample, 85% wanted DM education. Of these individuals 45% requested education about “other“ aspects of diabetes management including “foot care, complications, general knowledge/new research”. The proportion asking for education about nutrition, oral meds, insulin, hypoglycemia and hyperglycemia was between 20% and 31%. Desire for education about sick day management was relatively low (18%). In conclusion, knowledge and confidence were generally moderate. The number of individuals reporting “very” knowledgeable or “very” confident was highest for glycemic excursions, but lowest for medications (PSWs) nutrition (RPNs) and sick day management (RNs). Overall, there is a desire for more diabetes management education.

P-20: Nintendo Wii and Schizophrenia- a pilot study

Ewa Talikowska-Szymczak*, Raegan Mazurka, Martin Feakins

*Michael G. DeGroote School of Medicine Waterloo Regional Campus

1. To assess whether any benefit in daily functioning and quality of life can be gained from using the Nintendo Wii video game console and the Nintendo Wii Fit Plus games in people with Schizophrenia.
2. To determine feasibility of the study.

Methods: Five participants were recruited from the Community High Intensity Treatment Team to participate in the study and were provided a Nintendo Wii gaming system and Nintendo Wii Fit Plus games – fitness video games that use a motion-sensing remote and weight-sensitive balance board to track the physical movement of the player. Five separate home visits were completed with each patient over a 6-month period to evaluate Nintendo Wii use and assess their health, functioning and quality of life. Participants completed two self-report questionnaires and were evaluated on two standard measures of functioning with weight and Body Mass Index measurements collected.

1. One patient experienced statistically and clinically significant changes in overall health, daily functioning and quality of life due to significant weight loss in the process of increased physical activity after 6 months of using the Nintendo Wii gaming system and provided games.
2. Patients’ lack of motivation and lack of comprehension are the main explanations for the negative results of our study.
3. Our findings imply the feasibility of conducting such a study in a severely ill population of patients with Schizophrenia and limitations of the Nintendo Wii gaming system. Knowledge gained from this study will help us better prepare and conduct a study in the future.

P-21: The Role of Weight Loss and Obesity in Nocturnal Blood Pressure Non-Dipping

Pandey, Arjun*

Waterloo Collegiate Institute

In healthy individuals, sleep is associated with at least a 10% dip in Blood Pressure (BP). A lack of nocturnal BP dipping (LND) or a rise of BP nocturnally (RBPN) is associated with an increased risk of many cardiovascular diseases. In this study, we examine a potential correlation between obesity and a lack of nocturnal BP dipping as well as the impact of weight loss on nocturnal BP patterns.

We recruited 30 volunteers with a LND pattern, 30 volunteers with a RBPN pattern and 20 control volunteers, with a healthy nocturnal BP dip. 24-hour Ambulatory BP Monitor readings and BMI measurements were performed before and after a 2 month intervention employing the DASH diet and lifestyle program.

At baseline we observed a negative correlation between BMI and nocturnal BP dipping: The average BMI of the control group was 28.1 kg/m2. The average BMI of the LND group was 30.3 kg/m2 (mildly obese). The average BMI of the RBPN group was 35.3 kg/m2 (severely obese) (p<0.0001).

After the 2 month intervention, we observed that individuals who achieved a weight loss of 5% or more had an average 8.4% dip in nocturnal BP restoring a healthy nocturnal dip. Those who did not achieve a 5% weight loss & those who gained weight had blood pressure that rose by 3.2% at night on average (p<0.0001).
The findings of this study suggest that obesity may contribute to nocturnal BP abnormalities and weight loss, through diet and lifestyle modifications, may improve nocturnal blood pressure patterns.  

Symposium 2014 Program

View Final Symposium Program


There will be a mix of presentations in oral and poster format, with opportunities for discussion and interaction. Hospitality will be provided.

Time Description Location
12:00 Check-In, Poster Setup and Lunch Lecture Theatre (2018), Second Floor
12:30 Welcome, Introduction and Overview Lecture Theatre (2018), Second Floor
12:45 Keynote Address Lecture Theatre (2018), Second Floor
1:30 Oral Presentations — Session One Lecture Theatre (2018), Second Floor
2:30 Poster Viewing & Coffee Break Great Room, Third Floor
3:30 Oral Presentations — Session Two Lecture Theatre (2018), Second Floor
4:30 Social Break Great Room, Second Floor
4:45 Closing Ceremony and Presentation of Awards Lecture Theatre (2018), Second Floor
5:00 Symposium Adjourned


Awards will be given for top ranked oral and poster presentations.

Keynote Presentation

Accelerating Progress in Using Evidence to Improve Practice and Outcomes: A Model Emerging with Renewal of Homewood Research Institute

Roy Cameron

Dr. Roy Cameron, Executive Director of the Homewood Research Institute

Roy Cameron spent most of his academic career in the Faculty of Applied Health Sciences at the University of Waterloo, where he continues as Professor Emeritus in the School of Public Health and Health Systems.  He was Executive Director of the Propel Centre for Population Health Impact for 16 years, until 2011. Roy has been on faculty at the University of Saskatchewan, and a Visiting Scholar at Stanford. He has degrees in English literature and clinical psychology (from Waterloo) and did his internship at Duke University Medical Center.

For much of his career, Roy did impact oriented science designed to guide tobacco control programs and policies that prevent disease at a population level. More recently he has worked with the Canadian Cancer Society, CIHR, the Heart and Stroke Foundation, the Public Health Agency of Canada and other organizations to create an environment that values impact-oriented science, and to build capacity for such science.  The aim is to enable scientists to contribute to improving the well-being of individuals, organizations, and society.  To that end, he played a catalytic role as a collaborator in creating the Canadian Tobacco Control Research Initiative, the Population Health Intervention Research Initiative for Canada and other capacity development initiatives.  His Homewood role enables him to pursue this agenda of linking evidence and action in the mental health field.

Roy has received honours for his career contributions from a number of organizations including the Canadian Academy of Health Sciences (Fellow), the Society of Behavioral Medicine (Fellow), the National Cancer Institute of Canada (Diamond Jubilee Award), the University of Waterloo (University Professor and distinguished Professor Emeritus designations), and the Canadian Public Health Association (Honorary Life Membership).

Abstract Listing


Session 1: 1:30 – 2:30pm

O-1: The Treatment of Chronic Insomnia: Lessons from Patient Care using a Sleep Diary

Appavoo, Siva

Private Practice Psychiatrist          

Objectives: Chronic insomnia is a common, complex problem involving up to 30% of the population and more when accompanying psychopathology. There are many approaches to the treatment of chronic insomnia including medications, education, cognitive behavioural therapy and psychotherapy.

Methods: A sleep diary was given to patients to record parameters of their sleep patterns and followed during the course of their treatment. The approach will be outlined using histories, treatments and monitoring daily sleep recordings by patients using a sleep diary.

Results/Conclusions: A sleep diary is a useful tool to assess, treat and monitor illness. A simple sleep diary instrument could be used by physicians to enhance the understanding and treatment of psychopathology. More testing needs to be done to validate the usefulness of this tool in treating patients with psychiatric problems.

O-2: The Level of Standardization of Electronic Medical Records among Providers in Primary Care Settings: A Scoping Review

Flanigan, K.*, Slonim, K., & Alarakhia, M.

*Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Objectives: To describe the current status of standardization of Electronic Medical Record (EMR) data in primary care settings.

Methods: A scoping review of the literature published between 2008 to 2014 was completed using Ovid MEDLINE, Scopus, PubMed and CINAHL databases. Key search terms included EMR/EHR, standard*, interoperability, implement*, develop*, work-arounds and primary care. Articles related solely to hospital-based and personal health records were excluded. Articles were reviewed by 2 reviewers.

Results: The term 'standardization' is broad and encompassed a wide range of articles on EMR use. Three categories were identified 1) IT use (diagnostic coding, templates, Clinical decision support tools) 2) Condition specific (ie level of EMR standardization related to asthma, HIV) 3) Outcome specific (provider use and work-arounds).

Over 70 articles were reviewed from 18 countries.

Conclusions: The scoping review revealed a wealth of information which calls for further refinement of the question if a systematic review were to be carried out. The review however also revealed some intriguing emergent themes that weaved through the three categories identified above, which included: interoperability issues with differing EMRs and older legacy systems; more rigid standardization may mean less innovation; providers tend to use EMRs like electronic paper charting and selectively appropriate standards; and providers like the ability to use free text fields rather than standardized templates in certain circumstances.

O-3: Impact of Surgical Palliation Strategies on Outcomes in Children with Hypoplastic Left Heart Syndrome

Chetan, Devin*; Kotani, Yasuhiro; Jacques, Frederic; Poynter, Jeffrey; Benson, Lee; Lee, Kyong-Jin; Chaturvedi, Rajiv; Friedberg, Mark; Van Arsdell, Glen; Caldarone, Christopher; Honjo, Osami

The Hospital for Sick Children - The Labatt Family Heart Centre; *Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Objectives: More than 30% of the infants born with hypoplastic left heart syndrome (HLHS) die in the first year of life despite having multiple surgical palliative procedures. Currently, there are three different surgical strategies (Norwood, Sano, Hybrid) to treat this patient group. Each strategy may pose a risk of causing myocardial injury through different mechanisms. We sought to compare these strategies to understand longitudinal differences in ventricular dysfunction and its subsequent impact on transplant-free survival and atrioventricular (AV) valve regurgitation (AVVR) as well as the relationship between adverse events and ventricular function.

Methods: All echocardiograms were reviewed for 138 children palliated with Hybrid (H; n=54), Norwood/BT Shunt (N; n=73), or Sano (S; n=11) strategies from 2004 to 2011. Cardiac arrest and requirement of extracorporeal membrane oxygenation were defined as adverse events. Differences between strategies were compared with Kaplan-Meier analysis. Cox regression was used to identify risk factors.

Results: Freedom from moderate/severe ventricular dysfunction was comparable among groups at 3 and 6 months after stage I (H: 81%, 71%; N: 72%, 67%; S: 91%, 68%; p=0.73) and at 2 years after stage II palliation (H: 65%; N: 73%; S: 69%; p=0.70). Adverse events were identified as a predictor for the development of ventricular dysfunction after both stage I (p<0.001) and stage II (p=0.007) palliation. Palliation strategies were not significant risk factors. There was a reduction in freedom from ventricular dysfunction following adverse events in all 3 groups (p<0.001). Patients with ventricular dysfunction had lower transplant-free survival regardless of palliation strategy used (p<0.001). Palliation strategy did not affect the incidence of AVVR after stage I (p=0.87) or stage II (p=0.71). Predictors for AVVR were adverse events (p=0.013; stage I to II) and ventricular dysfunction (p=0.001; stage II to III).

Conclusions: Surgical palliation strategy does not affect mortality, ventricular dysfunction, or AVVR in children with HLHS. The different timing and mechanisms of myocardial injury between palliation strategies do not affect outcomes. Ventricular dysfunction adversely affects transplant-free survival and AV valve function. Adverse events are associated with the development of ventricular dysfunction. To improve outcomes, our goal should be on learning strategies that lead to better ventricular function.

O-4: Clinical Predictors of Protracted Length of Stay in CCC Facilities

Turcotte, Luke

University of Waterloo — School of Public Health and Health Systems

Shortening lengths of stay in acute care hospitals coupled with population aging, increased life expectancy, and the rising prevalence of chronic conditions amongst older adults has lead to an increased need for post-acute care in Canada, including access to Complex Continuing Care (CCC). CCC facilities experience patient flow pressures at both points of admission and discharge. While the number of Alternate Level of Care (ALC) patients occupying beds in CCC facilities remains stable, a group of difficult to place patients continues to consume a significant proportion of total ALC patient days. Early identification of patients that are likely to experience discharge barriers allows discharge planners to act in a timely manner to ensure that patients are situated in an appropriate care setting for their needs that maximizes quality of life. Through an analysis of Ontario MDS 2.0 data stratified by discharge setting, this presentation describes the clinical characteristics of long-stay CCC patients, barriers associated with long-term delayed discharge, and identifies a set of early clinical predictors that are indicative of need for care of long duration in a CCC facility. Identifying patients that are predicted to utilize the greatest number of patient days and implementing discharge planning that addresses potential discharge barriers early in the episode of care is anticipated to lead to a reduction in total ALC patient days.

Session 2: 1:30 – 2:30pm

O-5: Population based outcomes of initiating oral atenolol or metoprolol tartrate in patients with and without chronic kidney disease

Fleet, Jamie L.*; Weir, Matthew A.; McArthur, Eric; Ozair, Sundus; Devereaux, Philip J.; Roberts, Matthew A.; Jain, Arsh K.; Garg, Amit X.

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Background: Atenolol and metoprolol are commonly prescribed beta-blockers. Atenolol elimination depends on kidney function while metoprolol does not. We hypothesized that compared to metoprolol, initiating oral atenolol in the outpatient setting would be associated with more adverse events in older adults. We also hypothesized atenolol versus metoprolol would associate most with adverse events in patients with chronic kidney disease.

Methods: A population-based matched retrospective cohort study was conducted on older adults in Ontario, Canada prescribed oral atenolol vs. metoprolol between 2002 and 2011. The two groups were well matched (n=75,257 patients in each group), with no difference on 31 measured baseline characteristics. Patients with end-stage renal disease were ineligible, and 4.6% of patients had chronic kidney disease.

Outcomes: A composite outcome of hospitalization with bradycardia or hypotension, and all-cause mortality were assessed in 90-day follow-up.

Results: Compared to metoprolol, initiating atenolol was not associated with a higher risk of hospitalization with bradycardia or hypotension (incidence 0.71% vs. 0.79%, relative risk 0.90; 95% confidence interval [CI]; 0.80 to 1.01).  Atenolol initiation was associated with a lower 90-day risk of mortality than metoprolol (incidence 0.97% vs. 1.44%, relative risk 0.68 (95% CI 0.61 to 0.74). The presence of chronic kidney disease did not modify either association (p-value for interaction 0.5 and 0.6, respectively).

Conclusions:  Contrary to our expectation, we found atenolol versus metoprolol was associated with a lower 90-day risk of mortality in patients with and without chronic kidney disease, with no difference in the risk of hospitalization with bradycardia or hypotension.

O-6: Sepsis at Grand River Hospital: A Current State Analysis

Charles, Christopher*; Jackson, Liam*

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Sepsis is a potentially fatal whole-body inflammation caused by severe infection. Sepsis results in severe morbidity that often results in single or multiple organ dysfunction, and eventually death if not treated appropriately. Around the world, approximately 1,400 people die from this condition every day. Additionally, the personal and economic costs with sepsis are high, and the disease is linked to increased hospital resource utilization and prolonged stay in intensive care units. At Grand River Hospital (GRH), the annual incidence and management of suspected sepsis is unknown. This current state analysis examined all diagnosed cases of sepsis across the hospital, including the emergency department, intensive care unit, and outpatient and inpatient oncology wards. A chart review was conducted, and all charts from 2012/13 and 2013/14 were screened for inclusion. A total of 131 charts were assessed for primary diagnoses, co-morbidities, diagnostic criteria used, treatment utilized, and result of management efforts.  Preliminary findings suggest that sepsis poses a significant threat to the health and safety of patients at GRH. The results of this current state analysis will be used to develop tools and protocols for more timely detection and treatment.

O-7: Quantifying the effectiveness of restorative rehabilitation using the MDS ADL Long and Cognitive Performance Scale

Sinn, Chi-Ling J.       

University of Waterloo — School of Public Health and Health Systems

In Canada, there is a lack of system-wide information available for decision-making on restorative rehabilitation. For regular rehabilitation, public reporting is available through Functional Independence Measure (FIM) data in the National Rehabilitation Report System (NRS). Restorative rehabilitation patients who often receive care in complex continuing care facilities are excluded from the NRS; instead, they are assessed using the MDS. To date, the effectiveness of restorative rehabilitation remains unknown. Previous studies have attempted to convert FIM and MDS scores with limited success. Another option is to measure outcomes using scales native to the MDS, namely ADL Long and Cognitive Performance Scale (CPS). The objective of this research is to test the assumption that the FIM motor and cognitive subscales and corresponding MDS scales measure the same underlying construct. The sample (n=346) was drawn from the NRS database (2001-2011) and matched to MDS assessments prior to and/or after the rehabilitation episode. Pearson correlation coefficients showed strong or very strong correlations between FIM motor and ADL Long (-0.60 at admission and -0.79 at discharge, p<0.0001) and FIM cognitive and CPS (-0.71 at admission and -0.73 at discharge, p<0.0001). Additional variables in the MDS allowed for subgroup analysis: individuals with fewer aggressive symptoms, greater social engagement, and a preference to return to the community were significantly more likely to improve in ADL Long. These findings suggest that ADL Long and CPS may be used to measure and compare the benefits of restorative rehabilitation to support public accountability, clinical practices, and discussions about quality improvement.

O-8: Improving adherence to exercise regimens post-MI through a novel text message reminder system

Pandey, Avinash*; Choudhry, Niteesh M.D., Ph.D.

*Waterloo Collegiate Institute

Regular, structured exercise after myocardial infarction (MI) reduces the risk of recurrent cardiac events by 30-50% but non-adherence to exercise regimens is extremely common. While the causes of inactivity in post-MI patients have yet to be fully described, forgetfulness may be a contributor that has not been adequately assessed.  With the proliferation of cell phones, text message reminders may be a cost effective strategy to improve adherence to exercise regimens. The purpose of this study was to test the ability of an automated text message reminder system to reduce inactivity and define the potential role of forgetfulness in inactivity. Based on power analysis of an initial one month sixteen patient pilot study, fifty post-MI patients were recruited within two weeks of hospital discharge for this one year intervention study. After written informed consent, subjects were randomized into usual care or to receive text message reminders four times daily. The co-primary outcomes were the frequency of exercise and the total duration of exercise, assessed through self-reported logs. In addition, exercise endurance and aerobic fitness was formally tested at baseline, month three and month twelve through a cardiac stress test. Patients receiving text message reminders were 40% more adherent to their exercise regimen and had a 20% greater exercise capacity. In all measures of exercise: duration, frequency and an objective measure of cardiac endurance, those receiving text message reminders improved significantly. A system of text message reminders represents a simple and scalable method for improving adherence to exercise regimens in post-MI patients.


2:30-3:30 pm

P-1: Postpartum Screening in Gestational Diabetics at Centre for Family Medicine

Anastasia Blake and Robin Muir

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Background: Gestational diabetes mellitus (GDM) affects approximately 7% of pregnancies in North America. This disease is associated with a number of maternal adverse outcomes, but perhaps most importantly, women with GDM are at greater risk of developing type II diabetes mellitus (DM II). This risk is approximately 7% at 5 years postpartum and over 20% at 10 years postpartum, and eventually about half of women with GDM will develop DM II. Current Canadian recommendations are that women with GDM be tested 6-12 weeks postpartum to determine their glycemic status using both a fasting blood glucose and 75g oral glucose tolerance test. Our goal was to discover whether the physicians in our clinic were performing appropriate postpartum screening of patients with GDM.

Methods: We performed a retrospective chart review from January 2010 to January 2014 and present qualitative data about our practice patterns with respect to GDM and postpartum follow-up.

Results: 47 charts were included in our final analysis. We found that 40% of patients had no postpartum screening documented, while 43% had appropriate screening and 17% had inappropriate screening tests ordered. Only 47% of patients had a documented conversation regarding their increased lifetime risk of DM II. The majority (87%) of patients were referred to a diabetic education clinic, and many (76.5%) were cared for by an endocrinologist. 60% required insulin and 34% were treated solely with lifestyle modifications. A significant number (30%) of our GDM patients encountered obstetrical complications, including arrest of labour resulting in cesarean section, fetal distress, and shoulder dystocia. The cesarean section rate in our patients with GDM was 38%, more than the local average of 25%.

Conclusions: The patients in our practice with GDM are not being adequately screened postpartum for dysglycemia. This could be addressed with educational opportunities to clarify the role of family physicians in GDM follow-up care.

P-2: What's stopping you? Barriers to screening for abdominal aortic aneurysm in an Ontario Family Health Team

Philip Harvey and Edward Weiss          

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Background: Rupture of an abdominal aortic aneurysm (AAA) is disastrous but can be prevented. Current Canadian guidelines advocate for sonographic screening of all males between 65 and 75 years. We performed a chart review and survey to quantify screening rates, and to assess uptake of and barriers to screening.

Methods: Men eligible for AAA screening since 2007 at the Centre for Family Medicine were identified, and 280 charts were reviewed.  Demographic data and risk factors for AAA were abstracted, as well as whether AAA screening had been discussed. Additionally, all clinicians at the clinic were invited by email to complete an anonymous online survey.

Results: 111 patients had abdominal imaging performed for reasons other than AAA screening and were not eligible for screening. Within the remaining 169 patients, only 6 (3.6%) were specifically offered screening for AAA. One AAA was detected through screening. Response rate for the survey was 83%. 15% of clinicians surveyed were able to cite the guidelines correctly. Only 10% stated they screened for AAA routinely. Lack of awareness was the most often cited reason for not screening. Only 2% said access to outpatient ultrasound was a barrier.

Conclusions: Family physicians are routinely missing the opportunity to screen patients for AAA, predominantly because of a lack of awareness of the guidelines and evidence for screening. Access to imaging facilities is unlikely to represent a barrier in this urban setting.

P-3: 'Focus on POCUS' Day in Ultrasound: A Pilot Study of brief training in point-of-care ultrasound (POCUS) in a Family Practice Setting

Philip Harvey, Edward Weiss, Colin Yardley, John McCuaig, Greg Hall.

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Background: In the U.S.A., family physicians are trained in POCUS to screen for AAA and carotid stenosis. Some US schools are making POCUS training standard curriculum. We piloted a brief POCUS training intervention in a group of clinicians to assess attitudes towards adoption of POCUS in primary care in Canada.

Methods: All primary care providers (PCPs) at the centre were invited to participate in a 1.5 hour hands-on training session in bedside scanning for abdominal aneurysm on live models, based on the Emergency Department Echo (EDE) course. Participants completed a survey before and after the session and were interviewed in a focus group to assess attitudes and barriers towards use of ultrasound in primary care.

Results: Participants were predominantly residents, with 1 experienced physician and 2 nurse practitioners. None had formal ultrasound training. Compared to other PCPs at the centre, there was a higher baseline interest in learning how to use ultrasound and preference to screen for AAA in-office (50% vs 21%), reflecting self-selection. Following the hands-on POCUS training, 100% of participants reported the course was enjoyable and would recommend it. A significantly greater proportion of participants felt POCUS should be a standard part of the teaching curriculum (87.5%) compared to before the taking the course (56.2%). Everyone stated the device was easy to learn and use, but many still had concerns about false negatives and associated medico-legal liability. Capital cost and time required to do the scan were also stated barriers.

Conclusions: As a pilot project, Focus on POCUS served to stimulate interest in developing a standardized ultrasound curriculum and proved to be a practical intervention that was well-received.

P-4: Do Centre for Family Medicine After Hours Clinics decrease visits to Urgent Care and Emergency Departments?

Alison Delorme, Melissa Mills, Sonia Sehgal, Lindsay Woods

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Background: On call clinics are a large component of family health practices and require a great deal of time and resources to arrange. The goal of After Hours Clinics is to improve patient access to care and minimize healthcare costs by reducing the number of visits to urgent Care and Emergency Departments.  The primary outcome of the study was to determine the number of visits to Emergency Departments or Urgent Care Clinics that were prevented by offering after hours access to our patients. 

Methods: We conducted cross-sectional study using an anonymous, 5 question survey. The survey was given to patients who attended the After Hours Clinics over a 2 week period. Patients were included in the study if survey was submitted complete.  Data was analyzed using percentage and frequency distribution tables and graphs.

Results: The majority of patients attending the After Hours clinic were between the ages of 0-5 (37%) and 18-40 (31%). Thirty-four percent of patient would have gone to urgent care and 16% would have attended the emergency department if the After Hours Clinic was not available.

Conclusion: The availability of the After Hours Clinic at the Centre for Family Medicine reduced the number of combined Urgent Care and Emergency Department visits by 50% thereby proving their utility.

P-5: Abnormal vital signs at emergency department discharge: Documentation, adequacy of discharge instructions, and predictors of adverse 30-day outcomes

Andrew Davis, MD, BSc, Alex Folkl, MD, MSc, Keira J. Hodkinson, MD, BSc,Rose Noble, MD.

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Background: Abnormal vital signs (VS) may indicate serious illness. However, patients are sometimes discharged from the Emergency Department (ED) with abnormal VS, often without adequate explanation of these VS or appropriate discharge instructions. Abnormal VS at discharge from the hospital and ICU have been associated with adverse patient outcomes, but research had not examined patients discharged from the ED.

Methods: We conducted a chart review at four community EDs. A convenience sample of patients discharged with abnormal VS was compared with age, gender, and comorbidity-matched controls, who were discharged from the same ED with normal VS. We determined how often abnormal discharge VS were explained in the chart, how often adequate discharge instructions were documented, and whether abnormal VS at discharge predicted adverse 30-day outcomes, including re-presentation to the ED, hospital admission, and death.

Results: We enrolled 105 patients with abnormal VS and compared them to 105 matched controls. Of our 105 cases, only two had their abnormal VS explained. Approximately 60% of each group had adequate discharge instructions. Finally, there were fifteen adverse 30-day outcomes in the abnormal VS group (2 admissions and 13 ED re-presentations) and 19 adverse outcomes in the control group (2 admissions and 17 re-presentations).

Conclusions: Abnormal discharge VS were infrequently explained, and follow-up instructions were only adequate about 60% of the time. In this study, there was no statistical difference in 30-day adverse outcomes between patients discharged with abnormal VS and those with normal VS (RR: 0.76, [0.42-1.47], p=0.45).

P-6: The epidemiology of emergency department visits by adult patients from the Center of Family Medicine in 2013: A Review

Haralambos Lavranos, MD

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Importance: As emergency department wait times are a local and national concern for Canadians, and as trends in emergency referrals from a large family health team can help improve the quality of care at such an institution, an epidemiologic examination of our referrals merits regular analysis.

Objective: to examine the demographic data and the tentative and returning diagnoses from our local family health team.

Data Sources: the electronic medical record used at the center for family medicine, Physician Services Suite.

Method: a search was run in PS Suite to identify patients that had copies of emergency department notes scanned in their chart in the year 2013. These charts were reviewed and progress notes were examined within 2 weeks prior to that ED visit. Demographic data was collected for each patient.

Results: a total of 413 emergency department visits occurred for patients over 50 years old at the center for family medicine for which correspondence was received from the ED. The average age was 69.26, with a male:female ratio of 0.82:1. The diagnostic congruency of those patients who presented to their family doctor within two weeks  of their ED visit was 78.12%, though 63.24% of emerge visits were not seen (or called in to) the FHT.

Conclusions: A recommendation to the family health team would include education to their elderly patients on the nature of infections, as this accounted for the largest percentage of potentially correctible visits to the emergency department that were not recently seen by their family doctor.

P-7: Physician Perspectives on Needs, Gaps, and Opportunities for Improving the Care of Individuals with Severe Mobility Impairments in Primary Care

Lee, Joe; Milligan, Jamie; Hillier, Loretta; McMillan, Colleen; Bauman, Craig*

Centre for Family Medicine FHT

Purpose: To explore family physicians' perspectives on primary care for individuals with severe mobility impairments.

Methods: Qualitative study using structured interviews of family physicians practicing in family health teams within Waterloo-Wellington region in Southwestern Ontario. Twenty structured interviews were conducted in October and November 2012. Inductive analysis was used to identify reoccurring themes in the data.

Results: Barriers to care included getting to the office, lack of specialized equipment, limited physician academic preparation for clinical care, knowledge gaps, time constraints in practice, limited remuneration for extra time required and difficulty accessing community-based services, specialists and laboratories. For some physicians, accessing the Emergency Department to see patients was identified as an easy solution to accessibility challenges experienced in their medical office. Care gaps included the limited use of standardized tools to assess care needs, focus on episodic rather than preventative care, and limited opportunities to conduct proper physical examinations in the absence of specialized equipment. Needed resources to improve care included point-of-practice tools, knowledge of management strategies, staff training on safe patient transfers, greater remuneration, and access to consultation support

Conclusions: The low prevalence of patients with severe mobility impairment per individual family physician negatively impacts the acquisition of necessary equipment and knowledge required to care for these patients; novel approaches to providing care are needed to address this challenge. Multidisciplinary primary care Mobility Clinics established regionally within family health teams might be well positioned to address this gap.

P-8: The Role of Online/Smartphone Applications in Type II Diabetes Management

Rashid, Alina R*; Ho, Certina

*University of Waterloo — School of Pharmacy

Objectives: Multiple interventions, including smartphone applications (or apps), have been developed for patients to self-manage diabetes. This study intends to identify a list of smartphone applications that can be recommended to patients for self-management of diabetes with respect to medication adherence, physical activity, diet, and weight management.

Methods: An environmental scan was performed to identify and evaluate the top 7 diabetes management apps for iPhone, iPad, iPod Touch, Android, and Windows Phones. These apps were assessed based on features, usability, and their authority, accuracy, currency, objectivity, and quality. We interviewed 4 Certified Diabetes Educators (CDEs) and obtained their feedback and experience on the use of these apps in diabetes patient education.

Results: The assessment of the 7 apps revealed some key features that were available in some but not others – medication reminders; tracking of blood glucose readings, insulin dosing, physical activity, weight, blood pressure readings, and carbohydrate intake; electronic synchronization with healthcare providers, and glucometer compatibility. We identified that simplicity of the app, ease of use, and cost were the key factors in determining the best app for self-management of diabetes. iBG Star and Glucose Buddy both fulfilled these criteria, and Tactio Health was a close second.

Conclusions: Smartphones are now an integral part of everyday life. Patients play a critical role in chronic disease management. Pharmacists can expect to receive questions about the role of smartphone apps in the management of diabetes. When recommending phone apps to diabetic patients, it is important to individualize app selection to ensure optimal benefits to patient care.

P-9: The Role of an Online/Smartphone Service in Patient Adherence of Type 2 Diabetes Management: A Qualitative Study (Phase I)

Tsang, Corey*; Ho, Certina

University of Waterloo — School of Pharmacy

Objective: Few studies have taken a qualitative approach to determine the potential role of smartphone applications or 'apps' in the self-management of Type 2 Diabetes. This study aims to evaluate the perceived usefulness and usability of using smartphone and/or online apps in the self-management of Type 2 Diabetes.

Methods: A convenient sample of 15 participants will be recruited from The Centre for Family Medicine (CFFM) with the support and cooperation of the physician group. Patients will be randomized to use either iBG star or Glucose Buddy. Interviews will be conducted at 2 and 4 weeks to determine facilitators and barriers of use, impact on diabetes self-management, and overall patient-perceived impact on health. A qualitative thematic coding approach will be used to identify recurring themes.

Anticipated Results: It is anticipated participants will likely have a tremendously varied opinion regarding the perceived usefulness and usability of apps for the self-management of diabetes. This varied opinion may depend on participant's baseline familiarity with technology or baseline attitude towards self-management activities. 'Hassle' is likely to be a perceived barrier of use and unreliable technology will likely deter user uptake. However, if the technology can be reliably utilized it may help patients streamline their care with their healthcare professional.

P-10: Handbook for a Pilot Study to Reduce Potential Hospitalizations due to Preventable Drug-Drug Interactions

Kawano, Atsushi; Ho, Certina*.

*University of Waterloo — School of Pharmacy

Objectives: Hospital reports on medication incidents suggest 37-51% of reported adverse drug events, including drug-drug interactions (DDIs), may have been prevented with appropriate interventions. This study intends to compile a list of evidence-based DDIs with association to an increased risk of hospitalizations and develop a treatment algorithm handbook to facilitate pharmacists or clinicians in ambulatory care in identifying and offering recommendations to prescribers to prevent these DDIs.

Methods: A comprehensive literature search was conducted and articles were selected based on relevant DDIs that were associated with an increased risk of hospitalization. Evidence-based treatment algorithms were created to suggest alternative therapeutic options for three common community infections – Group A β-hemolytic Streptococcus pharyngitis, outpatient community-acquired pneumonia, and uncomplicated lower urinary tract infections.

Results: Evidence-based DDIs identified in this study involved either a macrolide or trimethoprim-sulfamethoxazole. In all cases, the evidence supported an alternative to either antibiotic for selected community infections. Older persons were underrepresented in trials evaluating antibiotic therapy for community infections. Selecting an appropriate antibiotic required using data derived primarily from children and adults. A treatment algorithm handbook was created for clinicians in ambulatory care.

Conclusions: The list of evidence-based DDIs with association to an increased risk of hospitalizations identified in this study was made available to all pharmacists via the Ontario College of Pharmacists quarterly publication, Pharmacy Connection, in Spring 2013. Pharmacists/clinicians have the option of using the treatment algorithm handbook developed in this project to help resolve and prevent these DDIs.

P-11: Knowledge Translation & Exchange: An Evidence-Based Snapshot Summary of findings from a review of KTE literature and field-expert interviews

Paes, Danielle*

University of Waterloo — School of Pharmacy

Background:  There is ample research being done to improve patient health outcomes, yet it is well known that practice often lags behind science.  Health innovations with proven benefit often fail to translate into clinical practice change due a gap between the generation of knowledge and its integration into practical application. 

Objective:  This poster aims to inform Ontario Pharmacy Research Collaboration (OPEN) knowledge users and their affiliates about the purpose and importance of Knowledge Translation & Exchange (KTE) in research and to promote the early adoption of transfer strategies.

Methods:  A snowball sampling technique was used to identify relevant published literature and produce a list of KTE field-experts to be interviewed.  A general overview of investigation findings, including a summary of two existing frameworks and interview excerpts is presented.

Results: There is a large body of research looking into the study of methods and theories to encourage the uptake and integration of novel findings into clinical practice. Given the vast amount of scientific knowledge available in the field of KTE, researchers who hope to influence positive change using pharmacists as key agents, stand to benefit from a conscious effort to incorporate existing theories into their work.

Conclusion: Adequate consideration must be given to the examination of how knowledge is created, synthesized, disseminated and exchanged when applied to healthcare delivery. Encouraging researchers to start thinking about KTE early in their work, will help ensure new knowledge generated is effectively used to improve care giving and policy making in Ontario.

P-12: The Role of Obesity in Idiopathic Pulmonary Arterial Hypertension

Pandey, Arjun*

* Waterloo Collegiate Institute

Idiopathic Pulmonary Arterial Hypertension (IPAH), defined as elevated pulmonary pressures with no identified secondary triggers, is a progressive condition that ultimately leads to premature mortality. In this study, we examined a potential correlation between obesity and pulmonary pressures, as well as the impact of weight loss on pulmonary pressures. For our study, we recruited 30 individuals with IPAH and 30 individuals with normal pulmonary pressures (control). Participants were prescribed the DASH (Dietary Approaches to Stop Hypertension) diet for an intervention period of two months. Echo-cardiogram studies, to assess pulmonary pressures, and Body Mass Index (BMI) measurements for each individual were compared before and after the two month intervention period. At baseline, participants with IPAH had an average 7.1 kg/m2 greater BMI than the control population (p<0.0001). 100% of participants with IPAH had a BMI greater than 30.0 kg/m2, classifying them as an obese population. All patients with IPAH who lost weight had a reduction in pulmonary pressures from baseline. Participants who achieved a clinically significant weight loss, (5% or greater reduction in BMI), had pulmonary pressures that decreased by 25% on average. Linear regression analysis demonstrated strong, positive correlations between obesity (measured through BMI) and pulmonary pressures (r=0.8975, p<0.0001), as well as weight loss, and reductions in pulmonary pressures (r=0.9225, p<0.0001). Based on the findings of this study, it would appear that obesity may be a contributor to Idiopathic Pulmonary Arterial Hypertension and a weight loss strategy employing the DASH diet may be a potential therapeutic avenue warranting further investigation.

P-13: PHQ-9 versus Clinical Judgment as a Superior, Objective Method of Monitoring Depression

A. Alangh, S. Gervais, & J. Penhearow

Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Description: The present study assessed the perceived purpose, strengths, weaknesses, utility and usefulness of the PHQ-9 by 29 staff and resident physicians practicing at the Center for Family Medicine family health team in Kitchener, Ontario fromDecember 2013 to January 2014.

Background:The Patient Health Questionnaire – 9 (PHQ-9) is an objective tool employed by clinicians to identify and monitor depression in a primary health care setting. The PHQ-9 is reported to be 92% sensitive and 80% specific for establishing a depressive episode and reduces clinician personal bias, transference, and countertransference which may cloud the diagnostic process(Gilbody et al., 2007). Yet tools used in a busy clinical setting must be both efficient and useful to both the practicing clinician and patient.

Methods:Physicians completed a pre-survey assessing the PHQ-9's purpose, strengths and weaknesses as well as present use of the PHQ-9 within their patient population. During thetwo month study periodphysicians were encouraged to incorporate PHQ-9 surveys using paper, electronic, or both formats into clinical practice at their discretion. A post-survey was then administered to assess any change in PHQ-9 utility, present use, and likelihood of continued use into future practice.

Results:Collected data revealed that most participants (89%) agreed that the PHQ-9 was useful for both identifying and monitoring depression. The data suggested approximately half of participants did not use or rarely used the PHQ-9 in clinical practice (30% vs. 26%), with the other half of participants using the scale more frequently. Interestingly, despite this trend the majority of participants rated their planned future use of the PHQ-9 scale more than likely (88%). Those that used the PHQ-9 were more likely to utilize the paper copy (55%) as opposed to the electronic stamp (30%) or both formats (15%). There was no statistical significant difference between pre- and post-survey for perceived usefulness of the PHQ-9 to diagnose and monitor depression (95% CI -0.596 to 0.044; p= 0.088).

Conclusion:The authors offer an exploration of the study's findings, strengths and weaknesses, and potential implications. Finally, recommendations for future research regarding the ongoing diagnosis and monitoring of clinical depression are offered.

P-14: Discharging Patients Admitted for Acute Psychiatric Stabilization in Guelph: Caring for Their Needs in the Community

Snelgrove, Natasha*, BMSc, MD; Costa, Andrew, PhD; Eppel, Alan, MB, FRCPC

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

*McMaster University — Department of Psychiatry and Behavioural Neurosciences

Background: Care transitions are a critical part of mental health care for patients discharged from inpatient settings. At Homewood Health Centre, the Crisis and Stabilization Unit relies primarily on CADS (Community Addiction Division Services) and CMHA (formerly Trellis) for outpatient resources for discharged patients.

Methods: A retrospective chart review of 25 charts during the July to December 2012 time period was undertaken to look at how referral processes could be better tailored to provide more seamless follow-up care for discharged inpatients. We explored demographic and clinical variables, including diagnosis, to length of stay (LOS) and links to follow-up care within the community.

Results:Although diagnoses of SPMI (Severe and Persistent Mental Illness) and primary Axis II diagnoses positively predicted LOS (16.6 +/- 5.2 and 22.0 +/- 7.1 days respectively), and Substance Use Disorder (SUD) negatively predicted LOS (10.6 +/- 5.9 days), no demographic or clinical factors correlated with later ongoing follow-up with mental health or psychiatric supports in the community.

Furthermore, many patients with SUD were not referred for treatment with CADS (43% of patients lacked referral).

In addition, the SPMI population showed some preliminary evidence of both increased complexity and severity of illness as well as underserviced needs, as demonstrated by multiple factors, including increased likelihood of HCV positive status (37.5% of sample vs 0% of non-SPMI) and lack of primary care physician (37.5%).

Conclusion:Many areas for potential intervention to improve discharge and better use our limited psychiatric and mental health resources may be possible as a result of this preliminary data.

P-15: McMaster Physician Wellness Week

Mountjoy, Margo*, Costa, Andrew

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Background: Medical students and residents are at high risk of burnout because of the immense demands during their education. Evidence shows that intervention to increase the use of active coping and social support, to reduce reliance on avoidance coping, and to decrease work and family stressors can have a beneficial effect on residents' well-being.

Objective: The Wellness Committee of Michael G. DeGroote School of Medicine at McMaster University implemented a programme to promote wellness by facilitating physical-, emotional- and mental health promoting activities during the week of March 17th, 2014.

Methods: The McMaster Wellness/Mindfulness Week is a multifaceted educational project designed to promote all domains of wellness in the three distributed campuses targeting the undergraduate and post graduate level students. The Wellness week focused on five themes: mental health, health nutrition, physical fitness, the arts, and laughter. A pre-post cohort study was completed that measured burnout, depression, and mindfulness at baseline, post wellness week, and 90 days post wellness week. Maslach's Burnout Inventory, PRIME MD Patient Health Questionnaire and Toronto Mindfulness Scale were used.

Results: Pre-survey results showed that there was considerable interest in wellness week activities. This suggests that wellness initiatives are valuable from many learner's perspective. Before wellness week, the majority of learners were experiencing high burnout across all dimensions. Almost half of learners had potential major depression. Mindfulness scores where low overall. The data show that helping to reduce burnout in medical students and residents is crucial. This study offers initial support for continuing wellness initiatives at our school, which in future may be shared with other medical schools across Canada

Conclusions: Effectiveness of the program is pending. Follow-up is now underway.

P-16: Adoption of dose-escalated prostate radiotherapy at Grand River Regional Cancer Centre

Stephens, Robert F.*; Xu, Samuel S.*; Costa, Andrew; Gopaul, Darin.

* Grand River Hospital – Grand River Regional Cancer Centre

* Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Objective: To report the trends in radiotherapy dose-escalation for curative intent prostate cancer treatment at Grand River Regional Cancer Centre (GRRCC) from 2005 to 2013.

Methods and Materials: The radiation therapy patient database was queried to obtain all patients undergoing curative intent radiotherapy for prostate cancer at GRRCC from 2005 to 2013. Data was collected regarding dose and fractionation and year of treatment. The GRRCC policy for prostate treatment was reviewed to assess compliance. A review of the literature was also performed to identify publications supporting dose escalation, and advancements in radiation-delivery techniques that may have contributed to dose-escalation in radiotherapy. In total, data from 354 patients were included.

Results: 354 men were treated with curative intent for prostate cancer at GRRCC from 2005 to 2013 inclusive. A trend in dose-escalation was observed for men receiving radiotherapy at GRRCC for the treatment of prostate cancer. The absolute number of men receiving 78 Gy progressively increased from 1 patient in 2005 to 79 patients in 2013. The percentage of men receiving 78 Gy increased from 12.5% in 2005 to 100% in 2013.

Conclusion: In compliance with recent research and policy changes, GRRCC has progressively increased the dose of radiation delivered to the prostate of men being treated with curative intent for prostate cancer from 2005 to 2013.

P-17: Effects of intestinal microbiota on the postnatal development of dopaminergic myenteric neurons

Mungovan, Kal A.*; Borojevic, Rajka; Ratcliffe, Elyanne M.

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Objectives: The composition of the intestinal flora, although largely stable in adulthood, is relatively labile during infancy. In the present study, we investigated whether composition of the intestinal microbiota influences postnatal development of the enteric nervous system (ENS). We focused our analysis on dopaminergic neurons, which play an important role in modulating intestinal motility.

The proportion of enteric dopaminergic neurons has been shown to be dependent upon the availability of serotonin. In the GI tract, serotonin can be of either neuronal or enterochromaffin cell origin. We investigated serotonin from both cell types as a potential intermediary for microbiota-driven changes in enteric dopaminergic neurons.

Methods: Using immunohistochemistry, the myenteric plexus and intestinal mucosa were respectively examined in whole-mount and cross-sectional preparations of specific pathogen-free (SPF) and germ-free (GF) mice at three time-points: postnatal day 1 (P1), P7, and P28.

Results: The density of dopaminergic neurons did not differ significantly between SPF and GF mice in any region of the intestine examined at P1. However, at P7, GF mice had significantly fewer myenteric dopaminergic neurons in the ileum than did SPF mice, and this difference persisted at P28. Neither the density of serotonergic neurons, nor that of enterochromaffin cells was affected by GF status during the postnatal period.

Conclusions: The finding of reduced enteric dopaminergic neuron densities in GF mice is consistent with the notion that intestinal microbiota can influence the development of the ENS. The mechanism underlying this effect has yet to be determined but is likely independent of intestinal serotonin.

P-18: 'Let's just get a CT' … The not-so-benign consequences of contrast dyes: A case report

Dr. Stephen Giilck*, Kunal Bhanot, and Dr. Khalid Azzam

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

When discussing implications of imaging modalities with patients, radiation exposure and nephrotoxic consequences of contrast dyes are often cited. Anaphylactoid reactions associated with contrast dyes are also of particular concern. Although iodinated contrast dyes are generally well tolerated and nephrotoxic effects mitigated through fluid boluses, management of cutaneous drug reactions in these instances are particularly challenging.

Here we present a case of a 69-year-old woman who was admitted to hospital with a 3-4 day history of subjective fever, general malaise, and skin lesions following renal imaging with administration of iodinated non-ionic iso-osmolar contrast dye.

The cutaneous lesions were diffuse eruptions of edematous erythematous papules that were non-crusting and non-exfoliating and found on over 70% of major body surfaces, including genitalia. A working diagnosis of erythema multiforme/toxic epidermal necrolysis (TEN) was established. Subsequent management with intravenous immunoglobulin (IVIg) and hydroxyzine was initiated and able to resolve the lesions with minimal remnants remaining on the scalp and neck.

This case highlights the importance of maintaining a high-degree of suspicion for contrast dye associated reactions and provides a management strategy for substantial cutaneous effects.

P-19: Intravitreal Ranibizumab (Lucentis) for Treatment of Marathon Runner's Retinopathy: A Case Report

Soon, Alexander*; Chow, David

*Michael G. DeGroote School of Medicine — Waterloo Regional Campus

Objectives: To report a case of atypical retinopathy in a 24-year old marathon runner with no other significant medical history.

Methods: Case Report

Results: At presentation, ocular examination revealed 20/100 and 20/20 visual acuity in the right (OD) and left (OS) eyes. Pupils were equal and reactive to light with no afferent pupillary defect. Slit lamp examination was normal. Dilated fundus exam revealed diffuse, florid retinal and optic disc edema, venous dilation and tortuosity in all quadrants, disc hemorrhages, and multiple perifoveal  hard exudates. Fluorescein angiography confirmed non-ischemic central retinal vein occlusion. Macular integrity assessment (MAIA) demonstrated a fixation defect in the form of an abnormal preferred fixation locus. Over the course of eight months, six intra-ocular injections of ranibizumab (Lucentis) were administered following a treat and extend protocol. Final visual acuity of 20/25 OD was achieved with complete resolution of retinal findings and MAIA defects. 

Conclusions: Extreme physical activity favours a hypercoagulable state through abnormal activation of platelets and other clotting elements. This results in an increased risk of thrombus formation and subsequent non-ischemic central retinal vein occlusion. Administration of anti-VEGF therapy using Intra-ocular Lucentis proves to be a promising treatment option to resolve ocular complications.

P-20: Following celebrities' medical advice: a meta-narrative analysis

Tan, Charlie*; Hoffman, Steven J.

*Michael G. DeGroote School of Medicine – Waterloo Regional Campus

Rationale: Celebrities can have substantial influence as medical advisors. However, their impact on public health is equivocal: depending on the advice's validity, celebrity engagements can benefit or hinder efforts to educate patients on evidence-based behaviours and improve their health literacy.

Objective: To synthesize multiple disciplinary insights explaining the influence celebrities have on people's health-related behaviours.

Methods: A meta-narrative analysis of economics, marketing, neuroscience, psychology, and sociology literatures was conducted. Empirical evidence and established theories from each discipline were prioritized in crafting each narrative.

Results: According to the economics literature, celebrities distinguish endorsed items from competitors and can catalyze herd behaviour. Marketing studies tell us that celebrities' characteristics are transferred to endorsed products, and that the most successful celebrity advisors are those viewed as credible, a perception they can create with their success. Neuroscience research supports these explanations, finding that celebrity endorsements activate brain regions involved in making positive associations, building trust and encoding memories. The psychology literature tells us that celebrity advice conditions people to react positively toward it. People are also inclined to follow celebrities if the advice matches their self-conceptions or not following it creates cognitive dissonance. Sociology explains how celebrities' advice spreads through social networks and how their influence is a manifestation of people's desire to acquire celebrities' social capital.

Conclusion: The influence of celebrity status is a deeply rooted process that can be harnessed for good or abused for harm. A better understanding of celebrity can empower health professionals and public health practitioners to take this phenomenon seriously and educate the public about sources of health information and their trustworthiness.

P-21: Care recipient health conditions and informal caregiver distress

Betini, Raquel*; Bowyer, Judy; Weylie, Sean; Parkinson, Carrie; Curtin-Telegdi, Nancy and Hirdes, John.

University of Waterloo — School of Public Health and Health Systems

Background: A shortage of long-term care beds and the desire of Canadians for aging at home are two of the issues facing a population with an increasing number of elderly. With the aim of addressing these issues, the Mississauga Halton LHIN launched the Caregiver Recharge Program (CRP), an initiative that provides flexible hours of respite to minimize the burden of caregiver activities.

Objective: The objective of this study is to better understand the needs and issues of informal caregivers who are providing care to those with complex health problems.

Methods: Caregivers completed an interRAI Caregiver Survey at program entry and at 6 and 12 months after program entry. Care recipients were assessed using the interRAI CHA or RAI-HC. The Caregiver Survey and care recipient assessments were linked to evaluate the impact of the MH LHIN CRP on health outcomes of clients and their caregivers. Bivariate frequency distributions were used to identify variables linking caregiver distress and care recipient characteristics.

Results: Preliminary results suggest that informal caregivers caring for persons with Alzheimer's disease experience higher levels of emotional distress and anxiety, and report more often feelings of loneliness than caregivers caring for persons who do not have Alzheimer's disease. They also are more likely to report that the person they are caring for would be better off elsewhere.

Conclusions: Understanding the relationship between client and informal caregiver characteristics can assist organizations in shaping or modifying their care environments that ultimately improves caregiver's ability to execute their informal caregiver role.

P-22: An evaluation of the quality of RAI-Home Care data in Ontario

Hogeveen, Sophie*, Jantzi, Micaela, Hirdes, John

University of Waterloo — School of Public Health and Health Systems

Objectives: The aim of this project is to describe the quality of data collected using the RAI – Home Care (RAI-HC) from 2003 to 2013. This project seeks to determine whether the same techniques used to evaluate the quality of data in Canada's Continuing Care Reporting System (CCRS) can be adapted and used to monitor the quality of RAI-HC data.

Methods: Data from the RAI-HC implementation in Community Care Access Centres across Ontario were analyzed using various statistical techniques in order to assess trends in population characteristics and associations between items, convergent validity, and scale reliability.

Results: Initial results indicate that there is a stable moderate correlation between Activities of Daily Living (ADL)-long form scale items and Cognitive Performance Scale items. Further, ADL-long form scale items and depression ratings scale items both have high internal consistency stable over time. The findings are comparable to the findings observed in the evaluation of the CCRS.

Conclusions: The results from this work provide insight into the quality of data collected using the RAI-HC and may indicate strengths and areas for improvement at both a practice and policy level as high quality data and information is vital when used for decision-making to improve quality of care and enhance quality of life.  This work also provides a new method for evaluating the quality of data obtained through community-based measures.

P-23: Feasibility of implementing the Lifestyle-integrated Functional Exercise (LiFE) intervention in primary care for adults over 75 years of age: proposed protocol for an implementation study

Gibbs, Jenna*; McArthur, Caitlin; Milligan, James; Clemson, Lindy; Lee, Linda; Boscart, Veronique; Heckman, George; Keller, Heather; Rojas-Fernandez, Carlos; Stolee, Paul; Giangregorio, Lora.

*University of Waterloo — Department of Kinesiology

Objectives: Our goal is to evaluate how to implement an evidence-based lifestyle-integrated strength and balance exercise (LiFE) intervention in primary care to promote increased physical activity (PA) and improvements in function and quality of life (QOL) in older adults ≥75yrs. This pilot study will evaluate the public health impact of the LiFE intervention using the RE-AIM model: reach (recruitment), effectiveness (PA levels), adoption (physician acceptance), implementation (fidelity), and maintenance (retention, adherence).

Methods: The proposed design is a pre-post feasibility study delivered in primary care. All patients ≥75yrs presenting at Centre for Family Medicine over a six-month period who are not acutely ill will be screened. Those who do not exercise regularly and are medically cleared to participate in exercise will be eligible. The LiFE intervention includes movements prescribed to improve balance and increase strength that are integrated into daily life activities. Participants will attend one individual and four group-based sessions led by a physiotherapist over two months, and receive two phone calls.  Assessments will be completed at baseline and six months. Primary outcomes include feasibility of recruitment over six months and adherence measured using activity diaries. Secondary outcomes include PA levels measured using accelerometers, function via Short Physical Performance Battery, QOL via the EQ5D-5L, and fidelity.

Conclusions: The public health impact of the LiFE intervention for older adults will be evaluated, as well as the effects of the intervention on important secondary outcomes. If the intervention appears feasible, we will use the resultant information to design a larger pragmatic trial.

P-24: The Health of Elderly Korean, Chinese, and Other Home Care Clients, and Caregiver Distress in Ontario, Canada

Chang, Byung Wook; Hirdes, John P.

University of Waterloo — School of Public Health and Health Systems

Objectives Korean immigrants came to Canada in increasing numbers over the past two decades and they now represent 0.3% of the total Canadian population. Immigration later in life is stressful because it forces cultural adjustments and may pose language barriers. Elderly Korean immigrants often lack information and preparation to adjust to the major changes in cultural norms and social conditions. The purpose of this study is to examine the health of elderly Korean-Canadians with a particular emphasis on distress of families caring for elderly members.

Methods: A cross-cultural comparison of Korean, Chinese and other Canadian home care clients was done using the Resident Assessment Instrument – Home Care (RAI-HC) assessment that was done as part of normal clinical practice between January 2002 and December 2012 within Ontario. Data from a sample of 773,276 home care clients were analyzed using descriptive statistics and chi-square analysis at the bivariate level, and multiple logistic regression models were used to investigate risk factors for caregiver distress.

Results: The major finding of the present study was that Korean clients had higher physical impairments, and higher prevalence of major chronic diseases but they were less likely to receive personal support or nursing services. Moreover, the results provide clear evidence of the importance of language barriers for all linguistic minorities, including Korean-Canadians clients and their family members. 

In addition to ensuring cultural competence of staff members dealing with minority home care clients, the practical problems caused by language barriers should be addressed by health and social service providers.

P-25: The relationship between disruptive pain and social functioning in terminally-ill home care clients

Davidson Jake*, Guthrie Dawn M

Wilfrid Laurier University — Kinesiology and Physical Education

Background: Little is currently known about disruptive pain in the home care population who are considered end-of-life. The goal of this study was to identify which demographic, clinical and functional characteristics were risk factors for disruptive pain in clients with a terminal illness. 

Methods: Secondary data from Ontario were analyzed using information from the Resident Assessment Instrument for Home Care (RAI-HC). Disruptive pain was described as pain that impaired a client's ability to carry out usual activities, as identified by one item on the RAI-HC. Social functioning was captured by three items on the assessment and included the change in social activities (e.g., social, occupational or other preferred activities) and whether the person felt distressed by this, the amount of time spent alone and whether the client experienced loneliness. The sample included 2,757 home care clients aged 65+, with a prognosis of less than six months or severe health instability.

Results: The prevalence of disruptive pain was 42%.  There was a significant increased risk of disruptive pain for clients who felt distressed with a decline in social activities (odds ratio=1.80; 95% confidence interval:1.40, 2.3), and for those who reported loneliness (OR=1.43; CI: 1.1, 1.85).  These relationships were not confounded by age, sex, level of cognitive impairment or signs/symptoms of depression. 

Conclusion: Clients' perceptions of their level of social engagement are strongly related to the way they experience pain.  Interventions for home care clients that address social functioning, or their degree of pain, may have far-reaching benefits to their overall well-being.

P-26: Facilitators and Barriers of Implementing the Chronic Care Model in Primary Care: A systematic review

Kadu, Mudathira*; Stolee, Paul

University of Waterloo — School of Public Health and Health Systems

Introduction: The Chronic Care Model (CCM, Wagner, et al., 1996) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care.

Objectives: To identify facilitators and barriers encountered by primary care practices during the implementation of the CCM.

Methods: This study identified English-language, peer-reviewed research articles, describing the CCM in primary care settings. Searches were performed in three data bases: Web of Knowledge, Pubmed and Scopus. Articles were included if they met the following abstracts and titles were read based on whether they met the following inclusion criteria: 1) studies describing or evaluating the implementation of the CCM; 2) the care setting was primary care; 3) the target population of the study wasere adults over the age of 18 with chronic conditions. Studies were categorized byb reference, study design and methods, participants and setting, study objective, CCM components used, and description of the intervention. The next stage of data abstraction involved qualitative analysis using the Consolidating Framework for Research Implementation (Damschroder, et al, 2009).

Results: This review identified barriers and facilitators of implementation across various primary care settings in 22 studies. The major emerging themes were those related to the inner setting of the organization, the process of implementation and characteristics of the individual healthcare providers. These included: organizational culture, its structural characteristics, networks and communication, implementation climate and readiness, presence of supportive leadership, and provider attitudes and beliefs.

Conclusions: These findings highlight the importance of assessing organizational capacity and needs before implementing the CCM, as well as gaining a better understanding of health care providers' and organizational perspective.

P-27: A Profile of Community-Dwelling Stroke Survivors Receiving Home Care Services in Ontario

Zoratti, Michael*; Fisher, Kathryn; Elston, Dawn; Griffith, Lauren

*McMaster University — Clinical Epidemiology and Biostatistics

Background: Aging in the Canadian population is associated with a rising burden of chronic conditions and multimorbidity (diagnosis of 2+ concurrent conditions).  Nearly 25% of Canadian seniors have 3+ chronic conditions, accounting for 40% of health service use. Multimorbidity is particularly common in stroke patients, with administrative and home care databases indicating that 85-90% have 3+ chronic conditions. Most stroke research focuses on hospital rehabilitation units and shows that common co-morbid conditions include depression, hip fractures, cognitive impairment and declining mobility, dexterity and communications. However, little is known about the burdens facing community-dwelling stroke survivors.

Objective: This study will report on the chronic conditions, demographic and clinical characteristics, cognitive and physical functioning, social conditions and health care utilization in community-dwelling stroke survivors over the age of 65 in Ontario.

Methods: We will analyze Resident Assessment Instrument-Home Care data from 2007-2012 for Ontario's long-stay home care clients.  We will compare stroke survivors with 3+ co-morbidities (n=48,662) to those with less than 3 (n=8,247) and to non-stroke clients (n=262,785). Cluster analysis will be used to identify and compare multimorbidity patterns across groups.

Anticipated Results and Conclusions: Preliminary results indicate that approximately 57% of non-stroke patients have 3+ co-morbidities, compared to 86% of stroke patients. We hypothesize that higher multimorbidity in stroke patients will be associated with more functional and cognitive impairment, social problems and service utilization. Our results will highlight the complex needs of stroke survivors, and facilitate service planning to improve self-care skills and support stroke survivors to remain at home.

P-28: he Utility of Point of Care Tests to Diagnose Heart Failure in Long Term Care

Chetram, Vishaka*, Hinton, Stephanie, Hemraj, Atiya, Heckman, George

University of Waterloo — School of Public Health and Health Systems

Background/Objectives: Approximately 20% of heart failure patients in long term care are re-admitted as an unplanned transfer to hospital and those discharged back to long term care experience further decline and limited survival. Poor prognosis is linked to the decreased likelihood of frail, older LTC residents receiving recommended therapies due to physician concerns over geriatric syndromes and diagnostic accuracy. We sought to determine the utility of bedside tests to aid in the diagnosis of heart failure in long term care.

Methods: A scoping review was deemed appropriate to provide a holistic view of trends in current research and provide insight into future initiatives. Abstract screening identified 1,276 papers from 5 databases including Scopus, Pubmed, Cochrane, Web of Science and Embase, of which 9 articles met the inclusion criteria.

Results: Echocardiogram is considered the gold standard and recommended throughout many European and Canadian guidelines. However, recent findings have debated its' usefulness and provide evidence against its' utility. Pulse pressure, a test useful in diagnosing COPD provided poor sensitivity and specificity values. Jugular venous pressure, often an inappropriately administered clinical test can provide diagnostic utility and its' assessment can be easier using emerging technologies. Biomakers, particularly NTproBNP and BNP (brain natriuretic peptide) research is limited in this population and needs further investigation. 

Conclusions: Overall, research is limited in validating point of care tests to assist differential diagnosis of heart failure in long term care. The need to validate the use of biomarkers and jugular venous pressure are of paramount importance.

P-29: Responding to the Behavioural Needs of Seniors through 'Language' Creates a Positive Transformation of 'Culture'

Laura Holtom* Peg Muhbauer*

*Wellington Terrace Long Term Care Home

Objective: The use of language is critical in demonstrating that transforming a culture is essential.  It is important to educate families, residents, volunteers and staff in how to respond to the behavioural needs of residents.  Language demonstrates compassion, respect and dignity. It helps shift the attitude from 'aggressive residents' ' to a solution focused approach asking the question; 'how can we support each individual who's impairment has resulted in behaviours they have no control of'.  Language change in Long Term Care also helps eliminate the stigma that exists and helps create a culture of this is 'the Senior's Home'.

Method: The Method included: Education, Knowledge Transfer, Mentoring and Coaching.  Case based learning and recognition of Champions within the Home.

Results and Conclusions: Shift in language within the Long Term Care Home resulted in a positive approach that is solution focused and decreased labeling such as 'aggressive'.  A focus on supporting the resident decreased the focus of behaviours being labelled aggressive or aggression towards staff and resident to resident. Enhanced evidence of compassion, respect and dignity through the use of language for example is; the term 'bib' was replaced with the term 'apron'.  A collaborative approach within the Long Term Care Home resulted in an enhanced use of language by families, residents, volunteers and staff to support the transformation of culture in the 'Seniors Home'.

P-30: Improving Dementia Assessment:  Effect of a Structured Approach and 'Brain Map' Tool

Lee, Linda*; Hillier, Loretta M; Weston, W. Wayne

*Centre for Family Medicine FHT; Department of Family Medicine, McMaster University

Objective: Currently, dementia care provided by family physicians is suboptimal.  The objective of this study was to determine if a 3 hour Workshop incorporating a structured clinical reasoning approach and 'brain map' tool may help family physicians in assessing patients with memory difficulties.

Methods: 135 clinicians participated across six workshops; 126 participants completed a workshop reaction survey and 67 completed a 3-month follow-up survey to assess knowledge transfer.  5-point rating scales were used to assess the value of the brain map and clinical reasoning approach to clinical practice and workshop impacts on self-reported confidence and ability to assess and manage Cognitive Impairment (CI).

Results: 98% of respondents reported that this workshop was useful to their practice. At follow-up, 96% of respondents indicated they had applied what they learned to their practice. For the majority, the brain map (68%) and clinical reasoning approach (84%) were rated as 'very' or 'extremel' useful.  Compared  to prior to this workshop, the majority reported they were better able to assess (93%) and manage (96%) CI, and were more confident in their ability to assess (93%) and manage (96%) CI; respondents reported that quality of care had 'improved' (73%) or'much improved' (24%) as a result of this workshop.

Conclusions: A 3-hour workshop focused on CI, using the 'brain map' and clinical reasoning approach, was effective in improving participants' confidence to assess and manage patients with CI. This enhanced self-efficacy was associated, in a follow-up survey, with self-reported improvement to the quality of care provided.

P-31: Increasing Access to Specialized Geriatric Services by Decreasing Wait Times and Enhancing Wait List Management

Jane McKinnon Wilson* Dr. Carrie McAiney, Loretta Hillier, Maria Boyes, Audrey Devitt, Sheli O'Connor, Cathy Sturdy-Smith

Canadian Mental Health Association Waterloo Wellington Dufferin/Waterloo Wellington Geriatric Services Network

Background: In response to the long wait time (estimated at 18-months) and long wait list for specialized geriatric assessment across the Waterloo Wellington Local Health Integration Network  a collaboration was formed between Geriatric Medicine and the Geriatric Emergency Management Clinic Program to develop a Nurse Practitioner (NP) geriatric service. Working in collaboration with geriatricians, the NPs conduct comprehensive geriatric assessments, develop care plans, support primary care to implement the identified care plans and monitor progress and/ or adjust medications as needed. In addition to patients served in clinic, this NP Geriatric service includes home visits as a core service.

Objective: The ultimate objective of this initiative is to improve care for older adults by decreasing the risk of medical complications and supporting best practices for early intervention. It is anticipated that better management of the wait time and wait list for geriatric assessment will free up specialist resources to focus on high priority complex seniors.

Evaluation Objectives:  The identified objectives of this evaluation were to: Describe the seniors assessed and services provided by the NP Geriatric Service, identify impacts associated with the NP Geriatric Service, and describe the development and implementation of this initiative

Methods: Client and Service Information were used, as well as case studies, a survey of referral sources, and key informant interviews.


Across all three geriatric medicine sites the NP Geriatric Service, as supported by the clinical intake coordinator role, has achieved its objective of reducing wait times for geriatric assessment and in particular, wait time for urgent referrals and contributed to the overall reduction of the wait list for Specialized Geriatric Services, significantly reducing the number of patients on the wait list overall. The wait time decreased to 4-6 weeks in some geographical areas to 4 months in the area with the initial 18 month wait time in a time period of 5 months. Generally this care model was described as adding value to the existing system of care for seniors, ensuring that seniors have access to the 'right care, in the right place, at the right time', consistent with Ontario's Action Plan for improved healthcare.  This access is facilitated by the Clinical Intake Coordinator role, which was described by key informants as critical to ensuring access based on priority and need, and to streamline referrals to the most appropriate service and thus facilitating efficiencies in work of the NPs and geriatricians.

P-33: A conversational interview with older patients and families provides information that could complement standardized assessment data used for quality improvement

Lafortune, Claire*; Elliott, Jacobi; Dr. Egan, Mary; Dr. Stolee, Paul

University of Waterloo — School of Public Health and Health Systems

Objective:  Standardized assessments used in healthcare settings capture valuable information on patients' demographic and diagnostic characteristics, health conditions, and physical and mental functioning; these data are frequently used for care planning, clinical research, resource allocation, and quality improvement.  We sought information that older patients and families considered important that might not be included in standardized assessments, but that could be learned through a conversational interview. 

Methods: We conducted a secondary analysis of interview data collected as part of a larger ethnographic field study investigating care transitions for older hip fracture patients. Transcripts were analyzed from 29 interviews (21 patient interviews; eight caregiver interviews) relating to eight hip fracture patients from three sites [large urban (Vancouver), smaller urban (Kitchener-Waterloo), rural (Strathroy, ON)]. Each transcript was analyzed by two researchers using a combination of directed and emergent coding.  Results were reviewed in two focus group interviews with seniors and family members to assess potential generalizability. Themes were compared to items from standardized assessments, including the National Rehabilitation Reporting System and the Home Care Reporting System.

Results: Though several themes that emerged from the data were included in the standardized assessments, additional areas were identified that were important for these patients, such as their specific living situations, their feelings during the care process, and caregiver involvement in care.

Conclusion: Standardized assessment tools offer valuable patient information to healthcare providers, however a less-structured interview approach can yield information that would otherwise be missed.  Combining both sources could yield better-informed health care planning and quality improvement efforts.

P-34: Risk of Falls Associated with Anticonvulsant Medication Use in the Ambulatory Elderly Population: A Systematic Review

Maximos M*, Patel T.

*University of Waterloo — School of Pharmacy

Introduction: Although studies show a correlation between the use of anticonvulsants and an increase in the risk of falls, a systematic evaluation of the literature is not available to guide clinicians in the use and dosing of medications in this class.

Objective: This systematic review is intended to assess the risk of falls associated with anticonvulsant medication use in the ambulatory elderly population. Methods: Complete published texts were obtained from PubMed, EMBASE, MEDLINE and the Cochrane Library databases. The main search terms used were: falls, elderly/aged/older adults, anticonvulsants as a general search term and specific anticonvulsants. All trials, except for case studies and case series were assessed for inclusion.

Results: 96 separate searches were performed using different search terms and combinations, which resulted in a total of 1432 citations.  Of these, 399 were unique articles; the remaining 1033 articles were duplicates of searches already retrieved. Of the assessed articles, 7 studies were included for data analysis in this systematic review.

Conclusion: In accordance to published studies assessed in this systematic review on the elderly ambulatory population, the use of anticonvulsant medications increases the risk of falls by at least 1.62 times. Risk of repeated falls was increased by at least 2.5 times in anticonvulsant medication users than non-users.

P-35: Effectiveness of Extracurricular Journal Clubs on Pharmacy Students' Learning of Evidence-based Medicine and Critical Appraisal

Tsang, Joyce*; Ho, Certina; Wasfi, Olla; Power, Mary; Morphy, Brett; Patel, Saurabh; Poon, Calvin; Tong, Boris.

*University of Waterloo — School of Pharmacy

Objectives: Pharmacists are medication therapy experts. It is important to fully equip prospective pharmacists early in their undergraduate training on how to practice evidence-based medicine (EBM) and critical appraisal (CA) skills. This study intends to investigate the effectiveness of extracurricular student-driven journal clubs in enhancing pharmacy students' EBM knowledge and CA of primary literature.

Methods: Eight one-hour extracurricular journal club sessions were organized by students. Students who voluntarily attended journal clubs were asked to complete an online questionnaire to self-report their learning and understanding of EBM and CA concepts. Journal club presenters were invited to focus groups to share their experience.

Results: Attendance of each journal club ranged from 25-50 students. Out of the 28 students who completed the questionnaire, 57% agreed that they were able to critically appraise primary literature in a timely fashion; 68% believed that they were able to formulate clinically-relevant conclusions from research studies; and 57% were confident in presenting clinical decisions based on assessment of a research study. We conducted 3 focus groups with 22 student presenters who found themselves more proactive in seeking evidence-based clinical decisions and strived for continuous development of their CA skills.

Conclusions: Pharmacy students self-reported that journal clubs offered them a platform to further practice and apply their knowledge on EBM and CA skills. Traditional didactic teaching/learning in classroom serves as an introduction to EBM and CA. Students need to continuously practice these skills in order to fulfill the competencies of being a medication therapy expert capable of evaluating and applying EBM in practice.

P-36: Examination of Podcast Use in Higher Education and Development of a Framework for Podcast Creation to Supplement University of Waterloo Pharmacy Students Learning

Kani, Michael*; Ho, Certina

*University of Waterloo — School of Pharmacy

The objective of this project was to examine the use of podcasts in higher education and to develop a framework for creating podcasts to supplement pharmacy student learning at the University of Waterloo.

Podcasting is an asynchronous way of circulating multimedia files ('podcasts') using feeds that are syndicated (RSS) over the Internet for playback on portable media devices or computers at the user's convenience. Currently, the use of podcasts for teaching and learning at the University of Waterloo School of Pharmacy (UWSOP) is non-existent.

A conducted pharmacy student needs assessment with 138 UWSOP students indicated that 100% of respondents have access to podcast-capable devices for listening. As well, although 64% of students do not currently listen or subscribe to podcasts, they are nevertheless very interested or somewhat interested in pharmacy student-related content podcasts (77%).

Overall, literature suggests that students perceive podcasts as really useful additional resource to supplement their learning rather than as a substitute for more traditional methods of learning. Podcast takes advantage of the ubiquitous devices and networks to allow for 'anytime' learning 'anywhere'.

To initiate the creation of podcasts for pharmacy students, a framework was developed that takes into account the necessary steps and elements needed with minimal cost, ease of use, simple, and sustainable. This framework engages both faculty and students in knowledge creation.

In conclusion, podcasts may offer UW pharmacy students the opportunity of supplemental learning through the use of a technology that they already carry, depend on, and is part of their social practice.

P-37: Impact of Experiential Learning on the Professional and Personal Development of Undergraduate Pharmacy Students

Ho, Certina*; Kawano, Atsushi; Morphy, Brett.

University of Waterloo — School of Pharmacy

Objectives: The School of Pharmacy at the University of Waterloo is the only undergraduate pharmacy program in Canada that includes a co-op component. Pharmacy has evolved from a dispensing-focused to a patient-oriented health care profession over the last decade. This project uses an exploratory descriptive qualitative research to attempt to find out how co-op experiences affect the professional and personal development of pharmacy students.

Methods: In order to explore the skills development during co-operative experience of undergraduate pharmacy students, open-ended questions were used in semi-structured interviews and focus groups to allow pharmacy students, co-op employers, and faculty members to freely express their viewpoints. An inductive approach was applied when generating or developing themes from the data collected in this study.

Results: 19 pharmacy students from the vanguard class of 88 participated in the semi-structured interviews. Two faculty focus groups were held. 12 employers were interviewed by phone. Students expressed their experiential learning experience on medication therapy management, interprofessional collaboration, safety, quality assurance, professionalism and work ethics that contribute to their personal and intellectual growth. These findings were compared with independent themes captured from the faculty focus groups and employers' interviews.

Conclusions: Experiential learning acquired through co-op work terms has offered pharmacy students not only the opportunity to prepare them as pharmacists, but also the mechanism to reflect and integrate their professional and personal skills in providing patient-focused care in their future career. The skills acquired during students' co-op experience are not pharmacy-specific; they can be adapted to other disciplines.

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