Kimberlyn McGrail

Professor

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Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.

Investigating health outcomes and risk factors for adverse drug events to improve patient safety and identify strategies for health system improvements (2022)

Preliminary evidence suggests that 19-54% of patients diagnosed with adverse drug events (ADEs), unintended harm from medications, will be re-exposed to the culprit medication upon hospital discharge. The studies from which these estimates arise are small, descriptive, or rely solely on administrative data. Previous research reports an estimated 6-28% of adverse drug events can be identified using administrative data; these data are not well poised to examine adverse events. By triangulating multiple data sources (prospective, chart review, administrative claims data), we sought to: (1) Examine the proportion of re-exposure to culprit medication upon hospital or emergency department discharge, and identify any risk factors for culprit medication re-exposure using Cox regression models; (2) Investigate methods to identify medication non-adherence using claims data, and examine repeat medication non-adherence descriptively; and (3) Examine how administrative health data perform in identifying adverse drug events, including medication non-adherence, by calculating sensitivity and specificity, and conducting logistic regression. The results of our analyses indicated that re-exposure to culprit medication occurred for 45.2% of adverse drug events, though this was largely driven by necessary, irreplaceable medications. Re-exposure varied by type of ADE and duration of medication use. Analyses indicated that no method to identify medication non-adherence in administrative datasets performed well, but the proportion of days covered was the best measure. Finally, as expected, administrative claims data performed poorly in identifying adverse drug events. The administrative data source from which events were more readily detected was hospital data. Overall, the results of this dissertation suggest that while a large proportion of adverse drug events result in subsequent medication re-exposure, these may not be inappropriate re-exposures.ivFurther research is needed to draw this distinction. These results also demonstrate that adverse drug events, including medication non-adherence, are poorly identified in administrative claims data, and caution should be used when interpreting research that relies solely on their use. Previous work in the field has likely underestimated the burden of adverse drug events. Where possible, research on adverse drug events should include data that are prospectively collected at the point of care.

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Care coordination among survivors of childhood, adolescent and young adult cancer: patient sharing, healthcare utilization, quality of care, and cost (2021)

Background: The provision of long-term follow-up care for the growing population of cancer survivor poses a challenge to health care systems. Survivors of childhood, adolescent and young adult cancer have unique risks and needs due to their young age and respective developmental stages at diagnosis and treatment. This thesis addresses the role of primary care and the impact of primary care-based care coordination in the long-term follow-up care for survivors of childhood, adolescence and young adult cancer. Methods: This thesis includes a scoping review of the literature and a series of population-based studies using data that are part of the Childhood, Adolescent and Young Adult Cancer Survivors (CAYACS) research study, a retrospective cohort study, to assess 1) outpatient healthcare utilization, including patterns of physician visits and primary care-based continuity of care among survivors and sex- and age-matched population comparators; 2) survivor-specific factors associated with healthcare utilization, and 3) the association of care coordination and healthcare utilization (including hospitalization), cost and quality of care among survivors. Results: Survivors had higher rates of health care utilization, differences in patterns of physician visits, and increased numbers of specialist-type practitioners involved in survivors’ care compared to population comparators. Higher visit rates among survivors persisted after taking health status into account. Lower rates of specialist visits in more remote areas and lower probability of high care density for those residing in urban and more densely populated health authority regions (e.g., Vancouver Coastal) were found. The effect of care coordination captured via the care density metric was associated with volume of total visits, cost of care and, for those with the highest level of care density, odds of hospitalization.Conclusion: This research identifies sociodemographic, health system and clinical characteristics associated with healthcare utilization, continuity of and coordination of follow-up care among long-term survivors of childhood, adolescent and young adult cancer. It highlights the importance of care coordination with regard to outcomes such as healthcare utilization and cost of care.

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The effects of British Columbia hospital closures on delivery of health care services and the population's health (2017)

Background: In 2002, British Columbia (BC) began redistributing its hospital services. Existing facilities closed, were downsized or became specialized. Reasons for these changes included the centralization of the health authorities and subsequently the redistribution of services, along with safety concerns regarding small units, difficulties recruiting and retaining staff, and policy changes in the province’s Standards of Accessibility. At the same time, innovations in service delivery, such as inter-hospital transfer practices and telehealth initiatives (e.g. telestroke), modified how health care is provided. Effective health service delivery is a complex matter. Over a decade since redistribution began, there has been no evaluation of the changes in service distribution and their impact on patient health.Methods: This is a retrospective cohort study of all adult (18 years and over) acute myocardial infarction (AMI), stroke, and severe trauma events that occurred within the province between April 1 1999 and March 31 2013. Using administrative data, segmented regression and hierarchical hazards modelling techniques, this study examines the effect of service redistribution on patients’ mortality outcomes.Results: The interrupted time series models found service redistribution was not associated with changes in 30-day mortality outcomes, and was likely a response to facility underutilization. Although there was extensive variation in patient access to care (travel burden) across health authorities, the hierarchical Cox proportional hazards models showed that long travel time (>30 mins) was not associated with patient short term mortality after controlling for appropriateness and quality of care along with compensating mechanisms such as inter-hospital transfers, and telehealth services.Conclusion: This work demonstrates that efficiencies in health system delivery can be gained by eliminating underutilized acute care services but also identifies challenges in ensuring equitable access to care.

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Diagnosis and Disruption: Understanding Guideline-Consistent Dementia Care and Patterns of Transitions Experienced by Individuals with Dementia (2015)

Introduction Early detection and management, as outlined in dementia guidelines, can improve outcomes and potentially reduce the number of transitions experienced between care-facilities. The objectives of this thesis were to : conduct a critical assessment of the literature on actual versus guideline-consistent dementia care; use population-level data to examine variations in receipt of guideline-consistent dementia care; understand longitudinal patterns of transitions and the factors that contribute to transitions; and assess if receipt of guideline-consistent dementia care and/or high quality primary care are associated with the number of transitions experienced. MethodPopulation-level administrative data in British Columbia were used to identify cohorts of individuals newly diagnosed with dementia in 2001/02 and 2009/10. Dementia guidelines were used to characterize clinical care individuals could receive. The proportion of patients diagnosed with dementia in 2009/10 who received guideline-consistent dementia care and the probability that patient characteristics affected the likelihood of receiving each process was assessed. Those diagnosed with dementia in 2001/02 were followed forward 10-years after the first point of diagnosis and points of care when transitions were highest as well as factors that contribute to those transitions were assessed. The association of receipt of guideline-consistent dementia care and/or high quality primary care with the number of transitions experienced in the year of diagnosis was assessed using negative binomial regression. ResultsOlder patients were less likely to receive guideline-consistent dementia care. A quarter of the cohort received an antipsychotic or non-recommended benzodiazepine. Individuals living within rural health-authorities or of low income were more likely to receive antipsychotic treatment. Transitions were highest in the year of diagnosis and at end-of-life, driven by acute hospitalizations. Higher morbidity, living within rural health-authorities, and having behavioural symptoms associated with dementia were strongly associated with the number of transitions experienced. Lastly, receipt of guideline-consistent dementia care and high quality primary care, independently, were associated with fewer transitions across care settings. ConclusionPatterns of inequality by age and income may signal barriers to guideline-consistent dementia care. The spike in transitions in the year following diagnosis highlights a distressing period for individuals with dementia, but suggests a useful target for interventions.

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Understanding geographic variation in health care costs in British Columbia (2015)

Amidst concerns about escalating health spending, examining variation in health care delivery may reveal opportunities for improved efficiency. Influential research in the United States (US) has concluded that health care spending and service use vary substantially from place to place, and this cannot be explained by differences in the health status of populations or by better outcomes of care in higher-spending regions. Whether similar patterns exist in Canada is not clear. This thesis uses administrative health data to examine how and why health care use and costs vary within the Canadian province of British Columbia (BC). We developed networks of patients, physicians, and hospitals that correspond to actual service use, in order to ensure that observation of variation was not obscured by unit of analysis. We also identified areas of the province representing distinct health service environments, as an improvement over existing urban/rural classifications in understanding the role of geographic context. Access to individual-level data allowed more complete adjustment for population characteristics than is typically possible. In contrast to the US, this thesis suggests that variation in costs of physician and hospital services in BC is largely explained by population health status. The very different environments for health services that exist among metropolitan, non-metropolitan, and remote regions of the province also explained some area-level variation. Despite modest variation in total costs, there are clear differences in patterns of service use across the province due to substitution between categories of care (such as inpatient and outpatient, or generalist and specialist services). Though differences in costs are modest, marked differences in health outcomes are evident, and require further scrutiny. Results show there are no areas with systematically higher volume or more intensive service provision for populations with similar health needs. However, this does not mean that important variation does not exist and cannot be uncovered. It may be that examining variation at the level of provider, among population groups, or in treatment for specific diseases or conditions will yield more actionable results. Ultimately policy reforms aimed at system-wide quality and efficiency, rather than targeted at high-spending regions, will likely prove most promising.

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Master's Student Supervision

Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.

Individual and system-level factors associated with alternate level of care (ALC) in British Columbia (2022)

Background: Delayed discharge, or alternate level of care (ALC) as it is known in Canada occurs when patients stay in hospital even after they are medically fit for discharge as they wait for appropriate post-acute care services to become available. It is widely acknowledged as an ongoing issue of system inefficiency, and previous studies have examined patient characteristics associated with ALC. However, few studies have investigated ALC trends, the health system factors related to ALC, or accounted for the nesting of patients within health systems.Objective: The objectives of this thesis were to: (1) describe changes in ALC use in British Columbia (BC) from 2008 to 2019 and (2) examine the patient- and system-level factors associated with ALC designation. Methods: This thesis is a population-based retrospective analysis of all acute hospital discharges of patients 40 years and older in BC from 2008-2019 using linked administrative data and publicly available data. The first objective is addressed by describing trends in percent ALC hospitalizations and days based on selected characteristics from 2008-2019. The second objective is addressed using descriptive analyses and multivariable multi-level logistic regression modelling to examine patient-level and system-level characteristics associated with ALC hospitalization status from 2015-2019.Results: There was an upward trend in ALC use from 2008-2019 in BC; percent ALC hospitalizations rose from 6.0% to 6.9% while percent ALC days rose from 13.5% to 16.1%. Individual-level factors were dominant in predicting ALC use, with assisted living capacity being the only system-level factor significantly associated with ALC. Strong predictors of ALC included older age, longer acute length of stay, dementia, discharge designation, and fewer family physician visits after adjusting for other explanatory variables. Conclusion: ALC is a significant and growing issue in BC that has important policy implications. These findings highlight inequities in ALC use related to social determinants of health, and the importance of dementia, primary care access and discharge destination as predictors of ALC, suggesting investments in primary care and home and community care capacity are potential solutions. Future research should explore other health system factors and solutions related to delayed discharge.

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Building capacity for trauma and violence-informed care and deconstructing oppression in women's health care (2021)

Rationale: Experiences of oppression, trauma, daily discrimination, and structural violence are ubiquitous among people cared for within primary care. The unique impacts of these experiences on women – in particular on mothers, racialized and Indigenous women, and early childhoods – have been clearly demonstrated, including in the gendered impacts of the COVID-19 pandemic. These experiences can be perpetuated or mitigated within the health care system. Trauma and violence-informed (TVI) care acknowledges these impacts, yet its integration into the fabric of women’s health care and primary care services is limited. The landscape of women’s health services offers an important opportunity to learn about the implementation of TVI care across a continuum of services with variable orientations towards equity-oriented care. Objectives: 1. To describe the environments in which TVI care is practiced within a web of interdisciplinary women’s health care services centered within primary care, and the contextual, structural, and individual factors influencing the care provided; 2. To generate insights about the implementation of equity-oriented, trauma and violence-informed care at a critical time of primary care renewal in Canada, including in the COVID-19 pandemic recovery.Research Question: How do diverse ways of enacting TVI care for women expand understandings of how to implement and scale up TVI care in primary health care more broadly?Study Design: We conducted 23 qualitative, in-depth interviews with diverse practitioners of TVI care within a web of women’s health care services centered within primary care. We engaged in collaborative thematic analysis of the data, guided by interpretive description, and conducted by three women with dual experiences as trauma survivors and providers of TVI care. This study was informed by intersectional feminism, decolonizing and critical theories, and a social justice lens.Findings: Participants described: 1. Contextual and system-level factors influencing TVI implementation in women’s health care; 2. Process knowledge of how to enact and implement TVI care; and, 3. Clinical knowledge and approaches in TVI practice. The focus of this analysis is on the first two areas, which are described as: Oppressive systems – the landscape of trauma and violence-informed practice; and, Deconstructing oppression – the work of resistance and connection.

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Evaluating the effect of pharmacist-led medication review in high-risk emergency department patients on health services utilization (2019)

BackgroundOne in nine emergency department (ED) visits in Canada are caused by adverse drug events, the unintended and harmful effects of medication use. Medication reviews by clinical pharmacists are interventions designed to optimize medications and address adverse drug events to impact patient outcomes. However, the effect of medication review on long-term outpatient health services utilization is not well understood. This research studied the effect of medication review performed by clinical pharmacists on long-term outpatient health services utilization.MethodsData included information from 10,783 patients who were part of a prospective, multicentre quality improvement evaluation from 2011 to 2013. Outpatient health services utilization was defined as total ED visits and physician contacts, aggregated to four physician specialty groups: general and family practitioners; medical specialists; surgical specialists; and imaging and laboratory specialists. Medication review involved a critical examination of a patient’s medications to identify and resolve medication-related problems and communicate these results to community-based care providers. Interrupted time series analysis compared the effect of the intervention on health services utilization relative to the standard of care controlling for pre-intervention differences in utilization. ResultsED-based pharmacist-led medication review did not result in a significant level or trend change in total outpatient health services utilization, primary care physician visits, or ED visits relative to the standard of care in the 12 months following the intervention, even when stratified by age, hospital site, and whether patients were admitted to the hospital on their index visit.ConclusionThis was the first study to measure long term trends of physician visits following an ED-based medication review. The lack of differences in level and trend of GP and ED visits suggest that pharmacist recommendations may not have been adequately communicated to community care providers, and/or recommendations may not have affected health care delivery. Future studies should evaluate patient and physician acceptance of pharmacist recommendations and should encourage patient follow-up to community care providers following medication reviews.

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Small for Gestational Age Trends in Canada from 2000-2016 (An Analysis of Individual-level Factors and the Minimum Wage) (2019)

Background Earlier studies investigating birthweight trends in Canada indicated a downward trend in SGA births. Today, evidence suggests an unexplained upward trend, as well as regional differences, in SGA births from 2005-2014. These variations, over time and across jurisdictions, might be explained through downstream individual-level risk factors and/or more upstream contextual factors such as the minimum wage. Recent studies in the US found that higher minimum wages were associated with fewer adverse birth outcomes. Given the differences between the two countries, it is unclear if similar effects might be observed in Canada.Objective Describe and analyze trends in SGA births across Canada from 2000 to 2016 using individual and contextual-level data and then explore the association between minimum wage and SGA outcomes.Methods Retrospective cross-sectional analyses of all singleton births in Canada from 2000-2016 modeled SGA births through logistic regression, adjusting for individual and contextual risk factors. These models were then further adjusted for real minimum wage lagged by nine months. Analyses in both studies were stratified by four provinces (Ontario, Quebec, Alberta, and BC). Two subgroup analyses on single and all mothers residing in low income neighborhoods were further conducted. Results A secular upward trend in SGA births extended from 2000-2016 and was not completely explained by changes in maternal age, parental birthplace, marital status, community size and neighborhood income quintile. A dollar increase in real minimum wage was associated with 2% lower odds of an SGA birth (95% CI 0.97, 0.99), when adjusting for all other confounders. Provincially-stratified analyses and subgroup analysis of mothers in low income neighbourhoods, however, had null findings. For single mothers residing in low income neighbourhoods, a dollar increase in real minimum wage was associated with 3.0% [95% CI: 1.01, 1.05] higher odds of an SGA birth, adjusting for all other confounders. Conclusion SGA trends in Canada result from complex interactions of many variables. Not all of these variables, including risk factors such as smoking, were available at an individual level for analysis. Intermediate income and employment pathways between real minimum wage and SGA births, specifically for low income single mothers, require further exploration.

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HIV and Aging: Age-Associated Chronic Comorbidities among HIV-Positive Individuals on Highly Active Antiretroviral Therapy in British Columbia, Canada (2016)

Background: Highly active antiretroviral therapy (HAART) has transformed HIV from a once fatal condition into a treatable chronic disease. As people with HIV are living longer than in the past, understanding the effects of aging with HIV is of increasing importance. This dissertation aims to explore trends of several chronic diseases during the current HAART era, while also taking into consideration the impact of expanded access to HAART in British Columbia, Canada from 2000-2012. Methods: The studies presented in this dissertation are based on administrative data collected from the Comparative Outcomes and Health Service Utilization Trends (COAST) study. Various analytical methods were used to assess trends of chronic disease incidence of six common chronic diseases: cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD)/asthma, diabetes mellitus (DM), hypertension (HTN), chronic kidney disease (CKD) and chronic liver disease (CLD). Both studies were retrospective population-based cohort studies of HIV-positive individuals whom accessed HAART and identified as HIV-positive in the COAST study database by validated algorithms. Several measures were employed to determine risks and trends of chronic disease incidence. Results: The results of each study showed that trends and risks of chronic disease incidence were not all consistent. In the first study exploring trends of chronic diseases among 10,210 HIV-positive individuals whom had accessed HAART the adjusted incidence rate for HTN increased over time; CKD and CLD decreased over time; and no trend was observed for CVD, COPD/Asthma and DM. In the second study, among 4,840 HIV-positive individuals who initiated HAART during this period, the relative risk of CLD incidence was reduced in the post- (2006-2012) versus pre- (2000-2005) HAART expansion periods. The relative risk for CVD, DM, HTN, COPD/asthma and CKD were not statistically significant in the post expansion period. Conclusions: Results from this dissertation provide insight on trends and risks of several comorbidities during the current HAART era. Specifically, the results of this dissertation highlight the trend towards increasing incidence of HTN and decreasing incidence of CLD among HIV-positive aging populations. Understanding how chronic comorbidities affect future disability and death among people aging with HIV is an important area of further research.

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