18 minute read
Evidence matters
Evolving care models for people with HIV:
How might a primary care approach affect health outcomes?
By Sarah Garland
How can we better care for people living with HIV as they age? Antiretroviral therapies – treatments for people with HIV – are easier to access and more effective than ever before. This improvement in care means that people with HIV are living longer, and as they age, they face other chronic conditions associated with aging. People living with HIV also have an increased risk of complications with long-term antiretroviral therapies.
Currently, people living with HIV typically access care through HIV or infectious disease specialists, which are usually located in larger urban centres. However, the number of HIV specialist physicians is declining, and fewer physicians are entering this specialty. There is a need, and in fact has been a recent shift, to caring for people with HIV through primary care. Is it possible for primary care physicians to balance HIV care with other chronic conditions? What are the outcomes for people living with HIV when they receive care from primary care physicians?
CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – recently published a report on the management of HIV care in primary care settings. The report highlights current Canadian guidelines on HIV management and provides a summary of the relevant literature that describes the models for HIV management and the outcomes for people with HIV.
The CADTH report found 4 studies that identified patient outcomes associated with different HIV models of care. Based on the information in those studies, there was generally no difference in outcomes for people living with HIV whether they were seen by specialists or by primary care doctors. This is the case for most HIV-related outcomes as well as outcomes related to other chronic conditions. These studies looked at integrating HIV-specific care within primary care, embedding primary care within HIV clinics, or delivering HIV care at the same location as other health care services. Overall, the frequency of screening for chronic diseases, like cancer or diabetes, was also similar, regardless of type of clinician seen.
There are some unique challenges facing people with HIV who also have other chronic health conditions. Medication fatigue, due to having to take numerous drugs, can make it difficult to be consistent and adhere to all the medications a person may need to take. Increased medical costs can also be stressful and impact daily life and relationships. There can also be increased
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stigma associated with having both HIV and a chronic condition, but positive coping strategies can help with the stress of having multiple chronic conditions.
There were some limitations and gaps in the literature. Most of these studies looked at urban centres, so it is uncertain how people living with HIV in rural areas experience care. This is particularly important for a geographically large country like Canada, where even primary care may be limited in rural or remote areas.
Primary care doctors may need training to increase their knowledge of HIV-specific care and to increase their confidence in providing care. A consult service – where primary care doctors can virtually connect with HIV specialists – may be an option for improving care and building capacity in the primary care setting. Clinicians providing care for people with HIV should familiarize themselves with current guidelines – this includes screening for chronic conditions like cancer and diabetes as well keeping up to date with vaccinations. Some routine screening may be different compared with people without HIV, for example, current recommendations are to screen people with HIV for syphilis every 3 to 6 months.
As people living with HIV age, it is important to consider the range of care they might need. Shifting to primary care, or more fully integrating primary care into HIV care settings, may ensure that people living with HIV receive care that is inclusive of other chronic conditions.
The full report on HIV management in primary care, can be found at canjhealthtechnol.ca/index.php/cjht/ article/view/hc0028. To learn more about CADTH, visit us at www.cadth. ca, follow us on Twitter @CADTH_ ACMTS, or speak to a Liaison Officer in your region: cadth.ca/contact-us/ liaison-officers. ■ H
Sarah Garland is a knowledge mobilization officer at CADTH
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Germ-fighting robots and helpers
logged thousands of hours during the COVID-19 pandemic
Fraser Health’s fleet of 16 Ultraviolet Germicidal Irradiation (UVGI) robots now have UVGI ‘helpers.’ Two new UVGI disinfection pods have joined the team.
The robots and pods are deployed at hospitals across the region to kill viruses and bacteria that linger on surfaces and can potentially cause infection.
The pods reflect and trap UV rays and are easily moveable and collapsible so disinfection can occur in small areas without the need to close entire rooms. Mobile pieces of equipment such as wheelchairs, incubators
and IV poles are placed in the tentlike pods so the robots can do their work.
The stars of the disinfection process remain Fraser Health’s germ-zapping robots, purchased in 2020 and funded through local hospital foundations. The entire UVGI fleet has logged thousands of hours and disinfected nearly 62,000 rooms in the past 21 months.
The UVGI robots emit short pulses of UV light, damaging the DNA and RNA of harmful pathogens, including severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), Clostridioides difficile (C. difficile), carbapenemase-producing organisms (CPO), Candida auris (C. auris), and methicillin-resistant Staphylococcus aureus (MRSA). The robots light up as they disinfect, removing viruses and bacteria from a patient room in as little as 20 minutes.
The robots keep an internal timesheet of where and when they work, and the data is sent to a server so we can monitor usage. If they need some “downtime,” a backup robot is brought in.
Each robot is controlled by an environmental services (EVS) operator, working with Infection Prevention and Control, housekeeping staff and health care aides using traditional and chemical cleaning methods.
“We must remain vigilant to keep all viruses and bacteria out of our acute and community facilities,” says Ruth Dueckman, executive director, Infection Prevention and Control. “UVGI robots and pods are one of the innovative tools to help keep our patients and staff safe. We have seen a reduction in some hospital-acquired infections such as C. difficile and MRSA since we first introduced UVGI disinfection into the region in 2016.” ■ H
Can an easy excuse lead people to underestimate a COVID-19 diagnosis?
By Samantha Sexton
Medical care requires clinicians to think through complex uncertainties, assess risks analytically, and guard against possible biases in human judgment.
A new study, published this week, from Sunnybrook senior scientist Dr. Donald Redelmeier explores how an available simple diagnosis can skew complex medical decision making.
“Occam’s razor is the traditional idea that simple explanations should be preferred over more convoluted theories,” says Dr. Redelmeier, who is also a Sunnybrook staff physician and Canada Research Chair in Medical Decision Making. “Yet this idea has rarely been subjected to experimental testing for evidence-based medicine.”
Dr. Redelmeier and his co-author Dr. Eldar Shafir from Princeton University were interested in testing the concept in the context of the COVID-19 pandemic. “We hypothesized that an available alternative explanation might lead individuals to underestimate the likelihood of a COVID-19 diagnosis,” says Dr. Redelmeier.
The study asked community members and health-care professionals to judge the chances of COVID-19 in a hypothetical patient through a set of different surveys. Each survey provided a succinct description of a hypothetical patient scenario, suggestive of COVID-19. Each scenario was formulated in two versions randomized to participants, differing only in whether an alternative diagnosis was present or absent.
“Through scenarios involving a spectrum of risk, we found that respondents judged the probability of COVID to be much lower in the presence of another diagnosis, such as influenza or strep throat, compared with when an alternative diagnosis was absent,” says Dr. Redelmeier. This contradicts available microbiological evidence.
“The bias can lead individuals to mistakenly lower their judged likelihood of COVID or another disease when an alternate diagnosis is present. In turn, underestimating the risk of COVID infection might reduce a patient’s willingness to seek care and a clinician’s willingness to investigate a medical diagnosis.”
Dr. Redelmeier adds that the results suggest an available simple diagnosis can lead to premature closure and a failure to fully consider additional serious diseases.
“This bias occurs because risk factors such as crowded living spaces, lapses in hand hygiene, and poverty are risk factors for COVID infection, as well as for other diseases such tuberculosis. After diagnosing a patient with COVID, for example, a clinician might pause and check – is that really everything?”
He adds that as patients are living longer with multiple diagnoses occurring together, an over-reliance on Occam’s razor can contribute to misplaced complacency and discourages the search for additional contributing factors.
“The bias may be important to recognize for the COVID-19 pandemic, other diseases, and for the next disease outbreak.” ■ H
Task Force puts equity, diversity and inclusion at the core of research
By Ana Gajic
Approaching research through an equitable lens is a core principle emerging at Unity Health Toronto. Vast inequities in healthcare experiences and outcomes surrounding who is cared for, how treatment is administered, and how illnesses are prevented are results that can emerge without this approach.
We engaged two members of the Research Equity, Diversity and Inclusion (REDI) Task Force, researchers shaping our strategy at Unity Health, to learn about their work and goals. Galo F. Ginocchio and Dr. Cheryl Pritlove are members of Unity Health’s Research Equity, Diversity and Inclusion (REDI) Task Force.
To get started, can you please share information about your social location? These reflect intersections of a person’s experience based on social characteristics such as (and not limited to) race, gender, and sexual orientation.
Galo F. Ginocchio, a research coordinator in the St. Michael’s Hospital Emergency Department and MAP Centre for Urban Health Solutions: I am an able-bodied, Queer, Latino, cisgender man, and a second generation Canadian graduate student.
Dr. Cheryl Pritlove, scientist at the Applied Health Research Cen-
tre: I am a young and healthy cisgender woman of European decent, born in Canada to a working class family. I am a feminist, I am left-leaning in my political views, and I am university-educated in a socio-cultural health sciences stream.
Why is it important for research to have a focused task force on equity, diversity and inclusion (EDI)?
Ginocchio: Equitable lenses and approaches can be powerful routes to identify and reduce inequities in healthcare experiences and outcomes. Our scientists aim to incorporate these responsibly, and a task force like ours empowers our network to identify opportunities to integrate emerging best practices, and directly apply the knowledge and research findings we produce locally.
Dr. Pritlove: Researchers are producers of scientific knowledge and we know that knowledge generated affects health outcomes and experiences. We are aware of the very real dangers when the power and privilege afforded to this position are predominated by a demographically homogeneous group.
It is important to have a task force committed to addressing EDI in research because if we fail to create more diverse, equitable, and inclusive spaces in the fields of medicine and health science, then the biology, lived experiences, needs, and preferences of many members of our society will continue to be inadequately and inappropriately represented in the science that ultimately informs healthcare and its delivery.
Ginocchio: One of the things I like about REDI is we’re always seeking views and experiences from racially, sexually, and gender-diverse staff, physicians, and learners to help us ensure that our academic environment is a place that everyone can participate and feel safe in, to learn and grow together.
What drove each of you to choose to participate in the task force?
Dr. Pritlove: My research is focused on critically interrogating issues of EDI in healthcare contexts, from both patient and staff perspectives. Through this work I’ve accrued knowledge about the complex contributors to the inequities we’re seeing in research and medicine. It can be disheartening to sit with this information and not have an accessible path through which to affect change. I was driven to join REDI because I saw it as a potential pathway through which to translate knowledge to action.
Ginocchio: I’ve been involved with health equity and activism for much of my life, and my scholarly work focuses on public health for communities that struggle with mental health and addictions. I thought REDI could be a great route to support these groups. It had not occurred to me that I would work alongside colleagues with globally renowned expertise, informed by our own lived experiences, to create thoughtful solutions to longstanding inequities together. This is a space where we can hear each other, and discuss what community members are experiencing in an authentic, and honest way.
We’re doing equity, rather than just talking about it. It’s cool to see new international best practices being applied here – we’re effecting meaningful changes in our approach to health research and by extension, the healthcare system, starting at Unity Health. Examples of this are the new three-tiered Patient and Community Engagement in Research Guide developed at Unity Health, and the innovative work the Knowledge Translation Program creates, such as advancing gender equity in medicine.
What would you like to achieve through REDI?
Ginocchio: Employment equity is a topic that we are presently discussing. We are exploring approaches to integrate these ideas here at Unity Health. We have been examining these topics, and are navigating how we might apply our own findings on economic justice in the research institute. In this case, advocating for employment equity, and establishing a living wage across Research.
Dr. Pritlove: Big picture, I hope our work leads to greater representation in the research institute across all levels. I would love to see improved opportunity and equity in both position and pay for our people. I hope our work helps foster an environment where people feel safe, respected and valued. And, I hope we can contribute to the development of a suite of resources to better support individuals in adopting EDI principles in their research.
In order for these big picture changes to happen, we need to first disrupt and dismantle the very strong, political and historically charged foundations that contribute to the production and maintenance of the inequities that we see in medicine. In the immediate, I hope we can chip away at, unsettle, and start to rebuild this foundation in ways that will permit for a sustainable commitment to EDI within the institution.
What are some of the projects that REDI has taken on?
Ginocchio: The bulk of our work has been identifying barriers to health equity in Research, and developing collaborations across Unity Health to align our current internal practices with newly emerging global research standards. Like Cheryl said, the labour that we have put in is about chipping away at the foundations – it’s about scrutinizing things that haven’t been questioned before, and asking uncomfortable, unpopular questions and being bold in that exploration. In the setting of a pandemic, it’s been pretty remarkable how much we’ve accomplished in such a short time.
Dr. Pritlove: We’ve been consulting with different groups within the organization, like the Office of Research Administration, Human Resources, the MAP Centre for Urban Health Solutions and the Anti-Racism, Equity and Social Accountability Office to discuss issues like job description, compensation rates, community engagement, and our hiring practices.
We have provided feedback to the Grants and Awards Office for creating materials that will support researchers in thinking about and integrating EDI into their grant applications and research studies. We are also in the process of creating a Distinguished Lecture Series which will help with education and knowledge raising.
What do you hope the impact of the projects REDI takes on will be?
Ginocchio: We should begin to ask ourselves the perspective and the identity that we are approaching research questions from, and how historical lenses and routine practices can perpetuate injustices. Doing so will mean
that we can begin to decolonize healthcare research, and act upon the calls to action put forth by the Truth and Reconciliation Commission of Canada.
I hope we succeed in creating a space where everybody – regardless of who they are, where they come from, or what their identity is – feels that this is a welcome space that they can learn, grow, and conduct scientific activities in.
Dr. Pritlove: My hope is that the work that we are doing will promote better education and awareness. Inequities and -isms are often invisible, and that’s by design. The work we are doing will be critical to drawing these inequities out of the shadows. With education will come greater dialogue, and potentially discomfort. I hope we as an institution lean into, rather than shy away from, this discomfort, as it is an essential building block of change, and in my view, a sign of progress.
What have you learned during your tenure with REDI so far?
Ginocchio: Decolonizing how I approach and see the world is a continual process that doesn’t happen overnight. You need to deliberately seek out knowledge about health equity, and not put the emotional labour on people from diverse communities to do the work for you. It’s about taking responsibility for your own education, and doing the hard work for yourself through reflection.
Part of that looks like speaking out when you hear that racist comment your colleague expresses, or recognizing when something you have said is oppressive to say and causes preventable harm. The good thing about equitable tools is that they allow you to scrutinize your behaviour so that you can be mindful of how to support and empower the communities you seek to support. In the context of research, this is essential because it puts the integrity of the work at risk if you’re if you’re unwilling to empathize with populations under study in ways beyond the superficial.
Dr. Pritlove: Meaningful and sustained change doesn’t, can’t and probably shouldn’t happen overnight. It takes time, patience and resolve. While it is challenging to remain patient when change is long overdue, I’ve learned that meaningful change requires a great degree of critical thought and diverse wisdoms. It involves the dedication of many people and ongoing collaboration across diverse departments, committees and communities. It is the undoing of a deep-seated history that continues to affect people differently; it is complex and it takes time.
This interview has been condensed and edited. ■ H
Ana Gajic is a senior communications advisor at Unity Health Toronto.
