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Background: Substitute decision-makers (SDMs) make decisions that honor medical, personal, and end-of-life wishes for older adults who have lost capacity, including those with dementia. However, SDMs often lack support, information, and problem-solving tools required to make decisions and can suffer with negative emotional, relationship, and financial impacts. The need for adaptable supports has been identified in prior meta-analyses. This scoping review identifies evidence-based decision-making resources/tools for SDMs, outlines domains of support, and determines resource/tool effectiveness and/or efficacy., Methods: The scoping review used the search strategy: Population-SDMs for older adults who have lost decision-making capacity; Concept-supports, resources, tools, and interventions; Context-any context where a decision is made on behalf of an adult (>25 years). Databases included MEDLINE, Embase, CINAHL, PsycINFO, and Abstracts in Social Gerontology and SocIndex. Tools were scored by members on the research team, including patient partners, based on domains of need previously identified in prior meta-analyses., Results: Two reviewers independently screened 5279 citations. Articles included studies that evaluated a resource/tool that helped a family/friend/caregiver SDMs outside of an ICU setting. 828 articles proceeded onto full-text screening, and 25 articles were included for data extraction. The seventeen tools identified focused on different time points/decisions in the dementia trajectory, and no single tool encompassed all the domains of caregiver decision-making needs., Conclusion: Existing tools may not comprehensively support caregiver needs. However, combining tools into a toolkit and considering their application relevant to the caregiver's journey may start to address the gap in current supports., (© 2024 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: The impact of social frailty on older adults is profound including mortality risk, functional decline, falls, and disability. However, effective strategies that respond to the needs of socially frail older adults are lacking and few studies have unpacked how social determinants operate or how interventions can be adapted during periods requiring social distancing and isolation such as the COVID-19 pandemic. To address these gaps, we conducted a scoping review using JBI methodology to identify interventions that have the best potential to help socially frail older adults (age ≥65 years)., Methods: We searched MEDLINE, CINAHL (EPSCO), EMBASE and COVID-19 databases and the grey literature. Eligibility criteria were developed using the PICOS framework. Our results were summarized descriptively according to study, patient, intervention and outcome characteristics. Data synthesis involved charting and categorizing identified interventions using a social frailty framework.  RESULTS: Of 263 included studies, we identified 495 interventions involving ~124,498 older adults who were mostly female. The largest proportion of older adults (40.5%) had a mean age range of 70-79 years. The 495 interventions were spread across four social frailty domains: social resource (40%), self-management (32%), social behavioural activity (28%), and general resource (0.4%). Of these, 189 interventions were effective for improving loneliness, social and health and wellbeing outcomes across psychological self-management, self-management education, leisure activity, physical activity, Information Communication Technology and socially assistive robot interventions. Sixty-three interventions were identified as feasible to be adapted during infectious disease outbreaks (e.g., COVID-19, flu) to help socially frail older adults., Conclusions: Our scoping review identified promising interventions with the best potential to help older adults living with social frailty., (© 2024. The Author(s).)

Background: Despite decades of anti-racism and equity, diversity, and inclusion (EDI) interventions in academic medicine, medical racism continues to harm patients and healthcare providers. We sought to deeply explore experiences and beliefs about medical racism among academic clinicians to understand the drivers of persistent medical racism and to inform intervention design., Methods: We interviewed academically-affiliated clinicians with any racial identity from the Departments of Family Medicine, Cardiac Sciences, Emergency Medicine, and Medicine to understand their experiences and perceptions of medical racism. We performed thematic content analysis of semi-structured interview data to understand the barriers and facilitators of ongoing medical racism. Based on participant narratives, we developed a logic framework that demonstrates the necessary steps in the process of addressing racism using if/then logic. This framework was then applied to all narratives and the barriers to addressing medical racism were aligned with each step in the logic framework. Proposed interventions, as suggested by participants or study team members and/or identified in the literature, were matched to these identified barriers to addressing racism., Results: Participant narratives of their experiences of medical racism demonstrated multiple barriers to addressing racism, such as a perceived lack of empathy from white colleagues. Few potential facilitators to addressing racism were also identified, including shared language to understand racism. The logic framework suggested that addressing racism requires individuals to understand, recognize, name, and confront medical racism., Conclusions: Organizations can use this logic framework to understand their local context and select targeted anti-racism or EDI interventions. Theory-informed approaches to medical racism may be more effective than interventions that do not address local barriers or facilitators for persistent medical racism., (© 2024. The Author(s).)

Background: Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups., Methods: This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis., Results: Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions., Conclusions: This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC., (© 2024. The Author(s).)

Objective: To evaluate the impact of administering probiotics to prevent Clostridioides difficile infection (CDI) among patients receiving therapeutic antibiotics., Design: Stepped-wedge cluster-randomized trial between September 1, 2016, and August 31, 2019., Setting: This study was conducted in 4 acute-care hospitals across an integrated health region., Patients: Hospitalized patients, aged ≥55 years., Methods: Patients were given 2 probiotic capsules daily (Bio-K+, Laval, Quebec, Canada), containing 50 billion colony-forming units of Lactobacillus acidophilus CL1285, L. casei LBC80R, and L. rhamnosus CLR2. We measured hospital-acquired CDI (HA-CDI) and the number of positive C. difficile tests per 10,000 patient days as well as adherence to administration of Bio-K+ within 48 and 72 hours of antibiotic administration. Mixed-effects generalized linear models, adjusted for influenza admissions and facility characteristics, were used to evaluate the impact of the intervention on outcomes., Results: Overall adherence of Bio-K+ administration ranged from 76.9% to 84.6% when stratified by facility and periods. Rates of adherence to administration within 48 and 72 hours of antibiotic treatment were 60.2% -71.4% and 66.7%-75.8%, respectively. In the adjusted analysis, there was no change in HA-CDI (incidence rate ratio [IRR], 0.92; 95% confidence interval [CI], 0.68-1.23) or C. difficile positivity rate (IRR, 1.05; 95% CI, 0.89-1.24). Discharged patients may not have received a complete course of Bio-K+. Our hospitals had a low baseline incidence of HA-CDI. Patients who did not receive Bio-K+ may have differential risks of acquiring CDI, introducing selection bias., Conclusions: Hospitals considering probiotics as a primary prevention strategy should consider the baseline incidence of HA-CDI in their population and timing of probiotics relative to the start of antimicrobial administration.

Background: Long-term care (LTC) was overwhelmingly impacted by COVID-19 and unnecessary transfer to emergency departments (ED) can have negative health outcomes. This study aimed to explore how the COVID-19 pandemic impacted LTC to ED transfers and hospitalizations, utilization of community paramedics and facilitated conversations between LTC and ED physicians during the first four waves of the pandemic in Alberta, Canada., Methods: In this retrospective population-based study, administrative databases were linked to identify episodes of care for LTC residents who resided in facilities in Alberta, Canada. This study included data from January 1, 2018 to December 31, 2021 to capture outcomes prior to the onset of the pandemic and across the first four waves. Individuals were included if they visited an emergency department, received care from a community paramedic or whose care involved a facilitated conversation between LTC and ED physicians during this time period., Results: Transfers to ED and hospitalizations from LTC have been gradually declining since 2018 with a sharp decline seen during wave 1 of the pandemic that was greatest in the lowest-priority triage classification (CTAS 5). Community paramedic visits were highest during the first two waves of the pandemic before declining in subsequent waves; facilitated calls between LTC and ED physicians increased during the waves., Conclusions: There was a reduction in number of transfers from LTC to EDs and in hospitalizations during the first four waves of the pandemic. This was supported by increased conversations between LTC and ED physicians, but was not associated with increased community paramedic visits. Additional work is needed to explore how programs such as community paramedics and facilitated conversations between LTC and ED providers can help to reduce unnecessary transfers to hospital., (© 2024. The Author(s).)

Objectives: To identify candidate quality indicators from existing tools that provide guidance on how to practice knowledge translation and implemenation science (KT practice tools) across KT domains (dissemination, implementation, sustainability, and scalability)., Study Design and Setting: We conducted a scoping review using the Joanna Briggs Institute Manual for Evidence Synthesis. We systematically searched multiple electronic databases and the gray literature. Documents were independently screened, selected, and extracted by pairs of reviewers. Data about the included articles, KT practice tools, and candidate quality indicators were analyzed, categorized, and summarized descriptively., Results: Of 43,060 titles and abstracts that were screened from electronic databases and gray literature, 850 potentially relevant full-text articles were identified, and 253 articles were included in the scoping review. Of these, we identified 232 unique KT practice tools from which 27 unique candidate quality indicators were generated. The identified candidate quality indicators were categorized according to the development (n = 17), evaluation (n = 5) and adaptation (n = 3) of the tools, and engagement of knowledge users (n = 2). No tools were identified that appraised the quality of KT practice tools., Conclusions: The development of a quality appraisal instrument of KT practice tools is needed. The results will be further refined and finalized in order to develop a quality appraisal instrument for KT practice tools., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +)., Methods: We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research., Results: A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals., Conclusions: Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study., (© 2023. The Author(s).)

Objective: Older adults visit emergency departments (EDs) at higher rates than their younger counterparts. However, less is known about the rate at which older adults living with dementia visit and revisit EDs. We conducted a systematic review and meta-analysis to quantify the revisit rate to the ED among older adults living with a dementia diagnosis., Methods: We searched MEDLINE, Embase, and CINAHL, as well as gray literature, to identify observational studies reporting on older adults living with dementia that revisited an ED within 30 days of a prior ED visit. We calculated pooled rates of 30-day revisit as percentages using random effects models, and conducted stratified analyses by study data source, study population, and study period. We assessed between-studies heterogeneity using the I 2 statistic and considered [Formula: see text] > 50% to indicate substantial heterogeneity. All analyses were performed in R software., Results: We identified six articles for inclusion. Percentages of 30-day ED revisit among older adults living with dementia ranged widely from 16.1% to 58.0%. The overall revisit rate of 28.6% showed significant heterogeneity. Between-studies heterogeneity across all stratified analyses was also high. By data source, 30-day revisit percentages were 52.3% (public hospitals) and 20.0% (administrative databases); by study population, revisit percentages were 33.5% (dementia as main population) and 19.8% (dementia as a subgroup). By study period, revisit percentages were 41.2% (5 years or greater) and 18.9% (5 years or less)., Conclusion: Existing literature on ED revisits among older adults living with dementia highlights the medical complexities and challenges surrounding discharge and follow-up care that may cause these patients to seek ED care at an increased rate. ED personnel may play an important role in connecting patients and caregivers to more appropriate medical and social resources in order to deliver an efficient and more rounded approach to care., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Recent advances in the management of inflammatory bowel disease (IBD) striving for new treatment targets may have decreased rates of hospitalization for flares. We compared all-cause, IBD-related, and non-IBD-related hospitalizations while accounting for the rising prevalence of IBD., Methods: Population-based, administrative health care databases identified all individuals living with IBD in Alberta between fiscal year 2002 and 2018. Hospitalization rates (all-cause, IBD-related, and non-IBD-related) were calculated using the prevalent Alberta IBD population. Hospitalizations were stratified by disease type, age, sex, and metropolitan status. Data were age and sex standardized to the 2019 Canadian population. Log-linear models calculated Average Annual Percentage Change (AAPC) in hospitalization rates with associated 95% confidence intervals (CIs)., Results: From 2002-2003 to 2018-2019, all-cause hospitalization rates decreased from 36.57 to 16.72 per 100 IBD patients (AAPC, -4.18%; 95% CI, -4.69 to -3.66). Inflammatory bowel disease-related hospitalization rate decreased from 26.44 to 9.24 per 100 IBD patients (AAPC, -5.54%; 95% CI, -6.19 to -4.88). Non-IBD-related hospitalization rate decreased from 10.13 to 7.48 per 100 IBD patients (AAPC, -1.82%; 95% CI, -2.14 to -1.49). Those over 80 years old had the greatest all-cause and non-IBD-related hospitalization rates. Temporal trends showing decreasing hospitalization rates were observed across age, sex, IBD type, and metropolitan status., Conclusions: Hospitalization rates are decreasing for all-cause, IBD-related, and non-IBD-related hospitalizations. Over the past 20 years, the care of IBD has transitioned from hospital-based care to ambulatory-centric IBD management., (© 2023 Crohn’s & Colitis Foundation. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation.)

Background & Aims: The evolving epidemiologic patterns of inflammatory bowel disease (IBD) throughout the world, in conjunction with advances in therapeutic treatments, may influence hospitalization rates of IBD. We performed a systematic review with temporal analysis of hospitalization rates for IBD across the world in the 21st century., Methods: We systematically reviewed Medline and Embase for population-based studies reporting hospitalization rates for IBD, Crohn's disease (CD), or ulcerative colitis (UC) in the 21st century. Log-linear models were used to calculate the average annual percentage change (AAPC) with associated 95% confidence intervals (95% CIs). Random-effects meta-analysis pooled country-level AAPCs. Data were stratified by the epidemiologic stage of a region: compounding prevalence (stage 3) in North America, Western Europe, and Oceania vs acceleration of incidence (stage 2) in Asia, Eastern Europe, and Latin America vs emergence (stage 1) in developing countries., Results: Hospitalization rates for a primary diagnosis of IBD were stable in countries in stage 3 (AAPC, -0.13%; 95% CI, -0.72 to 0.97), CD (AAPC, 0.20%; 95% CI, -1.78 to 2.17), and UC (AAPC, 0.02%; 95% CI, -0.91 to 0.94). In contrast, hospitalization rates for a primary diagnosis were increasing in countries in stage 2 for IBD (AAPC, 4.44%; 95% CI, 2.75 to 6.14), CD (AAPC, 8.34%; 95% CI, 4.38 to 12.29), and UC (AAPC, 3.90; 95% CI, 1.29 to 6.52). No population-based studies were available for developing regions in stage 1 (emergence)., Conclusions: Hospitalization rates for IBD are stabilizing in countries in stage 3, whereas newly industrialized countries in stage 2 have rapidly increasing hospitalization rates, contributing to an increasing burden on global health care systems., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Previous research in our department on equity-deserving groups revealed that physician leaders could improve their understanding of barriers faced by physicians from these groups. We developed EDI Moments, a brief, recurring educational intervention, to raise the EDI literacy of physician leaders in our Department of Medicine. In addition to being considered a good use of time by attendees, EDI Moments have led to new processes and policies to improve EDI in our department. Teams that implement EDI Moments should leverage local EDI expertise and select topics suited for their audience's baseline knowledge., Competing Interests: The authors have no conflicts of interest related to this manuscript., (© 2023 Ruzycki, Holroyd-Leduc, Brown; licensee Synergies Partners.)

Background and Objective: Frailty is an important aspect of biological aging, referring to the increased vulnerability of individuals with frailty to physical and psychological stressors. While older adults with epilepsy are an important and distinct clinical group, there are no data on frailty in this population. We hypothesize that frailty will correlate with the seizure frequency and especially the tolerability of antiseizure medications (ASMs) in older adults with epilepsy., Methods: We recruited individuals aged 60 years or older with active epilepsy from 4 Canadian hospital centers. We reported the seizure frequency in the 3 months preceding the interview, while ASM tolerability was quantified using the Liverpool Adverse Events Profile (LAEP). We applied 3 measures of frailty: grip strength as a measure of physical frailty, 1 self-reported score (Edmonton frail score [EFS]), and 1 scale completed by a healthcare professional (clinical frailty scale [CFS]). We also administered standardized questionnaires measuring levels of anxiety, depression, functional disability, and quality of life and obtained relevant clinical and demographic data., Results: Forty-three women and 43 men aged 60-93 years were recruited, 87% of whom had focal epilepsy, with an average frequency of 3.4 seizures per month. Multiple linear regression and zero-inflated negative binomial regression models showed that EFS and CFS scores were associated with decreased ASM tolerability, each point increase leading to 1.83 (95% CI: 0.67-4.30) and 2.49 (95% CI: 1.27-2.39) point increases on the LAEP scale, respectively. Neither the EFS and CFS scores nor grip strength were significantly associated with seizure frequency. The EFS was moderately correlated with depression, anxiety, quality of life, and functional disability, demonstrating the best construct validity among the 3 tested measures of frailty., Discussion: The EFS was significantly, both statistically and clinically, associated with ASM tolerability. It also showed multiple advantages in performance while assessing for frailty in older adults with epilepsy, when compared with the 2 other measures of frailty that we tested. Future studies must focus on what role the EFS during epilepsy diagnosis may play in ASM selection among older adults with epilepsy., (© 2022 American Academy of Neurology.)

Background: Older adults experience symptoms of depression, leading to suffering and increased morbidity and mortality. Although we have effective depression therapies, physical distancing and other public health measures have severely limited access to in-person interventions., Objective: To describe the efficacy of virtual interventions for reducing symptoms of depression in community-dwelling older adults., Design: Systematic review., Setting: We searched MEDLINE, EMBASE, Cochrane Libraries, PsycINFO, and gray literature from inception to July 5, 2021., Participants and Interventions: We included randomized trials (RCTs) comparing the efficacy of virtual interventions to any other virtual intervention or usual care in community-dwelling adults ≥60 years old experiencing symptoms of depression or depression as an outcome., Measurements: The primary outcome was change in symptoms of depression measured by any depression scale., Results: We screened 12,290 abstracts and 830 full text papers. We included 15 RCTs (3100 participants). Five RCTs examined persons with depression symptoms at baseline and ten examined depression as an outcome only. Included studies demonstrated feasibility of interventions such as internet or telephone cognitive behavioral therapy with some papers showing statistically significant improvement in depressive symptoms., Conclusions: There is a paucity of studies examining virtual interventions in older adults with depression. Given difficulty in accessing in-person therapies in a pandemic and poor access for people living in rural and remote regions, there is an urgent need to explore efficacy, effectiveness, and implementation of virtual therapies.

Objective: Recent deaths of Indigenous patients in the Canadian healthcare system have been attributed to structural and interpersonal racism. Experiences of interpersonal racism by Indigenous physicians and patients have been well characterised, but the source of this interpersonal bias has not been as well studied. The aim of this study was to describe the prevalence of explicit and implicit interpersonal anti-Indigenous biases among Albertan physicians., Design and Setting: This cross-sectional survey measuring demographic information and explicit and implicit anti-Indigenous biases was distributed in September 2020 to all practising physicians in Alberta, Canada., Participants: 375 practising physicians with an active medical licence., Outcomes: Explicit anti-Indigenous bias, measured by two feeling thermometer methods: participants slid an indicator on a thermometer to indicate their preference for white people (full preference is scored 100) or Indigenous people (full preference, 0), and then participants indicated how favourably they felt toward Indigenous people (100, maximally favourable; 0, maximally unfavourable). Implicit bias was measured using an Indigenous-European implicit association test (negative scores suggest preference for European (white) faces). Kruskal-Wallis and Wilcoxon rank-sum tests were used to compare bias across physician demographics, including intersectional identities of race and gender identity., Main Results: Most of the 375 participants were white cisgender women (40.3%; n=151). The median age of participants was 46-50 years. 8.3% of participants felt unfavourably toward Indigenous people (n=32 of 375) and 25.0% preferred white people to Indigenous people (n=32 of 128). Median scores did not differ by gender identity, race or intersectional identities. White cisgender men physicians had the greatest implicit preferences compared with other groups (-0.59 (IQR -0.86 to -0.25); n=53; p<0.001). Free-text responses discussed 'reverse racism' and expressed discomfort with survey questions addressing bias and racism., Conclusions: Explicit anti-Indigenous bias was present among Albertan physicians. Concerns about 'reverse racism' targeting white people and discomfort discussing racism may act as barriers to addressing these biases. About two-thirds of respondents had implicit anti-Indigenous bias. These results corroborate the validity of patient reports of anti-Indigenous bias in healthcare and emphasise the need for effective intervention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Model-based economic evaluations require conceptualization of the model structure. Our objectives were to identify important health states, events, and patient attributes to be included in a model-based cost-effectiveness analysis of fall prevention interventions, to develop a model structure to examine cost-effectiveness of fall prevention interventions, and to assess the face validity of the model structure., Methods: An expert panel comprising clinicians, health service researchers, health economists, a patient partner, and policy makers completed two rounds of online surveys to gain consensus on health states, events, and patient attributes important for fall prevention interventions. The surveys were informed by a literature search on fall prevention interventions for older adults (≥65 years) including economic evaluations and clinical practice guidelines. The results of the Delphi surveys and subsequent discussions can support the face validity of a state-transition model for an economic evaluation of fall prevention interventions., Results: In total, 11 experts rated 24 health states/events and 41 patient attributes. Consensus was achieved on 14 health states/events and 26 patient characteristics. The proposed model structure incorporated 12 of the 14 selected health states/events. Panelists confirmed the face validity of the model structure during teleconferences., Conclusions: There is a dearth of studies presenting the model conceptualization process; consequently, this study involving multiple end user partners with opportunities for input at several stages adds to the literature as another case study. This process is an example of how a fall prevention economic model was developed using a modified Delphi process and assessed for face validity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Saunders et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: The COVID-19 pandemic presented new barriers and exacerbated existing inequities for physician scholars. While COVID-19's impact on academic productivity among women has received attention, the pandemic may have posed additional challenges for scholars from a wider range of equity-deserving groups, including those who hold multiple equity-deserving identities. To examine this concern, the authors conducted a scoping review of the literature through an intersectionality lens., Method: The authors searched peer-reviewed literature published March 1, 2020, to December 16, 2021, in Ovid MEDLINE, Ovid Embase, and PubMed. The authors excluded studies not written in English and/or outside of academic medicine. From included studies, they extracted data regarding descriptions of how COVID-19 impacted academic productivity of equity-deserving physician scholars, analyses on the pandemic's reported impact on productivity of physician scholars from equity-deserving groups, and strategies provided to reduce the impact of the COVID-19 pandemic on academic productivity of physician scholars from equity-deserving groups., Results: Of 11,587 unique articles, 44 met inclusion criteria, including 15 nonempirical studies and 29 empirical studies (22 bibliometrics studies, 6 surveys, and 1 qualitative study). All included articles focused on the gendered impact of the pandemic on academic productivity. The majority of their recommendations focused on how to alleviate the burden of the pandemic on women, particularly those in the early stages of their career and/or with children, without consideration of scholars who hold multiple and intersecting identities from a wider range of equity-deserving groups., Conclusions: Findings indicate a lack of published literature on the pandemic's impact on physician scholars from equity-deserving groups, including a lack of consideration of physician scholars who experience multiple forms of discrimination. Well-intentioned measures by academic institutions to reduce the impact on scholars may inadvertently risk reproducing and sustaining inequities that equity-deserving scholars faced during the pandemic., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Background: The prevalence of harassment and discrimination in medicine differs by race and gender. The current evidence is limited by a lack of intersectional analysis., Objective: To evaluate the experiences and perceptions of harassment and discrimination in medicine across physicians stratified by self-identified race and gender identity., Design: Quantitative and framework analysis of results from a cross-sectional survey study., Participants: Practicing physicians in the province of Alberta, Canada (n=11,688)., Main Measures: Participants completed an instrument adapted from the Culture Conducive to Women's Academic Success to capture the perceived culture toward self-identified racial minority physicians (Black, Indigenous, and People of Color (BIPOC)), indicated their perception of gender inequity in medicine using Likert responses to questions about common experiences, and were asked about experiences of reporting harassment or discrimination. Participants were also able to provide open text comments., Key Results: Among the 1087 respondents (9.3% response rate), 73.5% reported experiencing workplace harassment or discrimination. These experiences were least common among White cisgender men and most common among BIPOC cisgender women (52.4% and 85.4% respectively, p<0.00001). Cisgender men perceived greater gender equity than cisgender women physicians, and White cisgender men physicians perceived greatest racial equity. Participant groups reporting the greatest prevalence of harassment and discrimination experiences were the least likely to know where to report harassment, and less than a quarter of physicians (23.8%) who had reported harassment or discrimination were satisfied with the outcome. Framework analysis of open text responses identified key types of barriers to addressing racism, including denial of racism and greater concern about other forms of discrimination and harassment., Conclusions: Our results document the prevalence of harassment and discrimination by intersectional identities of race and gender. Incongruent perceptions and experiences may act as a barrier to preventing and addressing harassment and discrimination in the Canadian medical workplace., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objective: The objective of this scoping review is to identify and characterize relevant knowledge translation methods tools (those that provide guidance for optimized knowledge translation practice) to uncover candidate quality indicators to inform a future quality assessment tool for knowledge translation strategies., Introduction: Knowledge translation strategies (defined as including knowledge translation interventions, tools, and products) target various knowledge users, including patients, clinicians, researchers, and policy-makers. The development and use of strategies that support knowledge translation practice have been rapidly increasing, making it difficult for knowledge users to decide which to use. There is limited evidence-based guidance or measures to help assess the overall quality of knowledge translation strategies., Inclusion Criteria: Empirical and non-empirical documents will be considered if they explicitly describe a knowledge translation methods tool and its development, evaluation or validation, methodological strengths or limitations, and/or use over time. The review will consider a knowledge translation methods tool if it falls within at least one knowledge translation domain (ie, implementation, dissemination, sustainability, scalability, integrated knowledge translation) in the health field., Methods: We will conduct a systematic search of relevant electronic databases and gray literature. The search strategy will be developed iteratively by an experienced medical information specialist and peer-reviewed with the PRESS checklist. The search will be limited to English-only documents published from 2005 onward. Documents will be independently screened, selected, and extracted by 2 researchers. Data will be analyzed and summarized descriptively, including the characteristics of the included documents, knowledge translation methods tools, and candidate quality indicators., Scoping Review Registration: Open Science Framework ( https://osf.io/chxvq )., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 JBI.)

Background: Efforts to reduce barriers and disparities faced by marginalised physicians are limited by a lack of data on the current diversity of the Canadian physician workforce. We aimed to characterise the diversity of the Albertan physician workforce., Methods: This cross-sectional survey, open to all Albertan physicians from 1 September 2020 to 6 October 2021, measured the proportion of physicians from traditionally under-represented groups, including those with diverse gender identities, disabilities and from racial minorities., Results: There were 1087 respondents (9.3% response rate); of whom 33.4% identified as cisgender men (n=363), 46.8% as cisgender women (n=509) and less than 3% as gender diverse. Fewer than 5% were members of the LGBTQI2S+community. Half were white (n=547), 4.6% were black (n=50) and fewer than 3% were Indigenous or Latinx. Over one-third reported a disability (n=368, 33.9%). There were 303 white cisgender women (27.9%), 189 white cisgender men (17.4%), 136 black, Indigenous or person of colour (BIPOC) cisgender men (12.5%) and 151 BIPOC cisgender women (13.9%). Compared with BIPOC physicians, white participants were over-represented in leadership positions (64.2% and 32.1%; p=0.06) and academic roles (78.7% and 66.9%; p<0.01). Cisgender women had less often applied for academic promotion than cisgender men (85.4% and 78.3%, respectively, p=0.01), and BIPOC physicians had been denied promotion more frequently (7.7% compared with 4.4%; p=0.47)., Conclusion: Many Albertan physicians may experience marginalisation through at least one protected characteristic. There were race-based and gender-based differences in experiences of medical leadership and academic promotion which may explain observed disparities in these positions. To increase diversity and representation in medicine, medical organisations should focus on inclusive cultures and environments. Universities should focus efforts on supporting BIPOC physicians, especially BIPOC cisgender women, in applying for promotion., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Caregivers of persons with dementia and depression experience adverse effects associated with their role. The aim of this scoping review was to identify the challenges faced by caregivers of people with dementia and depression, along with interventions to support them. The MEDLINE®, Embase and PsycINFO databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Grey literature was assessed using the Canadian Agency for Drugs and Technologies in Health's Gray Matter tool.The population consisted of caregivers of people with dementia and depression; the concept was to identify the negative impacts that caregivers experience and whether there are interventions to reduce them; the context was any study design targeting family or friends who were caregivers. A total of 12,835 citations were identified; 139 studies were included. Dementia and depression have variable impacts on outcomes experienced by caregivers, including burden/strain ( n = 52), depression ( n = 27), distress ( n = 53), quality of life ( n = 5) and health/well-being ( n = 9). Pharmacological and non-pharmacological interventions have mixed effects. This study is important considering that depression in people with dementia is associated with caregiver distress. The use of a variety of non-pharmacological interventions could be beneficial to the latter.

Objective: The objective of this review is to critically analyze and synthesize the experiences and perceptions of health care professionals making decisions that result in treatment recommendations for older adults living with memory loss who are experiencing health problems., Introduction: Health care professionals provide care to older adults living with memory loss and other coexisting health conditions across all clinical settings. Older adults living with memory loss most commonly experience impaired independent decision-making, which can challenge health care professionals when decisions about treatment need to be made. These challenges contribute to older adults with memory loss receiving inappropriate treatment and experiencing higher morbidity than those without memory loss. To date, existing reviews have not focused on the experiences and perceptions of health care professionals who are making treatment decisions when older adults living with memory loss experience health problems. A deeper exploration of this evidence is needed to understand health care professionals' experiences and perceptions of treatment decision-making to support the goal of improving care for older adults., Inclusion Criteria: This systematic review will consider studies across all clinical settings focused on the experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss who are experiencing health problems., Methods: We will conduct a comprehensive systematic search using CINAHL, MEDLINE, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Two reviewers will independently appraise the selected studies and extract qualitative data using the recommended JBI method for study selection, critical appraisal, data extraction, and data synthesis. The ConQual approach will be applied to provide a level of confidence for the review findings., Systematic Review Registration Number: PROSPERO CRD42021271485., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 JBI.)

Background and Objectives: Frailty has been investigated for decades with a proliferation of frailty instruments attributed to many existing conceptual models and operational criteria. The purpose of this systematic review was to understand how instruments were developed to assess frailty in community dwelling older adults., Research Design and Methods: This review followed standard conduct, reporting, and quality assessment guidelines. Articles published in English that described instruments used to measure frailty in community dwelling older adults 65 years of age or older; and instruments developed for research purposes or in clinical practice were included. MEDLINE, CINAHL, and EMBASE (March 2022) and Abstracts in Social Gerontology (March 2020) were searched., Results: A total of 32 frailty instruments were identified with self-reported, performance-based, or researcher/clinician observed items. Common characteristics across instruments were categorized as follows: frailty conceptualized as a state or a syndrome; frailty operationalized as continuous, categorical, or dichotomous; and instruments developed for clinical, research or both purposes. All items in the instruments were developed based on theories of frailty; some were informed by panels of experts; and others used statistical methods to compare variables across instruments., Discussion and Implications: Results from this review will assist clinicians/researchers select appropriate instruments to assess frailty in older adults living in the community. It is time to pause on the development of more instruments. Instead, efforts must be directed toward advancing research and clinical practice using existing validated instruments to inform clinical decision-making and health care coordination to avoid, delay, or manage frailty in the community., Tweetable Abstract: More research and clinical practice using existing validated frailty instruments to assess frailty in older adults living in the community is a must!, Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective., Methods: We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights., Results: We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the 'Identify the problem' phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the 'Assess barriers/facilitators to knowledge use' phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the 'Select, tailor, implement interventions' phase (mean = 6.36, SD = 1.08)., Conclusions: Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future., Trial Registration: Open Science Framework Registration: osf.io/qgh64., (© 2022. The Author(s).)

Background: Family carers of persons living with dementia who are residing in long term care (LTC), often experience significant changes in their roles and relationships which affects mental and physical health. Research has focused on describing the carers' experience, but not on how they deal with these changes or their perceptions of support needs. The purpose of this study was to explore how family carers of persons living with dementia residing in LTC deal with significant changes and to understand how best to support these carers., Methods: Eight face-to-face audio-recorded focus group interviews were conducted with 45 participants from September 2019 to January 2020, as part of a larger study aimed at guiding the adaptation of an online toolkit to support family carers of persons living with dementia residing in LTC. Applied thematic analysis was used to analyze the focus group data., Findings/results: Carers dealt with the significant changes they experienced through the process of "building a new life" consisting of two sub-processes: a) building new relationships (with their family member, LTC staff and others outside of LTC), and b) finding space for themselves (sharing of care and finding balance). Understanding dementia, support from others (staff, family and friends), connecting with resources, and being included in care decisions helped carers build a new life., Conclusion: The process of building a new life describes the ways that family carers deal with the life-altering changes they experienced when a family member is admitted to LTC. Carers may be supported in building their new life, by providing them with information about dementia and how to relate to staff and their family member living with dementia. The quality of care being provided and the LTC environment may also play an important role in how carers deal with the significant changes they experience., (© 2022. The Author(s).)

Objective: Develop a Conservative Kidney Management (CKM) Pathway for patients unlikely to benefit from dialysis. We sought to determine (1) core components of care and (2) implementation strategies across a multisector healthcare system., Design: We used the Knowledge to Action Cycle and the Theoretical Domains Framework to identify barriers and facilitators to CKM. Activities included a current state assessment, World Cafés, interviews, focus groups and readiness for change assessments., Setting: A provincial initiative in Alberta, Canada., Participants: 282 participants were purposively selected to reflect those involved in the care of patients receiving CKM. This included policy-makers, multidisciplinary healthcare professionals, patients and their family., Main Outcome Measures: Theoretical domains linked to pathway content and implementation strategies., Results: Environmental context and resources, social/professional role and identity, knowledge and social influences were the most influential behaviour change domains identified. The most effective strategies for facilitating behaviour change were identified to be education, training, environmental restructuring and modelling. Core components of care were determined to be guidelines for treating symptoms and disease complications consistent with the philosophy of CKM, timely communication of the choice for CKM, coordination with community services, crisis planning, advance care planning and tools to enhance patients' capacity for self-management and shared decision-making. This resulted in development of Alberta's CKM Pathway, an interactive, digital, decision-support tool consisting of: (1) a patient decision aid; (2) a patient/family portal; and (3) a healthcare professional portal, where all resources can be freely accessed., Conclusions: The pathway was codesigned by patients and healthcare professionals and involves tailor-made combinations of tools to address unique patient needs and system-community circumstances. Most of the strategies are adaptable to local context and are likely translatable to the implementation of sustainable CKM in other national and international jurisdictions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To determine the incidence of falls, risk factors, and adverse outcomes, among patients admitted to the ICU., Design: Retrospective cohort study., Setting: Seventeen ICUs in Alberta, Canada., Patients: Seventy-three thousand four hundred ninety-five consecutive adult patient admissions between January 1, 2014, and December 31, 2019., Measurements and Main Results: A mixed-effects negative binomial regression model was used to examine risk factors associated with falls. Linear and logistic regression models were used to evaluate adverse outcomes. Six hundred forty patients experienced 710 falls over 398,223 patient days (incidence rate of 1.78 falls per 1,000 patient days [95% CI, 1.65-1.91]). The daily incidence of falls increased during the ICU stay (e.g., day 1 vs day 7; 0.51 vs 2.43 falls per 1,000 patient days) and varied significantly between ICUs (range, 0.37-4.64 falls per 1,000 patient days). Male sex (incidence rate ratio [IRR], 1.37; 95% CI, 1.15-1.63), previous invasive mechanical ventilation (IRR, 1.82; 95% CI, 1.40-2.38), previous sedative and analgesic medication infusions (IRR, 1.60; 95% CI, 1.15-2.24), delirium (IRR, 3.85; 95% CI, 3.23-4.58), and patient mobilization (IRR, 1.26; 95% CI, 1.21-1.30) were risk factors for falling. Falls were associated with longer ICU (ratio of means [RM], 3.10; 95% CI, 2.86-3.36) and hospital (RM, 2.21; 95% CI, 2.01-2.42) stays, but lower odds of death in the ICU (odds ratio [OR], 0.09; 95% CI, 0.05-0.17) and hospital (OR, 0.21; 95% CI, 0.14-0.30)., Conclusions: We observed that among ICU patients, falls occur frequently, vary substantially between ICUs, and are associated with modifiable risk factors, longer ICU and hospital stays, and lower risk of death. Our study suggests that fall prevention strategies should be considered for critically ill patients admitted to ICU., Competing Interests: Dr. Bagshaw received funding from Baxter and CNA Diagnostics. Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objective: To examine the comparative efficacy and safety of cognitive enhancers by patient characteristics for managing Alzheimer's dementia (AD)., Design: Systematic review and individual patient data (IPD) network meta-analysis (NMA) based on our previously published systematic review and aggregate data NMA., Data Sources: MEDLINE, Embase, Cochrane Methodology Register, CINAHL, AgeLine and Cochrane Central Register of Controlled Trials up to March 2016., Participants: 80 randomised controlled trials (RCTs) including 21 138 adults with AD, and 12 RCTs with IPD including 6906 patients., Interventions: Cognitive enhancers (donepezil, rivastigmine, galantamine and memantine) alone or in any combination against other cognitive enhancers or placebo., Data Extraction and Synthesis: We requested IPD from authors, sponsors and data sharing platforms. When IPD were not available, we used aggregate data. We appraised study quality with the Cochrane risk-of-bias. We conducted a two-stage random-effects IPD-NMA, and assessed their findings using CINeMA (Confidence in Network Meta-Analysis)., Primary and Secondary Outcomes: We included trials assessing cognition with the Mini-Mental State Examination (MMSE), and adverse events., Results: Our IPD-NMA compared nine treatments (including placebo). Donepezil (mean difference (MD)=1.41, 95% CI: 0.51 to 2.32) and donepezil +memantine (MD=2.57, 95% CI: 0.07 to 5.07) improved MMSE score (56 RCTs, 11 619 participants; CINeMA score: moderate) compared with placebo. According to P-score, oral rivastigmine (OR=1.26, 95% CI: 0.82 to 1.94, P-score=16%) and donepezil (OR=1.08, 95% CI: 0.87 to 1.35, P-score=30%) had the least favourable safety profile, but none of the estimated treatment effects were sufficiently precise when compared with placebo (45 RCTs, 15 649 patients; CINeMA score: moderate to high). For moderate-to-severe impairment, donepezil, memantine and their combination performed best, but for mild-to-moderate impairment donepezil and transdermal rivastigmine ranked best. Adjusting for MMSE baseline differences, oral rivastigmine and galantamine improved MMSE score, whereas when adjusting for comorbidities only oral rivastigmine was effective., Conclusions: The choice among the different cognitive enhancers may depend on patient's characteristics. The MDs of all cognitive enhancer regimens except for single-agent oral rivastigmine, galantamine and memantine, against placebo were clinically important for cognition (MD larger than 1.40 MMSE points), but results were quite imprecise. However, two-thirds of the published RCTs were associated with high risk of bias for incomplete outcome data, and IPD were only available for 15% of the included RCTs., Prospero Registration Number: CRD42015023507., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: Depressive disorders are common in long-term care (LTC), however, there is no one process used to detect depressive disorders in this setting. Our goal was to describe the diagnostic accuracy of depression detection tools used in LTC settings., Methods: We conducted a systematic review and meta-analysis of diagnostic accuracy measures. The databases PubMed, EMBASE, PsycINFO and CINAHL were searched from inception to 10 September 2021. Studies involving persons living in LTC, assisted living residences or facilities, comparing diagnostic accuracy of depression tools with a reference standard, were included. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess risk of bias., Results: We identified 8,463 citations, of which 20 studies were included in qualitative synthesis and 19 in meta-analysis. We identified 23 depression detection tools (including different versions) that were validated against a reference standard. At a cut-off point of 6 on the Geriatric Depression Scale-15 (GDS-15), the pooled sensitivity was 73.6% (95% confidence interval (CI) 43.9%-76.5%), specificity was 76.5% (95% CI 62.9%-86.7%), and an area under the curve was 0.83. There was significant heterogeneity in these analyses. There was insufficient data to conduct meta-analysis of other screening tools. The Nursing Homes Short Depression Inventory (NH-SDI) had a sensitivity ranging from 40.0% to 98.0%. The 4-item Cornell Scale for Depression in Dementia (CSDD) had the highest sensitivity (67.0%-90.0%) for persons in LTC living with dementia., Conclusions: There are 23 tools validated for detection of depressive disorders in LTC, with the GDS-15 being the most studied. Tools developed specifically for use in LTC settings include the NH-SDI and CSDD-4, which provide briefer options to screen for depression. However, more studies of both are needed to examine tool accuracy using meta-analyses., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons' transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.

Young women with chronic kidney disease (CKD) have disproportionately increased risk of cardiovascular mortality. Reduced anti-Müllerian hormone (AMH) is linked to poor cardiovascular outcomes in the general population, but whether AMH is associated with increased cardiovascular risk in the high-risk CKD population is unknown. This study examined the association between AMH and vascular function, validated markers of cardiovascular risk, in women with CKD. An exploratory cross-sectional study was performed in 47 young women with CKD. Laboratory measurements of AMH were collected. Using standardized protocols, endothelial function was measured with brachial artery flow-mediated dilation and hyperemic velocity time integral. Arterial stiffness was measured with aortic augmentation index and pulse wave velocity. Multivariate linear regression analyses were utilized to evaluate the association between AMH levels and each measure of vascular health. Forty women (36 ± 7 years) with non-dialysis-dependent CKD and 7 women (38 ± 6 years) with dialysis-dependent CKD participated. AMH levels were inversely associated with age (p = 0.01) but not associated with eGFR (p = 0.59) or dialysis status (p = 0.97). AMH was associated with brachial artery flow-mediated dilation (R 2  = 0.21 [p = 0.03]) and aortic augmentation index (R 2  = 0.20 [p = 0.04]) in the non-dialysis-dependent participants, and with aortic augmentation index in all participants (R 2  = 0.18 [p = 0.03]). No association between AMH and any measure of vascular function was demonstrated in the dialysis-dependent participants. AMH levels are associated with impaired vascular function in young women with CKD and may be an important marker of future cardiovascular risk. Further investigation into this female-specific cardiovascular risk factor is warranted in this high-risk population., (© 2022 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Family caregivers (FCGs) are an integral part of the healthcare system. Currently, FCGs provide 70%-90% of the care required by community-dwelling children and adults living with complex chronic conditions and frailty. Despite FCG's contributions and the growing proportion of distressed caregivers, support for FCGs has not been a health system priority. Researchers have proposed training to enhance the competencies of health providers to work effectively with FCGs. In the absence of best practices for the competency indicators for caregiver-centred care, we have developed a competency framework for training the health workforce to support FCGs. The objectives in this paper are fourfold: (a) a brief review of stakeholder engagement that led to the development of the competencies the health workforce needs to support FCGs, (b) a description of the process used to name the competency domains, (c) a report on the Modified Delphi process (conducted 2019) used to validate the domain indicators, and (d) a description of the competency framework. We adopted a caregiver and a multilevel interdisciplinary stakeholder codesign approach throughout the competency development process. The competency domains include: (a) Recognising the Caregiver Role, (b) Communicating with FCGs, (c) Partnering with FCGs, (d) Fostering Resilience in FCGs, (e) Navigating Health and Social Systems and Accessing Resources, and, (f) Enhancing the Culture and Context of Healthcare. Our Caregiver-Centred Care Competencies for the health workforce are only a first step in supporting FCGs in their vital roles. There are few education and training resources to enable and empower health providers to support FCGs, there is an urgent need to develop training resources for the health workforce to recognise and support FCGs., (© 2020 John Wiley & Sons Ltd.)

Background: To understand how best to approach dementia care within primary care and its challenges, we examined the evidence related to diagnosing and managing dementia within primary care., Methods: Databases searched include: MEDLINE, Embase, PsycINFO and The Cochrane Database of Systematic Reviews from inception to 11 May 2020. English-language systematic reviews, either quantitative or qualitative, were included if they described interventions involving the diagnosis, treatment and/or management of dementia within primary care/family medicine and outcome data was available. The risk of bias was assessed using AMSTAR 2. The review followed PRISMA guidelines and is registered with Open Science Framework., Results: Twenty-one articles are included. The Mini-Cog and the MMSE were the most widely studied cognitive screening tools. The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100 %, 95 % CI: 70-100 %) and specificity (82 %, 95 % CI: 72-90 %) within the shortest amount of time (3.16 to 5 min) within primary care. Five of six studies found that family physicians had an increased likelihood of suspecting dementia after attending an educational seminar. Case management improved behavioural symptoms, while decreasing hospitalization and emergency visits. The primary care educational intervention, Enhancing Alzheimer's Caregiver Health (Department of Veterans Affairs), was successful at increasing carer ability to manage problem behaviours and improving outcomes for caregivers., Conclusions: There are clear tools to help identify cognitive impairment in primary care, but strategies for management require further research. The findings from this systematic review will inform family physicians on how to improve dementia diagnosis and management within their primary care practice., (© 2021. The Author(s).)

Aims: This mixed methods longitudinal study evaluated Nav-CARE for feasibility, acceptability, ease of use, and satisfaction by older persons and volunteers., Methods: Nine volunteer navigators visited 23 older persons with serious illness every 3 to 4 weeks for 1 year. Data were collected from volunteer navigators, and older person participants at baseline, during the year- long implementation and post implementation., Results: Volunteer navigators and older persons reported Nav-CARE was easy to use, feasible and acceptable. The majority of older persons agreed or strongly agreed that they were satisfied with the navigation services (100%; 8/8), that navigation services were important to them (87%; 7/8), that they would recommend the program to someone else (87%; 7/8), and would participate in the program again (75%; 6/8). Similarly, volunteer navigators reported 100% (9/9) satisfaction with the program, 100% (9/9) would recommend it to others, and 67% (6/8) would participate again., Conclusions: Nav-CARE appears to be a feasible, acceptable, and satisfactory program for older persons with serious illness and volunteer navigators.

Objective: Although the prevalence of comorbid epilepsy and dementia is expected to increase, the impact is not well understood. Our objectives were to examine risk factors associated with incident dementia and the impact of frailty and dementia on mortality in older adults with epilepsy., Methods: The CALIBER scientific platform was used. People with incident epilepsy at or after age 65 were identified using Read codes and matched by age, sex, and general practitioner to a cohort without epilepsy (10:1). Baseline cohort characteristics were compared using conditional logistic regression models. Multivariate Cox proportional hazard regression models were used to examine the impact of frailty and dementia on mortality, and to assess risk factors for dementia development., Results: One thousand forty eight older adults with incident epilepsy were identified. The odds of having dementia at baseline were 7.39 [95% CI 5.21-10.50] times higher in older adults with epilepsy (n = 62, 5.92%) compared to older adults without epilepsy (n = 88, 0.86%). In the final multivariate Cox model (n = 326), age [HR: 1.20, 95% CI 1.09-1.32], Charlson comorbidity index score [HR: 1.26, 95% CI 1.10-1.44], and sleep disturbances [HR: 2.41, 95% CI 1.07-5.43] at baseline epilepsy diagnosis were significantly associated with an increased hazard of dementia development over the follow-up period. In a multivariate Cox model (n = 1047), age [HR: 1.07, 95% CI 1.03-1.11], baseline dementia [HR: 2.66, 95% CI 1.65-4.27] and baseline e-frailty index score [HR: 11.55, 95% CI 2.09-63.84] were significantly associated with a higher hazard of death among those with epilepsy. Female sex [HR: 0.77, 95% CI 0.59-0.99] was associated with a lower hazard of death., Significance: The odds of having dementia were higher in older adults with incident epilepsy. A higher comorbidity burden acts as a risk factor for dementia, while prevalent dementia and increasing frailty were associated with mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Health technology reassessment (HTR) is a field focused on managing a technology throughout its life cycle for optimal use. The process results in one of four possible recommendations: increase use, decrease use, no change or complete withdrawal of the technology. However, implementation of these recommendations has been challenging. This paper explores knowledge translation (KT) theories, models and frameworks (TMFs) and their suitability for implementation of HTR recommendations., Design: Cross-sectional survey., Participants: Purposeful sampling of international KT and HTR experts was administered between January and March 2019., Methods: Sixteen full-spectrum KT TMFs were rated by the experts as 'yes', 'partially yes' or 'no' on six criteria: familiarity, logical consistency/plausibility, degree of specificity, accessibility, ease of use and HTR suitability. Consensus was determined as a rating of ≥70% responding 'yes'. Descriptive statistics and manifest content analysis were conducted on open-ended comments., Results: Eleven HTR and 11 KT experts from Canada, USA, UK, Australia, Germany, Spain, Italy and Sweden participated. Of the 16 KT TMFs, none received ≥70% rating. When ratings of 'yes' and 'partially yes' were combined, the Consolidated Framework for Implementation Research was considered the most suitable KT TMF by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: Knowledge to Action framework. HTR experts selected two additional KT TMFs: Co-KT framework and Plan-Do-Study-Act cycle. Experts identified three key characteristics of a KT TMF that may be important to consider: practicality, guidance on implementation and KT TMF adaptability., Conclusions: Despite not reaching an overall ≥70% rating on any of the KT TMFs, experts identified four KT TMFs suitable for HTR. Users may apply these KT TMFs in the implementation of HTR recommendations. In addition, KT TMF characteristics relevant to the field of HTR need to be explored further., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There remains no effective intervention capable of reversing most cases of dementia. Current research is focused on prevention by addressing risk factors that are shared between cardiovascular disease and dementia (e.g., hypertension) before the cognitive, functional, and behavioural symptoms of dementia manifest. A promising preventive treatment is exercise. This study describes the methods of a randomized controlled trial (RCT) that assesses the effects of aerobic exercise and behavioural support interventions in older adults at increased risk of dementia due to genetic and/or cardiovascular risk factors. The specific aims are to determine the effect of aerobic exercise on cognitive performance, explore the biological mechanisms that influence cognitive performance after exercise training, and determine if changes in cerebrovascular physiology and function persist 1 year after a 6-month aerobic exercise intervention followed by a 1-year behavioural support programme (at 18 months)., Methods: We will recruit 264 participants (aged 50-80 years) at elevated risk of dementia. Participants will be randomly allocated into one of four treatment arms: (1) aerobic exercise and health behaviour support, (2) aerobic exercise and no health behaviour support, (3) stretching-toning and health behaviour support, and (4) stretching-toning and no health behaviour support. The aerobic exercise intervention will consist of three supervised walking/jogging sessions per week for 6 months, whereas the stretching-toning control intervention will consist of three supervised stretching-toning sessions per week also for 6 months. Following the exercise interventions, participants will receive either 1 year of ongoing telephone behavioural support or no telephone support. The primary aim is to determine the independent effect of aerobic exercise on a cognitive composite score in participants allocated to this intervention compared to participants allocated to the stretching-toning group. The secondary aims are to examine the effects of aerobic exercise on a number of secondary outcomes and determine whether aerobic exercise-related changes persist after a 1-year behavioural support programme (at 18 months)., Discussion: This study will address knowledge gaps regarding the underlying mechanisms of the pro-cognitive effects of exercise by examining the potential mediating factors, including cerebrovascular/physiological, neuroimaging, sleep, and genetic factors that will provide novel biologic evidence on how aerobic exercise can prevent declines in cognition with ageing., Trial Registration: ClinicalTrials.gov NCT03035851 . Registered on 30 January 2017.

Introduction: There is a diverse body of evidence investigating non-pharmacological treatment options for apathy in Parkinson's disease (PD). We aimed to better understand the context and mechanisms by which non-pharmacological interventions may improve apathy in persons with PD., Methods: We conducted a realist review of the body of evidence investigating treatment options for apathy in PD. Study authors used findings from a preceding scoping review to identify initial program theory. We then update the scoping review, which was originally conducted in 2017. Two authors independently reviewed and extracted data from studies that discussed non-pharmacological treatment options for apathy in PD. Any data concerning context, mechanisms, and outcomes of interventions for apathy in PD were extracted, synthesized, and analyzed., Results: Our review included nine studies. We categorized studies into two categories, exercise and mindfulness. There were seven exercise interventions included. Exercise interventions evaluated group exercise compared to individual exercise, aerobic exercise, dance, Nordic walking, and an equine program. There were two mindfulness interventions., Conclusion: Exercise interventions work best for persons with PD and apathy who are not significantly physically or cognitively impaired, and who have access to transportation, adapted programs, and specialized coaches. Exercise may improve apathy through goal-directed behaviour change and engagement in social interactions. Mindfulness interventions work best for persons with PD and apathy who are not significantly cognitively impaired, have caregiver support, and may improve apathy by targeting the emotional, cognitive, and goal-directed domains that define apathy., (© 2021 The Authors.)

Introduction: Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches., Methods and Analysis: Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation., Ethics and Dissemination: This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners., Trial Registration Number: NCT03442426;Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The Acute Care for the Elderly (ACE) model has demonstrated clinical benefit, but there is little evidence regarding quality of life after discharge. The Elder-friendly Approaches to the Surgical Environment (EASE) study was conducted to assess implementation of an ACE unit on an acute surgical service. Improved clinical and economic outcomes have been demonstrated, but post-discharge patient reported outcomes have not yet been reported., Methods: Prospective, concurrently controlled, before-after study at two tertiary care hospitals in Alberta, Canada. The SF-12, EQ-5D, Canadian Malnutrition Screening Tool (CMST) and patient satisfaction were collected from elderly (≥ 65 years old) patients, 6 weeks and 6 months after discharge from an acute care surgical service. A difference-in-difference (DID) method was used to analyze between-site effects., Results: At six weeks, patient satisfaction was high at 68%-86%, with significant improvement Pre-to Post-EASE at the control site (p < 0.001), but not the intervention site (p = 0.06). For the intervention site, within-site adjusted pre-post effects were nonsignificant for all patient reported outcomes [EQ-Index Score β coefficient (SE): 0.042 (0.022); EQ-Visual Analog Scale: 0.10 (2.14); SF-12 Physical Component Score: -0.57 (0.84); SF-12 Mental Component Score: 1.17 (0.84); CMST Score: -0.39 (0.34)]. DID analyses were also non significant for all outcomes except for SF-12 Mental Component Score (p < 0.001)., Conclusion: The clinically and economically beneficial EASE interventions do not appear to compromise quality of life, risk for malnutrition, or patient satisfaction in the post-discharge period. Further research with larger sample size is needed with comparisons to pre-intervention and the early post-discharge period., Competing Interests: The authors have no conflicts of interest to report., (© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.)

Background: Health Technology Reassessment (HTR) is a process that systematically assesses technologies that are currently used in the health care system. The process results in four outputs: increase use or decrease use, no change, or de-adoption of a technology. Implementation of these outputs remains a challenge. The Knowledge Translation (KT) field enables to transfer/translate knowledge into practice. KT could help with implementation of HTR outputs. This study sought to identify which characteristics of KT theories, models, and frameworks could be useful, specifically for decreased use or de-adoption of a technology., Methods: A qualitative descriptive approach was used to ascertain the perspectives of international KT and HTR experts on the characteristics of KT theories, models, and frameworks for decreased use or de-adoption of a technology. One-to-one semi-structured interviews were conducted from September to December 2019. Interviews were audio recorded and transcribed verbatim. Themes and sub-themes were deduced from the data through framework analysis using five distinctive steps: familiarization, identifying an analytic framework, indexing, charting, mapping and interpretation. Themes and sub-themes were also mapped to existing KT theories, models, and frameworks., Results: Thirteen experts from Canada, United States, United Kingdom, Australia, Germany, Spain, and Sweden participated in the study. Three themes emerged that illustrated the ideal traits: principles that were foundational for HTR, levers of change, and steps for knowledge to action. Principles included evidence-based, high usability, patient-centered, and ability to apply to the micro, meso, macro levels. Levers of change were characterized as positive, neutral, or negative influences for changing behaviour for HTR. Steps for knowledge to action included: build the case for HTR, adapt research knowledge, assess context, select interventions, and assess impact. Of the KT theories, models, and frameworks that were mapped, the Consolidated Framework for Implementation Research had most of the characteristics, except ability to apply to micro, meso, macro levels., Conclusions: Characteristics that need to be considered within a KT theory, model, and framework for implementing HTR outputs have been identified. Consideration of these characteristics may guide users to select relevant KT theories, models, and frameworks to apply to HTR projects.

Introduction: In response to the burden of chronic disease among older adults, different chronic disease self-management tools have been created to optimise disease management. However, these seldom consider all aspects of disease management are not usually developed specifically for seniors or created for sustained use and are primarily focused on a single disease. We created an eHealth self-management application called 'KeepWell' that supports seniors with complex care needs in their homes. It incorporates the care for two or more chronic conditions from among the most prevalent high-burden chronic diseases., Methods and Analysis: We will evaluate the effectiveness, cost and uptake of KeepWell in a 6-month, pragmatic, hybrid effectiveness-implementation randomised controlled trial. Older adults age ≥65 years with one or more chronic conditions who are English speaking are able to consent and have access to a computer or tablet device, internet and an email address will be eligible. All consenting participants will be randomly assigned to KeepWell or control. The allocation sequence will be determined using a random number generator.Primary outcome is perceived self-efficacy at 6 months. Secondary outcomes include quality of life, health background/status, lifestyle (nutrition, physical activity, caffeine, alcohol, smoking and bladder health), social engagement and connections, eHealth literacy; all collected via a Health Risk Questionnaire embedded within KeepWell (intervention) or a survey platform (control). Implementation outcomes will include reach, effectiveness, adoption, fidelity, implementation cost and sustainability., Ethics and Dissemination: Ethics approval has been received from the North York General Hospital Research and Ethics Board. The study is funded by the Canadian Institutes of Health Research and the Ontario Ministry of Health. We will work with our team to develop a dissemination strategy which will include publications, presentations, plain language summaries and an end-of-grant meeting., Trial Registration Number: NCT04437238., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In 2014, the province of Alberta, Canada implemented a province-wide policy and procedures for advance care planning (ACP) and goals of care designation (GCD) across its complex, integrated public healthcare system. This study was conducted to identify and operationalise performance indicators for ACP/GCD to monitor policy implementation success and sustainment of ACP/GCD practice change., Methods: A systematic review and environmental scan was conducted to identify potential indicators of ACP/GCD uptake (n=132). A purposive sample of ACP/GCD stakeholders was invited to participate in a modified Delphi study to evaluate, reduce and refine these indicators through a combination of face-to-face meetings and online surveys., Results: An evidence-informed Donabedian by Institute of Medicine (IOM) framework was adopted as an organising matrix for the indicators in an initial face-to-face meeting. Three online survey rounds reduced and refined the 132 indicators to 18. A final face-to-face meeting operationalised the indicators into a measurable format. Nine indicators, covering 11 of the 18 Donabedian×IOM domains, were operationalised., Conclusions: Nine ACP/GCD evidence-informed indicators mapping to 11 of 18 Donabedian×IOM domains were endorsed, and have been operationalised into an online ACP/GCD dashboard. The indicators provide a characterisation of ACP/GCD uptake that could be generalised to other healthcare settings, measuring aspects related to ACP/GCD documentation, patient satisfaction and agreement between medical orders and care received. The final nine indicators reflect the stakeholders' expressed intent to strike a balance between comprehensiveness and feasibility within a large provincial healthcare system., Competing Interests: Competing interests: JS is the Physician Consultant for Advance Care Planning and Goals of Care, Calgary Zone, Alberta Health Services. TLWM. was the Provincial Lead for Palliative End of Life Care Practice Development, Alberta Health Services at the time of this work., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: An estimated 20-30% of community-dwelling Canadian adults aged 65 years or older experience one or more falls each year. Fall-related injuries are a leading cause of hospitalization and can lead to functional independence. Many fall prevention interventions, often based on modifiable risk factors, have been studied. Apart from the magnitude of the benefits and harms from different interventions, the preferences of older adults for different interventions as well as the relative importance they place on the different potential outcomes may influence recommendations by guideline panels. These reviews on benefits and harms of interventions, and on patient values and preferences, will inform the Canadian Task Force on Preventive Health Care to develop recommendations on fall prevention for primary care providers., Methods: To review the benefits and harms of fall prevention interventions, we will update a previous systematic review of randomized controlled trials with adaptations to modify the classification of interventions and narrow the scope to community-dwelling older adults and primary-care relevant interventions. Four databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Ageline), reference lists, trial registries, and relevant websites will be searched, using limits for randomized trials and date (2016 onwards). We will classify interventions according to the Prevention of Falls Network Europe (ProFANE) Group's taxonomy. Outcomes include fallers, falls, injurious falls, fractures, hip fractures, institutionalization, health-related quality of life, functional status, and intervention-related adverse effects. For studies not included in the previous review, screening, study selection, data extraction on outcomes, and risk of bias assessments will be independently undertaken by two reviewers with consensus used for final decisions. Where quantitative analysis is suitable, network or pairwise meta-analysis will be conducted using a frequentist approach in Stata. Assessment of the transitivity and coherence of the network meta-analyses will be undertaken. For the reviews on patient preferences and outcome valuation (relative importance of outcomes), we will perform de novo reviews with searches in three databases (MEDLINE, PsycInfo, and CINAHL) and reference lists for cross-sectional, longitudinal quantitative, or qualitative studies published from 2000. Selection, data extraction, and risk of bias assessments suitable for each study design will be performed in duplicate. The analysis will be guided by a narrative synthesis approach, which may include meta-analysis for health-state utilities. We will use the CINeMa approach to a rate the certainty of the evidence for outcomes on intervention effects analyzed using network meta-analysis and the GRADE approach for all other outcomes., Discussion: We will describe the flow of literature and characteristics of all studies and present results of all analyses and summary of finding tables. We will compare our findings to others and discuss the limitations of the reviews and the available literature., Systematic Review Registration: This protocol has not been registered.

Background: Systematic reviews have established that exercise reduces falls in older adults, however the most effective types of exercise are not known. This secondary analysis determined the comparative effectiveness of fall prevention exercise approaches., Method: All fall prevention exercise interventions for older adults were identified from an existing search from inception until April 2017. Interventions were coded using a framework of 25 exercise types. Two reviewers independently screened studies, extracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. P-scores were used to rank exercise combinations., Results: One hundred and sixty-nine studies were included. NMA was conducted on 73 studies (30,697 participants) for the outcome of number of fallers. The exercise combination ranked with the greatest likelihood of being most effective relative to no exercise was: anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility (p-score = 0.95). This exercise combination also significantly reduced number of fallers compared to 16 other combinations. No exercise combination had a significantly greater effect on reducing number of fallers more than this combination., Conclusion: This analysis identified components of effective fall prevention exercise. The results can inform evidence-informed exercise recommendations and be used to design effective programs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community., Methods/design: We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care., Discussion: This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.