Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial

Lofters, Aisha; O’Brien, Mary Ann; Sutradhar, Rinku; Pinto, Andrew D.; Baxter, Nancy N.; Donnelly, Peter; Elliott, R.; Glazier, Richard H.; Huizinga, Joanne; Kyle, Robert; Manca, Donna; Pietrusiak, Mary-Anne; Rabeneck, Linda; Riordan, Benjamin C.; Selby, Peter; Sivayoganathan, K.; Snider, Christopher K.; Sopcak, Nicolette; Thorpe, Kevin E.; Tinmouth, Jill; Wall, Becky; Zuo, Fei; Grunfeld, Eva; Paszat, Lawrence

doi:10.1186/s12889-021-11452-x

Cited by 8 publications

(12 citation statements)

References 25 publications

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“…The primary results from BETTER WISE have now been published. In contrast to previous BETTER programme studies mentioned above,15–17 the primary intention-to-treat (ITT) analyses, which did not consider financial difficulty, show that the effectiveness of the BETTER WISE intervention was not statistically significant, although per-protocol analyses of participants enrolled prior to the imposition of the COVID-19 restrictions showed a 21% improvement (p=0.001) in CCDPS compared with usual care 19…”

Section: Introductioncontrasting

confidence: 57%

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial

Aubrey-Bassler,

Patel,

Fernandes

et al. 2024

BMJ Open

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ObjectiveBuilding on Existing Tools To improvE chronic disease pRevention and screening in primary care Wellness of cancer survIvorS and patiEnts (BETTER WISE) was designed to assess the effectiveness of a cancer and chronic disease prevention and screening (CCDPS) programme. Here, we compare outcomes in participants living with and without financial difficulty.DesignSecondary analysis of a cluster-randomised controlled trial.SettingPatients of 59 physicians from 13 clinics enrolled between September 2018 and August 2019.Participants596 of 1005 trial participants who responded to a financial difficulty screening question at enrolment.Intervention1-hour CCDPS visit versus usual care.Outcome measuresEligibility for a possible 24 CCDPS actions was assessed at baseline and the primary outcome was the percentage of eligible items that were completed at 12-month follow-up. We also compared the change in response to the financial difficulty screening question between baseline and follow-up.Results55 of 265 participants (20.7%) in the control group and 69 of 331 participants (20.8%) in the intervention group reported living with financial difficulty. The primary outcome was 29% (95% CI 26% to 33%) for intervention and 23% (95% CI 21% to 26%) for control participants without financial difficulty (p=0.01). Intervention and control participants with financial difficulty scored 28% (95% CI 24% to 32%) and 32% (95% CI 27% to 38%), respectively (p=0.14). In participants who responded to the financial difficulty question at both time points (n=302), there was a net decrease in the percentage of participants who reported financial difficulty between baseline (21%) and follow-up (12%, p<0.001) which was similar in the control and intervention groups. The response rate to this question was only 51% at follow-up.ConclusionThe BETTER intervention improved uptake of CCDPS manoeuvres in participants without financial difficulty, but not in those living with financial difficulty. Improving CCDPS for people living with financial difficulty may require a different clinical approach or that social determinants be addressed concurrently with clinical and lifestyle needs or both.Trial registration numberISRCTN21333761.

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Section: Introductioncontrasting

confidence: 57%

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial

Aubrey-Bassler,

Patel,

Fernandes

et al. 2024

BMJ Open

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“…Initiated by the 1995 Institute of Medicine report Setting Priorities for Clinical Practice Guidelines [ 30 ], several decades of investment have resulted in robust methods to create high-quality guidelines; however, to achieve intended outcomes, CPGs must be implementable in real-world practice. The BETTER program has demonstrated that nuanced clinical tools can be designed to facilitate decision-making between PCPs and patients across multiple chronic diseases and lifestyle factors [ 2 , 17 , 18 ]. In this evidence review, we extended our topic scope, included health policy makers and patients in the evidence synthesis process, and tailored the included clinical recommendations for implementation in 4 Canadian provinces.…”

Section: Discussionmentioning

confidence: 99%

“…The evidence-based prevention prescription is rooted in harmonized, high-quality CCDPS guidelines and tailored to patients based on their medical history, risk factors, and family history. This cost-effective intervention has been demonstrated to improve uptake of CCDPS actions in urban primary care settings as compared to usual care [ 2 ] and similar improvements have been observed in rural and remote communities [ 17 ] and public health settings [ 18 ] across Canada.…”

Section: Introductionmentioning

confidence: 92%

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care

Fernandes,

Campbell-Scherer,

Lofters

et al. 2024

BMC Prim. Care

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Background Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. Methods A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40–69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. Results We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40–69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. Conclusions Comprehensive care requires the ability to address a person’s overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

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“…Moreover, in the original BETTER trial, about half of the participants had an income of $100,000 (CAD) or higher [ 7 ]. Since a large number of Canadians do not have access to a primary care practitioner [ 12 ] and it was unknown if the BETTER intervention would be effective for people living with low income, we adapted the BETTER intervention to a public health setting (without access to electronic or paper medical records from any source) with public health nurses as PPs, and conducted a cluster randomized controlled trial (cRCT) that compared the adapted BETTER intervention to a wait-list control [ 13 , 14 ]. We previously reported that six months after the prevention visit participants in the intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22–1.84]) [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

Adaptation and qualitative evaluation of the BETTER intervention for chronic disease prevention and screening by public health nurses in low income neighbourhoods: views of community residents

O’Brien,

Lofters,

Wall

et al. 2024

BMC Health Serv Res

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Background The BETTER intervention is an effective comprehensive evidence-based program for chronic disease prevention and screening (CDPS) delivered by trained prevention practitioners (PPs), a new role in primary care. An adapted program, BETTER HEALTH, delivered by public health nurses as PPs for community residents in low income neighbourhoods, was recently shown to be effective in improving CDPS actions. To obtain a nuanced understanding about the CDPS needs of community residents and how the BETTER HEALTH intervention was perceived by residents, we studied how the intervention was adapted to a public health setting then conducted a post-visit qualitative evaluation by community residents through focus groups and interviews. Methods We first used the ADAPT-ITT model to adapt BETTER for a public health setting in Ontario, Canada. For the post-PP visit qualitative evaluation, we asked community residents who had received a PP visit, about steps they had taken to improve their physical and mental health and the BETTER HEALTH intervention. For both phases, we conducted focus groups and interviews; transcripts were analyzed using the constant comparative method. Results Thirty-eight community residents participated in either adaptation (n = 14, 64% female; average age 54 y) or evaluation (n = 24, 83% female; average age 60 y) phases. In both adaptation and evaluation, residents described significant challenges including poverty, social isolation, and daily stress, making chronic disease prevention a lower priority. Adaptation results indicated that residents valued learning about CDPS and would attend a confidential visit with a public health nurse who was viewed as trustworthy. Despite challenges, many recipients of BETTER HEALTH perceived they had achieved at least one personal CDPS goal post PP visit. Residents described key relational aspects of the visit including feeling valued, listened to and being understood by the PP. The PPs also provided practical suggestions to overcome barriers to meeting prevention goals. Conclusions Residents living in low income neighbourhoods faced daily stress that reduced their capacity to make preventive lifestyle changes. Key adapted features of BETTER HEALTH such as public health nurses as PPs were highly supported by residents. The intervention was perceived valuable for the community by providing access to disease prevention. Trial registration #NCT03052959, 10/02/2017.

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Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial

Cited by 8 publications

References 25 publications

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial

Chronic disease prevention and screening outcomes for patients with and without financial difficulty: a secondary analysis of the BETTER WISE cluster randomised controlled trial

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care

Adaptation and qualitative evaluation of the BETTER intervention for chronic disease prevention and screening by public health nurses in low income neighbourhoods: views of community residents

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