Research projects

Research projects

Translating shared decision making into clinical practices: Phase 1. An international collaboration

Phase 1: Proof of concepts

Shared decision making (SDM) is defined as the process by which a healthcare decision is made by both the practitioner and the patient (i.e. the practitioner-patient dyad). Engaging patients as partners in their own care increases patient satisfaction and correlates with a better quality of life. Yet the SDM approach has not been adopted by the population at large. There are several important barriers to the successful implementation of SDM in primary care. To identify and overcome these barriers, it is important to simultaneously evaluate patients' and health professionals' perspectives of the SDM process (dyadic decision-making). The main goal of this project was to bring together the resources and the expertise needed to develop an international research team dedicated to implementing SDM in clinical practice. This international collaboration addresses the challenges posed by the implementation of SDM through the use of a dyadic perspective. Ultimately, the results will improve how the Canadian healthcare system and its professionals understand and respond to public expectations about health services and healthcare management.

Phase 1 protocol was published in 2008 in Implementation Science

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DECISION+2: Randomized Control Trial

This project, carried out from 2009 to 2012, was based on the data gathered during a pilot randomized control trial of Decision+2. The main aim of the pilot was to establish the feasibility of conducting the project on a larger scale. The pilot project assessed the impact of DECISION+2 on antibiotics use for acute respiratory infections (ARI) – the main reason for consultations in primary care. This project was funded by the FRSQ-Conseil du Medicament.

Acute respiratory tract infections (ARIs) such as otitis media, rhinosinusitis, acute pharyngitis and bronchitis account for up to 10% of consultations in emergency departments. Several studies have shown that these infections are overwhelmingly of viral etiology and therefore self-limiting. Although antibiotic therapy is unnecessary in the treatment of acute respiratory infections of viral etiology, the use of antibiotics is still widespread among clinicians in North America. Inappropriate antibiotics consumption is associated with antibiotic resistance, increased risk of side effects and a higher rate of readmission. This is a major public health problem. Information tools are a promising way to inform patients and doctors about this problem. Information tools can support informed decision-making about an individual health issue. This can open the dialogue for shared decision-making between the patient and the doctor. Shared decision-making is a decision-making process in which the physician, the patient, and those around them share information that is informed by the highest level of evidence, evaluate all possible diagnostic and therapeutic options, identify the patient's priorities, deliberate, and jointly decide on the best care for the patient.

Bibliography

1. Hing E, Cherry DK, Woodwell DA. National Ambulatory Medical Care Survey: 2004 summary. Adv Data. 2006 Jun 23;(374):1–33 2. Murphy - Journal of Emergency Medicine RA, 2016. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. jem-journal.com [Internet]. 2016; Available from: www.jem-journal.com/article/S0736-4679(16)30470-X/abstract 3. Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf. 2014 Dec;5(6):229–41. 4. Opatowski M, Cosker K, Brun-Buisson C, Tuppin P, Salomon J, Watier L. Résistance bactérienne aux antibiotiques, apport du PMSI. Revue d’Épidémiologie et de Santé Publique. 2017 Mar 1;65(Supplement 1):S12. 5. Ventola CL. The antibiotic resistance crisis: part 1: causes and threats. P T. 2015 Apr;40(4):277–83.

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IPSDM - DOLCE

Improving decision making on location of care with the frail elderly and their caregivers

One of the toughest decisions faced by the frail elderly in Canada is whether to stay at home or move to a care facility. It is certainly difficult to make this decision alone, but can be even harder if someone else makes it for you. Shared decision making is when, instead of making decisions for the patient, healthcare professionals share information about what the evidence says, and they talk about what's important with the patient, and then make the decision together. In the case of the frail elderly in home care services, there are many health care professionals involved, e.g. the doctor, nurse and social worker. In this case decisions should be shared by all the professionals involved with the elderly person along with his or her caregivers. Unfortunately, in this context, shared decision making rarely occurs. We have designed a training program that teaches interprofessional teams how to share decisions with their frail elderly patients, and tested it in one Quebec City and one Edmonton home care team. This project tested the training program on a broader scale with 16 home care teams attached to community health centres across the province of Quebec, and compared the results with what happens when no one has completed the training (usual care). Results show that caregivers followed by the trained home care teams felt more involved in the decision making process, and that there was a better fit with the prefered choice and the choice made.

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Introducing Patient Perspectives in Health Technology Assessment

Summary

Recent recognition of the importance of engaging patients in decisions regarding their own medical care has led decision makers to incorporate patient perspectives in the decision making process. In the province of Quebec, university hospitals have created units for evaluating health technologies and intervention methods (Health Technology Assessment Units, or HTA Units) to meet their evaluation responsibilities and to promote evidence-based decision making. The creation of HTA Units within university hospitals is an opportunity for decision makers to increase the involvement of patients and the general public in decisions about health technologies. This said, little is known about interventions that have succeeded in achieving this. The present project aims at answering the needs of decision makers working in the sector of health technology assessment by exploring ways to involve patients in HTA Unit activities. To accomplish this objective, the study has three goals: 1. to synthesize international knowledge and experiences of patient involvement in health technology assessment activities; 2. to explore the perceptions of stakeholders (administrators, clinical managers, clinicians, other health professionals, health technology assessors, and patients) regarding strategies that involve patients in the various stages of health technology assessment; 3. to produce a consensual framework that will guide interventions for introducing a patient perspective into health technology assessment activities in HTA Units. This collaboration between decision makers, HTA experts, and a research team with complementary knowledge will allow participants to identify the best type, degree, and timing of patient involvement for any given HTA activity in an HTA Unit. The framework will be discussed among collaborators from the following bodies: Quebec's agency for the evaluation of health technologies and intervention methods (AETMIS), Quebec's university hospitals, the HTA Unit at McGill University Hospital, the HTA Unit of Centre Hospitalier de l'Université de Montréal, patient associations, and the research team.

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Translating shared decision making into clinical practice: Phase 2. Convening a community of practice

Translating shared decision making into clinical practice: Convening a community of practice

In clinical settings, the ideal pathway for knowledge transfer is through the sharing of decisions between clinician and patient. Embedded in a specific relationship, this process is known as shared decision making (SDM). Despite evidence supporting the merits of SDM, medical decision-making has been studied as if clinicians and patients lived in separate worlds. The main goal of this CIHR-funded project was to bring together the resources and the expertise necessary to develop an interdisciplinary and international research team dedicated to the study of implementing SDM in clinical practice using a theory-based dyadic perspective–that is, a relationship-centered approach. The objective of Phase 2 of the project is to foster and sustain a community of practice in this area. First, we will hire a project manager responsible for publicizing our activities; recruiting new participants; facilitating participant activities, including the e-journal club; acting as webmaster and updating the website; and tailoring activities to the participants' needs. Second, we will produce all of our materials in both of Canada's official languages (French and English). Third, we will create three new open-access sections on our public website: 1) a virtual library of relevant documents; 2) a training section for researchers and trainees for which OPD-165691 workshop material will be used; and 3) a dyadic data analytical exercise in the implementation of SDM in clinical practice.

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IPSDM - Stepped wedge

Implementing shared decision-making in interprofessional home care teams

One of the toughest decisions faced by the frail elderly in Canada is whether to stay at home or move to a care facility. Decisions that are informed, shared and supported produce better results. An interprofessional approach to shared decision making is when older persons and their caregivers are supported by not just one but by all the professionals involved in their care. In the case of the frail elderly in home care services, there are many health care professionals involved, e.g. the doctor, nurse and social worker. In this case decisions should be shared by all the professionals involved with the elderly person along with his or her caregivers. We have designed a training program that teaches interprofessional teams how to share decisions with their frail elderly patients. Results of a previous project (IPSDM - DOLCE) showed that caregivers followed by the trained home care teams felt more involved in the decision making process, and that there was a better fit with the prefered choice and the choice made. This project uses a stepped wedge cluster randomized trial design. It will measure the impact of the training program in interprofessional shared decision making (IPSDM) above that of the passive dissemination of the decision guide by measuring to what extent older persons and their caregivers say they took active part in the decision-making process. Other outcome measures will be: i) what option they chose, whether they feel conflict or regret about their decision, and the burden of care they feel; ii) the quality of life of the frail elderly.

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DECISION+

DECISION+ is an innovative training program for physicians. It integrates multiple educational/behavioural change components that aim to promote shared decision making about taking antibiotics for acute respiratory infections. We hypothesized that shared decision making should result in a common decision based on best evidence and on the patients' values, leading to best prescribing practices for physicians and their best use by patients.

Pilot Study

The objective of DECISION+ pilot RCT was to evaluate the feasibility of a larger trial, in order to determine the program's efficacy for promoting optimal use of antibiotics for acute respiratory infections.

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EXACKTE 2

Exploiting the Clinical Consultation as a Knowledge Transfer and Exchange Environment

Shared decision making requires two basic elements: the patient being actively involved in decisions pertaining to his or her health, and knowledge to be adequately transferred from the healthcare worker to the patient. The transfer and exchange of knowledge through clinician–patient interactions requires both parties sharing information, being sensitive to the others' preferences and positions, and coming to an agreement about tests and treatments that influence healthcare outcomes. Even if brief, a consultation can affect the other person's emotions and behavior. In order to improve the effectiveness of knowledge translation interventions in clinical encounters, our study aims to use a SDM model to explore how patients and clinicians influence one another. Using a longitudinal design, with 400 clinician–patient pairs, our study will unfold in three phases: 1. development and validation of a set of reciprocal measures; 2. performance of a series of statistical analyses that explore how patients and clinicians influence one another during the translation and exchange of knowledge within the SDM model; 3. use of the results of these analyses as reference material for designing new knowledge translation interventions for clinical encounters. The acceptability and feasibility of these interventions will be tested during a pilot study with focus groups of patients and clinicians. This project emphasizes the "exchange" aspect of knowledge translation and exchange during clinician–patient interactions.

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Antibiotiques en médecine d'urgence

Le programme Decision+2 s’est avéré efficace pour réduire le taux de recours à une antibiothérapie dans le traitement des IVRS en première ligne et ce, sans augmenter le taux de complications associées (1). Or, son applicabilité au département d’urgence était incertaine. En effet, les départements d'urgence sont des environnements chaotiques où l'achalandage est élevé et où la pression de voir des patients rapidement sont des facteurs importants à considérer lorsque l’on souhaite y implanter une nouvelle pratique (2). Grâce à l’utilisation d’un design centré sur l’utilisateur ayant impliqué 18 patients, plusieurs urgentologues de l’Hôtel-Dieu de Lévis et du CHUL et des designers graphiques de l’Université Laval, nous avons adapté l’outil d’aide à la décision au contexte de l’urgence. Cet outil d’aide à la décision est toutefois utilisable dans tous les milieux de soins.

Bibliographie

1. Legare F, Guerrier M, Nadeau C, Rheaume C, Turcotte S, Labrecque M. Impact of DECISION + 2 on patient and physician assessment of shared decision making implementation in the context of antibiotics use for acute respiratory infections. Implement Sci. 2013;8:144. 2. Nugus P, Forero R. Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. Int Emerg Nurs. 2011 Apr;19(2):69–74.

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Cochrane review

Interventions for Improving the Adoption of Shared Decision Making by Healthcare Professionals

BACKGROUND: Shared decision making (SDM) can reduce overuse of options not associated with benefits for all and respects patient rights, but has not yet been widely adopted in practice. OBJECTIVES: To determine the effectiveness of interventions to improve healthcare professionals’ adoption of SDM SEARCH METHODS: For this update we searched for primary studies in The Cochrane Library, MEDLINE, EMBASE, CINAHL, the Cochrane Effective Practice and Organisation of Care (EPOC) Specialsied Register and PsycINFO for the period March 2009 to August 2012. We searched the Clinical Trials.gov registry and the proceedings of the International Shared Decision Making Conference. We scanned the bibliographies of relevant papers and studies. We contacted experts in the field to identify papers published after August 2012. SELECTION CRITERIA: Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies evaluating interventions to improve healthcare professionals' adoption of SDM where the primary outcomes were evaluated using observer-based outcome measures (OBOM) or patient-reported outcome measures (PROM). DATA COLLECTION AND ANALYSIS: The three overall categories of intervention were: interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Studies in each category were compared to studies in the same category, to studies in the other two categories, and to usual care, resulting in nine comparison groups. Statistical analysis considered categorical and continuous primary outcomes separately. We calculated the median of the standardized mean difference (SMD), or risk difference, and range of effect across studies and categories of intervention. We assessed risk of bias. MAIN RESULTS: Thirty-nine studies were included, 38 randomised and one non-randomised controlled trial. Categorical measures did not show any effect for any of the interventions. In OBOM studies, interventions targeting both patients and healthcare professionals had a positive effect compared to usual care (SMD of 2.83) and compared to interventions targeting patients alone (SMD of 1.42). Studies comparing interventions targeting patients with other interventions targeting patients had a positive effect, as did studies comparing interventions targeting healthcare professionals with usual care (SDM of 1.13 and 1.08 respectively). In PROM studies, only three comparisons showed any effect, patient compared to usual care (SMD of 0.21), patient compared to another patient (SDM of 0.29) and healthcare professional compared to another healthcare professional (SDM of 0.20). For all comparisons, interpretation of the results needs to consider the small number of studies, the heterogeneity, and some methodological issues. Overall quality of the evidence for the outcomes, assessed with the GRADE tool, ranged from low to very low. AUTHORS' CONCLUSIONS: It is uncertain whether interventions to improve adoption of SDM are effective given the low quality of the evidence. However, any intervention that actively targets patients, healthcare professionals, or both, is better than none. Also, interventions targeting patients and healthcare professionals together show more promise than those targeting only one or the other.

The review is now published and accessible.

Pubmed

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PEGASUS: PErsonalized Genomics for prenatal Aneuploidy Screening USing maternal blood

Each year, 450,000 Canadian women become pregnant and, as a result of their participation in prenatal screening for Down syndrome, approximately 10,000 of them will have an amniocentesis (i.e. sampling of liquid surrounding the fetus) and of those, 315 will be found to carry a baby with Down syndrome and 70 normal pregnancies will be lost from complications of the procedure. It has been discovered recently that, during pregnancy, there is fetal DNA in maternal blood in sufficient quantities to be analyzed and methods have been proposed to detect the presence of a fetus with Down syndrome using maternal blood. The introduction of genomic blood testing as proposed in the context of this project could lead to increased detection of Down syndrome, less invasive screening with 9,700 amniocenteses avoided each year in Canada, improving the peace of mind of pregnant women, and preventing the accidental loss of 70 normal fetuses, at a lower overall cost than current practice. However, these methods still need to be validated before being appropriately introduced in routine care. This project proposed to carry out an independent study that validated the performance and utility of these new genomic technologies for screening in pregnant women using maternal blood. The team of researchers identified an evidence-based cost-effective approach for implementation of this new technology in the Canadian health care system. They developed decision-making tools that assist couples in making informed decisions, as well as educational tools for health care professionals, all integral components of the implementation of genomics-based non-invasive prenatal diagnosis. The results of this project may enable decision makers–pregnant women and their partner–to make informed choices pertaining to prenatal genetic screening and diagnosis, such as screening for Down syndrome, and to reduce the risk to pregnancies associated with amniocentesis.

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  • Decision box:What are my options regarding prenatal screening tests? Next update: April 2018
  • Official website: PEGASE
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LABORATOIRE DE RECHERCHE ET D’INNOVATION EN MÉDECINE DE PREMIÈRE LIGNE (LABORATOIRE ARIMED)

Description du laboratoire : ARIMED est un laboratoire de recherche de première ligne offrant la possibilité aux résidents en médecine de famille de raffiner leurs connaissances scientifiques ou de participer à des projets de recherche innovateurs. Il a été fondé en 2017 par le Dr Jean-Sébastien Paquette au sein du Groupe de médecine de famille universitaire de Saint-Charles-Borromée (GMF-SCB). Il est affilié au département de médecine familiale et de médecine de l'Université Laval (DMFMU) et au Centre de recherche sur les soins et les services de première ligne de l’Université Laval (CERSSPL-UL) dont nous sommes une extension régionale. Nous avons créé une structure organisationnelle qui a pour but de favoriser l'épanouissement de la recherche de première ligne par l’enseignement, l'innovation et l'optimisation des trajectoires pour différents projets de recherche qui émergent de notre milieu ou qui sont réalisés en collaboration avec d'autres chercheurs.

Missions du laboratoire ARIMED :

Pédagogique : Promouvoir et enseigner la recherche chez les étudiants en médecine de famille (stage option recherche, accompagnement des résidents dans leur projet d'érudition (programme ELPE, jumelage clinicien-chercheur) Transfert des connaissances : L'application des connaissances est primordiale pour notre équipe. Nous voulons contribuer à améliorer la pertinence clinique de la recherche en arrimant la théorie et la pratique. Amélioration de la qualité des soins : Améliorer la santé de la population en dispensant des soins de qualité. Ceci passe par une approche réflexive de l'organisation des soins et des pratiques fondées sur les données probantes centrées sur le patient. Axes de recherche : Quand l'obésité n'est qu'une petite partie du problème Axe Santé Autochtone - "Pratiquer sans réserve Axe Utilisation Optimale des Ressources et Surmédicalisation" - Parce que plus ne rime pas avec mieux Axe Recherche Translationnelle et Innovation - "Pour passer à la vitesse supérieure"

Nos réalisations:

Outils sur la prescription de médicaments potentiellement inappropriés chez la personne âgée de 65 ans et plus (PIM)

Pour nous contacter :

Laboratoire ARIMED: ARIMED@fmed.ulaval.ca Jean-Sébastien Paquette, directeur: jean-sebastien.paquette@fmed.ulaval.ca Julie Desmeules, coordonnatrice: Julie.Desmeules.csssnl@ssss.gouv.qc.ca

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PIM

PRESCRIPTIONS POTENTIELLEMENT INAPPROPRIÉES CHEZ LA PERSONNE ÂGÉE DE 65 ANS ET PLUS (PIM)


RÉSULTATS DE NOTRE ÉTUDE

Prévalence et facteurs de risque de prescription de médicaments potentiellement inappropriés (PIM) chez les personnes âgées de 65 ans et plus Mathieu PELLETIER, Anne-Sophie GRENON, Marjorie PANNETON, Sabrina LECLAIR Contexte : Les études portant sur les prescriptions de médicaments potentiellement inappropriés (PIM – Potentially inappropriate medications) chez les personnes âgées rapportent une prévalence se situant entre 23 et 74,7 %. Les facteurs associés avec la prescription de PIM sont moins bien connus. Objectifs : D’abord, mesurer la prévalence de prescription de PIM dans un échantillon de patients suivis en clinique de médecine familiale, en utilisant les critères de Beers. Ensuite, identifier certaines caractéristiques des patients qui reçoivent des PIM et des médecins qui les prescrivent. Méthodologie : Il s’agit d’une étude non-interventionnelle transversale dans laquelle 296 dossiers de personnes âgées de 65 ans et plus ont été étudiés. Les visites à l’étude avaient lieu dans deux cliniques de soins de première ligne, soit une clinique en milieu académique semi-urbain et une clinique rurale. Résultats : Parmi les 296 patients à l’étude, 72 ont reçu au moins une prescription d’un Médicament potentiellement inapproprié (PIM), soit 24,3 %. Les types de PIM les plus fréquents étaient les benzodiazépines (53,2 %) et le zopiclone (16,5 %). Chez les patients, le sexe masculin (RC 0,53 p = 0,02) et l’absence d’antécédents médicaux (RC 0,26 p = 0,002) étaient des facteurs associés à un risque moindre de recevoir un PIM. À chaque médicament de plus sur la liste du patient, le risque de se voir prescrire un PIM supplémentaire était multiplié par 1,18 (RC 1,18 ; p = 0,003). La présence d’antécédents psychiatriques était associée à un risque plus grand de recevoir un PIM (RC 7,15 p < 0,001). Chez les médecins, seul le fait d’avoir assisté à un congrès gériatrique dans les deux années précédentes étaient associé avec un risque moindre de prescrire un PIM (RC 0,39 p = 0,0035). Conclusion :Cette étude contribue à mieux comprendre la problématique des médicaments potentiellement inappropriés chez les personnes âgées et à sensibiliser les cliniciens en vue de changements positifs dans leur pratique. Rev Geriatr 2017 ; 42 (8) : 455-63. http://www.revuedegeriatrie.fr/

Les critères de PIM:

Il existe plusieurs outils permettant d’identifier les PIM chez les personnes âgées de 65 ans et plus. Parmi ceux-ci on retrouve les critères de BEERS, STOPP/START et FORTA. Selon une étude récente, le STOPP/START se démarquerait au BEERS:https://www.sciencedirect.com/science/article/pii/S075549821630207X 1. Les critères de BEERS : https://www.dcri.org/beers-criteria-medication-list/ 2. Les critères STOPP/START : http://www.pharmactuel.com/index.php/pharmactuel/article/view/1095/www.pharmactuel.com 3. Les critères FORTA (Fit for The Aged) : https://www.umm.uni-heidelberg.de/ag/forta/FORTA_List_2015_English_light_version.pdf 1. Réseau canadien de déprescription: https://www.deprescribingnetwork.ca/fra 2. Mets à votre disposition des algorithmes de déprescription pour plusieurs molécules voici des tableaux tirés de leur site que nous vous invitons à consulter : https://deprescribing.org/fr/ PDF « Déprescrire benzo » PDF « Déprescrire antipsychotique » PDF « Déprescrire hypoglycémiant » 3. Un outil de déprescription gratuit en ligne : http://medstopper.com 4. Les brochures « vous êtes à risque » et « comment passer une bonne nuit de sommeil sans médication » du Dre Cara Tannenbaum sont disponibles via sa page web : http://www.criugm.qc.ca/fr/chercheurs/directeurs/63-cara-tannenbaum.html EN RÉSUMÉ Notre équipe recherche composée de résident en médecine familiale et de médecin de famille du groupe de médecine familiale universitaire de St-Charles-Borromée (GMF-U) a mené une étude, dans le cadre d’un projet d’érudition, sur la prescription de médicaments potentiellement inappropriés chez la personne âgée de 65 ans et plus (PIM). Celle-ci a été publiée dans La Revue de Gériatrie (voir le lien et le résumé plus haut) et a reçu le prix Réseau-1 Québec de reconnaissance des projets d’érudition des résidents en médecine familiale pour l’année 2016 et le prix « Meilleur article scientifique de recherche, catégorie résidents en médecine » du Collège des médecins de famille du Canada en 2016 également. PROBLÉMATIQUE DES PIM La prescription de PIM chez la personne âgée de 65 ans et plus peut avoir de graves conséquences chez cette clientèle (augmentation de la mortalité et de la morbidité). Il existe plusieurs outils pour aider le clinicien à identifier et déprescrire ces médicaments (Voir les Outils de déprescription plus bas). Nous avons mené notre étude dans notre GMF-U en utilisant un de ces outils, les critères de BEERS, dont les résultats ont été publié dans La Revue de Gériatrie (voir le résumé ci-joint). Cette page d’information a été rendu possible grâce à une bourse de Réseau-1 Québec et grâce à la collaboration de l’équipe du Dre France Légaré. Laboratoire de recherche et d’innovation en médecine de 1ère ligne situé au GMF-U de St-Charles-Borromée.

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Axe Santé Métabolique - "Quand l'obésité n'est qu'une petite partie du problème"

Description : L’obésité et les problèmes de santé associés constituent une réelle menace à la santé et à la vitalité des communautés dans le monde, en plus d’occasionner des coûts importants aux systèmes de santé. Ce qui est le plus inquiétant n’est pas le surpoids lui-même, mais également la maladie métabolique sous-jacente. Plusieurs facteurs (environnementaux, nutritionnels, activité physique, génétique et psychologiques) ont un impact métabolique important sur notre physiologie. De plus, il y a un lien entre l’obésité et plusieurs maladies chroniques dont l’hypertension, le diabète, les maladies cardiovasculaires et le cancer. Notre laboratoire s’intéresse à développer une expertise en santé métabolique à divers niveaux. Dans un premier temps, nous voulons implanter une clinique de première ligne en traitement et prévention de l’obésité et des problèmes de santé associés. Parallèlement, nous désirons approfondir les connaissances des mécanismes physiologiques et biologiques impliqués dans le syndrome métabolique afin d’intégrer des outils innovateurs de dépistage et de suivi en première ligne. Par conséquent, nous désirons travailler à optimiser les stratégies thérapeutiques à divers niveaux (physique, pharmacologique, psychologique, physiologique et biologique) pour les adapter au patient. Projets en cours : 1) Paquette JS, Boudreault S, Breault P, Deschambeault J, Gagnon J, Leclair S, Desmeules J, Labelle J, Poirier F et al. « Développement d’un protocole d’implantation en clinique de première ligne d’un modèle de collaboration interprofessionnelle axée sur le patient et fondée sur les meilleures pratiques en matière de prévention et de prise en charge de l’obésité et des problèmes de santé associés ». (Bourse développement Réseau-1 Québec 2018). Responsable de l’axe : Dr Jean-Sébastien Paquette Projets réalisés et bourses obtenues: lien vers réalisations Mots clés : collaboration interprofessionnelle, obésité, syndrome métabolique, impact métabolique, diabète, prévention en première ligne, approche centrée sur le patient, dépistage, marqueurs métaboliques.

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Axe Recherche Translationnelle et innovation - "Pour passer à la vitesse supérieure"

Description : La recherche translationnelle est une science innovatrice en soi. Elle fait le pont entre deux réseaux de recherche afin d’optimiser les découvertes. Traditionnellement, la recherche fondamentale s’intéresse à effectuer des travaux expérimentaux ou à élaborer des théories dans le but d’acquérir des nouvelles connaissances sur les fondements des phénomènes et des faits sans qu’il y ait un but d’application pratique, il s’agit donc de travaux éloignés de la réalité clinique (*). D’un autre côté, la recherche en première ligne, qui consiste à effectuer des travaux ayant un impact réel sur le terrain, ne mets pas toujours à sa disposition les récentes découvertes fondamentales. L’écart entre les deux communautés de pratique est si grand que de nombreux travaux de recherche sont gaspillés et n’atteignent jamais le niveau de l’application des connaissances. Ce fossé est surnommé la « Vallée de la Mort » (Valley of death). Bien que ce surnom n’ait pas pour objectif de créer un scénario hollywoodien, il veut surtout représenter l’ampleur du problème. Le fait que peu de chercheurs s’y intéressent est un signe que chacun travaille dans son domaine sans bien connaitre les autres secteurs d’activité. Notre laboratoire développe la recherche translationnelle grâce à l’expertise du Dr Jean-Sébastien Paquette acquise dans le cadre du programme TUTOR-PHC (Transdisciplinary Understanding and Training on Research Primary Health Care). Nous élaborons une plateforme pour mettre en contact fondamentalistes, chercheurs, cliniciens et patients-partenaires. Ainsi, le fil conducteur qui relie tous ces intervenants constitue la richesse de la recherche translationnelle. De façon complémentaire à la recherche translationnelle, nous désirons être à l’affût des nouvelles technologies afin d’avoir une meilleure pratique. Qu’on le veuille ou non, plusieurs innovations voient le jour à chaque année. Il est de notre devoir, en tant que laboratoire universitaire de première ligne, de bien connaître ces innovations afin de les évaluer dans le but d’effectuer un transfert des connaissances dans notre communauté. La médecine personnalisée (dont la pharmacogénomique), l’intelligence artificielle, les réseaux sociaux, l’utilisation de logiciels, l’utilisation des données, et bien d’autres, sont tous des sujets qui nous intéressent. Plusieurs membres de notre laboratoire effectuent diverses études concernant les innovations ou la recherche translationnelle. (*). Selon le site Statistics Explained, glossaire des termes de l’Union Européenne – Tapez « recherche fondamentale ». Projets en cours : 1. Paquette, J.-S. et Légaré F. « Modèle et plateforme de collaboration intersectoriels et interprofessionnels entre les réseaux de recherche axée sur les pratiques de première ligne (RRAPPL ou PBRN) et les réseaux de médecine moléculaire ». Programme TUTOR-PHC (projet en cours). 2. Paquette, J.-S., Pelletier, M. « Étude observationnelle du niveau d’expression sérique de la protéine klotho chez des sujets atteints de différentes maladies reliées au vieillissement ». 3. Pilon, M.-H., Paquette, J.-S., Martel, E., Pelletier, M., Boudreault, S. « Étude observationnelle sur la relation entre la protéine klotho au niveau sérique et le cancer du sein » Responsable de l’axe : Dr Jean-Sébastien Paquette Projets réalisés et bourses obtenues: lien vers réalisations Mots clés : collaboration interprofessionnelle, patient-partenaire, recherche translationnelle, réseaux de recherche, recherche fondamentale, innovation, cancer du sein, klotho, dépistage.

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Axe Santé Autochtone - "Pratiquer sans réserve"

Description : La santé des populations autochtones (Premières Nations, Métis et Inuits) est un enjeu important à l’échelle canadienne. Les médecins de famille doivent être outillés et sensibilisés aux enjeux spécifiques rencontrés par ces clientèles. Fort d’un partenariat de plus de cinq ans avec le Centre de santé Masko-Siwin situé dans la communauté attikamekw de Manawan, le GMF-U Saint-Charles-Borromée offre aux résidents en médecine familiale une occasion unique de développer leurs aptitudes et compétences à offrir des soins appropriés aux patients vivant en communauté et à l’extérieur de la communauté. Tablant sur ce lien unique, le laboratoire ARIMED s’est donné comme axe de recherche prioritaire de promouvoir les projets en lien avec une meilleure compréhension des barrières auxquelles font face ces patients dans l’accès aux soins et sur les meilleures stratégies pour les surmonter. Médecine fondée sur les données probantes : Apprendre à constamment soigner sa culture médicale La médecine évolue constamment et les médecins de famille sont aux premières loges des changements et de l’application des nouvelles connaissances. Une responsabilité croissante leur incombe de maîtriser et de critiquer les données probantes de manière à pouvoir conseiller leurs patients afin que ces derniers puissent prendre des décisions éclairées par rapport à leur santé. Le laboratoire ARIMED est résolument commis dans le développement de nouvelles méthodes d’enseignement destinées à promouvoir et à engager les résidents, l’équipe professorale et les autres professionnels de la santé du GMF-U Saint-Charles-Borromée dans un processus d’amélioration continue de la qualité des actes médicaux et à valoriser la maîtrise des habiletés liées à une pratique de qualité fondée sur les données probantes. Projets en cours : 1. Tremblay M.-C., Renaud J.-S., Fletcher C., Beaulieu M., Breault P., Robertson F., Niquay D. « Stigmatisation envers les patients autochtones : Développement collaboratif d’un instrument de mesure basé sur des vignettes de cas » (CERSSPL-UL, 2018) 2. Paquette J.-S., Lessard L., Charbonneau A., Poirier F., Carreau E. « Étude exploratoire descriptive de la collaboration interprofessionnelle dans l’équipe SAPL Nord au GMF-U de St-Charles-Borromée auprès des patients présentant une maladie chronique. » 3. Tremblay M.-C., Dogba M.J., Breault P, Careau E., Paquette J.S., Witteman H. « Outiller à la sécurisation culturelle les professionnels de santé dans le contexte de la prestation de soins à des patients autochtones ». (CERSSPL-UL, 2018). Responsable de l’axe : Dre Pascale Breault Réalisations: lien vers réalisations Mots clés : Santé autochtone, stigmatisation, sécurisation culturelle, collaboration interprofessionnelle, maladie chronique.

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Axe Utilisation optimale des ressources et surmédicalisation - "Parce que plus ne rime pas avec mieux"

Description : Page En construction

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teChnology tO suppORt DecIsioN Making about Aging aT homE (COORDINATEs)

Background

Most older adults prefer to stay at home as long as possible. Effective self-management for people losing autonomy depends on reliable monitoring of their mobility, health and safety and active implication in decision-making. New technologies have the potential to provide information about changing patterns that reflect changing care needs. This information could support older adults, their caregivers and healthcare professionals in shared decision making (SDM) about housing options.

Objective

1)      Assess autonomy and mobility of older adults with early-stage dementia living at home, 
2)      Codesign technology that facilitates self-management 
3)      Inform shared decision making processes about housing options for all those involved.

Methods and expected results

A 3-year multiple-case, mixed-methods study in Canada, Sweden and the Netherlands. We will a) use mixed methods to assess autonomy and mobility of 20 older adults in their homes and neighbourhoods; b) with end-users, co-design an enhanced version of a health tracking platform; c) use mixed methods to assess use of enhanced platform and larger feasibility survey; d) triangulate and compare data in 3 countries. Self-reported and objectively measured data about mobility and health changes in older adults living at home in 3 countries; enhanced technical support platform for selfmanagement; factors influencing potential uptake; instructions and recommendations for implementation; information for shared decision making about housing options among endusers, including policy makers.

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Meta-LARC Advance Care Planning

Full Title

A Cluster-randomized Trial Comparing Team-based Versus Primary Care Clinician-led Advance Care Planning in the Meta-LARC Practice-based Research Networks

Project description

The Serious Illness Care Program (SICP) is an advance care planning program targeting people with reduced life expectancy. It is a validated tool and is designed to help clinicians initiate meaningful conversations about health care at the right time and in the right way so that patients and families can make more informed choices based on their values and preferences. The objective of this project is to determine whether, in primary care settings, it is more effective to target the implementation of the SICP with a clinician-centred approach, where a single clinician is responsible for having a conversation about advance care planning given the nature of the patient-clinician relationship, or whether it would be better to use a team-based approach given the time and resource constraints faced by clinicians. The target population is adults living in the community with serious diseases who have a life expectancy of two years or less, as well as their families. This is a cluster randomized trial. This study will be conducted in 42 primary care settings within seven Practice-Based Research Networks (PBRNs) 5 located in U.S. states and 2 in Canadian provinces: Colorado, Iowa, North Carolina, Oregon, Wisconsin, Quebec and Ontario. The specific objectives are to 1) evaluate the comparative effectiveness of the two approaches on the match between care and patients' goals and time spent at home (primary outcomes) and on patients' anxiety, depression and quality of life (secondary outcomes); and 2) explore the contextual factors influencing the implementation of the two approaches.  Data collections for patients and caregivers will be conducted at study entry, at 6 months and 12 months, while healthcare professionals will be interviewed after receiving training, as well as at 1 and 2 years after training. The data from this study will help determine the most effective approach to advance care planning for primary care settings. Healthcare professionals who are trained in the use of the SICP will be more comfortable having conversations about advance care planning with their patients. Thus, this study has the potential to improve the delivery of care to patients with serious illnesses and reduced life expectancy, by ensuring that the care provided is consistent with the objectives, values and preferences of the patient and family.  

 

Project Coordinator

LeAnn Michaels, Oregon Rural Practice-Based Research Network
Sabrina Guay-Bélanger, Centre de recherche sur les soins et les services de première ligne de l’Université Laval (CERSSPL-UL)
Danielle Caron, Centre de recherche sur les soins et les services de première ligne de l’Université Laval (CERSSPL-UL)
 

Project Team

Annette Totten, Oregon Health & Science University
France Légaré, MD, Université Laval
Lyle J. Fagnan, Oregon Health & Science University
Donald Nease, University of Colorado 
David Hahn, University of Wisconsin
Rowena Dolor, Duke University
Barcey Levy, University of Iowa
Michelle Greiver, University of Toronto
Jean-Sébastien Paquette, Université Laval
Patrick Archambault, Université Laval
And the Meta-LARC ACP Trial Team
 

Project funding agency

Patient Centered Outcome Research Institute (PCORI)
 

Start and end dates of project financing

2017-2021

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DECISION+2: Randomized Control Trial

Acute respiratory tract infections (ARIs) such as otitis media, rhinosinusitis, acute pharyngitis and bronchitis account for up to 10% of consultations in emergency departments. Several studies have shown that these infections are overwhelmingly of viral etiology and therefore self-limiting. Although antibiotic therapy is unnecessary in the treatment of acute respiratory infections of viral etiology, the use of antibiotics is still widespread among clinicians in North America. Inappropriate antibiotics consumption is associated with antibiotic resistance, increased risk of side effects and a higher rate of readmission. This is a major public health problem. Information tools are a promising way to inform patients and doctors about this problem. Information tools can support informed decision-making about an individual health issue. This can open the dialogue for shared decision-making between the patient and the doctor. Shared decision-making is a decision-making process in which the physician, the patient, and those around them share information that is informed by the highest level of evidence, evaluate all possible diagnostic and therapeutic options, identify the patient's priorities, deliberate, and jointly decide on the best care for the patient. This project was based on the data gathered during a pilot randomized control trial of Decision+. The main aim of the pilot was to establish the feasibility of conducting the project on a larger scale. The pilot project assessed the impact of DECISION+ on antibiotics use for acute respiratory infections (ARI) – the main reason for consultations in primary care. This project was funded by the FRSQ-Conseil du Medicament.

Project Financing Agency

This project is funded by the FRSQ-Conseil du médicament.

Start and end dates for project financing

2009 to 2012

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IPSDM - DOLCE

Full  title of the project

Improving decision making on location of care with the frail elderly and their caregivers

Project description 

One of the toughest decisions faced by the frail elderly in Canada is whether to stay at home or move to a care facility. It is certainly difficult to make this decision alone, but can be even harder if someone else makes it for you. Shared decision making is when, instead of making decisions for the patient, healthcare professionals share information about what the evidence says, and they talk about what's important with the patient, and then make the decision together. In the case of the frail elderly in home care services, there are many health care professionals involved, e.g. the doctor, nurse and social worker. In this case decisions should be shared by all the professionals involved with the elderly person along with his or her caregivers. Unfortunately, in this context, shared decision making rarely occurs. We have designed a training program that teaches interprofessional teams how to share decisions with their frail elderly patients, and tested it in one Quebec City and one Edmonton home care team. This project tested the training program on a broader scale with 16 home care teams attached to community health centres across the province of Quebec, and compared the results with what happens when no one has completed the training (usual care). Results show that caregivers followed by the trained home care teams felt more involved in the decision making process, and that there was a better fit with the prefered choice and the choice made. 

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EXACKTE 2

Full title of the project

Exploiting the Clinical Consultation as a Knowledge Transfer and Exchange Environment

Project description

Shared decision making requires two basic elements: the patient being actively involved in decisions pertaining to his or her health, and knowledge to be adequately transferred from the healthcare worker to the patient. The transfer and exchange of knowledge through clinician–patient interactions requires both parties sharing information, being sensitive to the others' preferences and positions, and coming to an agreement about tests and treatments that influence healthcare outcomes. Even if brief, a consultation can affect the other person's emotions and behavior. In order to improve the effectiveness of knowledge translation interventions in clinical encounters, our study aims to use a SDM model to explore how patients and clinicians influence one another. Using a longitudinal design, with 400 clinician–patient pairs, our study will unfold in three phases: 1. development and validation of a set of reciprocal measures; 2. performance of a series of statistical analyses that explore how patients and clinicians influence one another during the translation and exchange of knowledge within the SDM model; 3. use of the results of these analyses as reference material for designing new knowledge translation interventions for clinical encounters. The acceptability and feasibility of these interventions will be tested during a pilot study with focus groups of patients and clinicians. This project emphasizes the "exchange" aspect of knowledge translation and exchange during clinician–patient interactions.


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DECISION+

Project description

DECISION+ is an innovative training program for physicians. It integrates multiple educational/behavioural change components that aim to promote shared decision making about taking antibiotics for acute respiratory infections. We hypothesized that shared decision making should result in a common decision based on best evidence and on the patients' values, leading to best prescribing practices for physicians and their best use by patients. The objective of DECISION+ pilot RCT was to evaluate the feasibility of a larger trial, in order to determine the program's efficacy for promoting optimal use of antibiotics for acute respiratory infections.

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IPSDM - Stepped wedge

Project description

Implementing shared decision-making in interprofessional home care teams

One of the toughest decisions faced by the frail elderly in Canada is whether to stay at home or move to a care facility. Decisions that are informed, shared and supported produce better results. An interprofessional approach to shared decision making is when older persons and their caregivers are supported by not just one but by all the professionals involved in their care. In the case of the frail elderly in home care services, there are many health care professionals involved, e.g. the doctor, nurse and social worker. In this case decisions should be shared by all the professionals involved with the elderly person along with his or her caregivers. We have designed a training program that teaches interprofessional teams how to share decisions with their frail elderly patients. Results of a previous project (IPSDM - DOLCE) showed that caregivers followed by the trained home care teams felt more involved in the decision making process, and that there was a better fit with the prefered choice and the choice made. This project uses a stepped wedge cluster randomized trial design. It will measure the impact of the training program in interprofessional shared decision making (IPSDM) above that of the passive dissemination of the decision guide by measuring to what extent older persons and their caregivers say they took active part in the decision-making process. Other outcome measures will be: i) what option they chose, whether they feel conflict or regret about their decision, and the burden of care they feel; ii) the quality of life of the frail elderly.

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Translating shared decision making into clinical practice: Phase 2. Convening a community of practice

Full title of the project

Translating shared decision making into clinical practice: Convening a community of practice

Project description

In clinical settings, the ideal pathway for knowledge transfer is through the sharing of decisions between clinician and patient. Embedded in a specific relationship, this process is known as shared decision making (SDM). Despite evidence supporting the merits of SDM, medical decision-making has been studied as if clinicians and patients lived in separate worlds. The main goal of this CIHR-funded project was to bring together the resources and the expertise necessary to develop an interdisciplinary and international research team dedicated to the study of implementing SDM in clinical practice using a theory-based dyadic perspective–that is, a relationship-centered approach. The objective of Phase 2 of the project is to foster and sustain a community of practice in this area. First, we will hire a project manager responsible for publicizing our activities; recruiting new participants; facilitating participant activities, including the e-journal club; acting as webmaster and updating the website; and tailoring activities to the participants' needs. Second, we will produce all of our materials in both of Canada's official languages (French and English). Third, we will create three new open-access sections on our public website: 1) a virtual library of relevant documents; 2) a training section for researchers and trainees for which OPD-165691 workshop material will be used; and 3) a dyadic data analytical exercise in the implementation of SDM in clinical practice. 

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Introducing Patient Perspectives in Health Technology Assessment

Project description

Recent recognition of the importance of engaging patients in decisions regarding their own medical care has led decision makers to incorporate patient perspectives in the decision making process. In the province of Quebec, university hospitals have created units for evaluating health technologies and intervention methods (Health Technology Assessment Units, or HTA Units) to meet their evaluation responsibilities and to promote evidence-based decision making. The creation of HTA Units within university hospitals is an opportunity for decision makers to increase the involvement of patients and the general public in decisions about health technologies. This said, little is known about interventions that have succeeded in achieving this. The present project aims at answering the needs of decision makers working in the sector of health technology assessment by exploring ways to involve patients in HTA Unit activities. To accomplish this objective, the study has three goals: 1. to synthesize international knowledge and experiences of patient involvement in health technology assessment activities; 2. to explore the perceptions of stakeholders (administrators, clinical managers, clinicians, other health professionals, health technology assessors, and patients) regarding strategies that involve patients in the various stages of health technology assessment; 3. to produce a consensual framework that will guide interventions for introducing a patient perspective into health technology assessment activities in HTA Units. This collaboration between decision makers, HTA experts, and a research team with complementary knowledge will allow participants to identify the best type, degree, and timing of patient involvement for any given HTA activity in an HTA Unit. The framework will be discussed among collaborators from the following bodies: Quebec's agency for the evaluation of health technologies and intervention methods (AETMIS), Quebec's university hospitals, the HTA Unit at McGill University Hospital, the HTA Unit of Centre Hospitalier de l'Université de Montréal, patient associations, and the research team.

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Translating shared decision making into clinical practices: Phase 1. An international collaboration

Project description

Shared decision making (SDM) is defined as the process by which a healthcare decision is made by both the practitioner and the patient (i.e. the practitioner-patient dyad). Engaging patients as partners in their own care increases patient satisfaction and correlates with a better quality of life. Yet the SDM approach has not been adopted by the population at large. There are several important barriers to the successful implementation of SDM in primary care. To identify and overcome these barriers, it is important to simultaneously evaluate patients' and health professionals' perspectives of the SDM process (dyadic decision-making). The main goal of this project was to bring together the resources and the expertise needed to develop an international research team dedicated to implementing SDM in clinical practice. This international collaboration addresses the challenges posed by the implementation of SDM through the use of a dyadic perspective. Ultimately, the results will improve how the Canadian healthcare system and its professionals understand and respond to public expectations about health services and healthcare management.

Publications

Phase 1 protocol was published in 2008 in Implementation Science

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PEGASUS: PErsonalized Genomics for prenatal Aneuploidy Screening USing maternal blood

Project description

Each year, 450,000 Canadian women become pregnant and, as a result of their participation in prenatal screening for Down syndrome, approximately 10,000 of them will have an amniocentesis (i.e. sampling of liquid surrounding the fetus) and of those, 315 will be found to carry a baby with Down syndrome and 70 normal pregnancies will be lost from complications of the procedure. It has been discovered recently that, during pregnancy, there is fetal DNA in maternal blood in sufficient quantities to be analyzed and methods have been proposed to detect the presence of a fetus with Down syndrome using maternal blood. The introduction of genomic blood testing as proposed in the context of this project could lead to increased detection of Down syndrome, less invasive screening with 9,700 amniocenteses avoided each year in Canada, improving the peace of mind of pregnant women, and preventing the accidental loss of 70 normal fetuses, at a lower overall cost than current practice. However, these methods still need to be validated before being appropriately introduced in routine care. This project proposed to carry out an independent study that validated the performance and utility of these new genomic technologies for screening in pregnant women using maternal blood. The team of researchers identified an evidence-based cost-effective approach for implementation of this new technology in the Canadian health care system. They developed decision-making tools that assist couples in making informed decisions, as well as educational tools for health care professionals, all integral components of the implementation of genomics-based non-invasive prenatal diagnosis. The results of this project may enable decision makers–pregnant women and their partner–to make informed choices pertaining to prenatal genetic screening and diagnosis, such as screening for Down syndrome, and to reduce the risk to pregnancies associated with amniocentesis.

Tools 

  • Decision box:What are my options regarding prenatal screening tests? Next update: April 2018
  • Official website: PEGASE

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COORDINATEs

Project description

teChnology tO suppORt DecIsioN Making about Aging aT homE 

Most older adults prefer to stay at home as long as possible. Effective self-management for people losing autonomy depends on reliable monitoring of their mobility, health and safety and active implication in decision-making. New technologies have the potential to provide information about changing patterns that reflect changing care needs. This information could support older adults, their caregivers and healthcare professionals in shared decision making (SDM) about housing options.
Objectives:
1)      Assess autonomy and mobility of older adults with early-stage dementia living at home, 
2)      Codesign technology that facilitates self-management 
3)      Inform shared decision making processes about housing options for all those involved.
A 3-year multiple-case, mixed-methods study in Canada, Sweden and the Netherlands. We will a) use mixed methods to assess autonomy and mobility of 20 older adults in their homes and neighbourhoods; b) with end-users, co-design an enhanced version of a health tracking platform; c) use mixed methods to assess use of enhanced platform and larger feasibility survey; d) triangulate and compare data in 3 countries. Self-reported and objectively measured data about mobility and health changes in older adults living at home in 3 countries; enhanced technical support platform for selfmanagement; factors influencing potential uptake; instructions and recommendations for implementation; information for shared decision making about housing options among endusers, including policy makers.

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