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Primary care physicians, who manage the care of most children with asthma, often do not optimally assess disease control, prescribe asthma controller medications, or provide family asthma education. We developed a pediatric asthma clinical pathway embedded in an electronic medical record (EMR) for use by primary care practices, and we sought to evaluate its effects on prescription and use of asthma controller medication for children with asthma. We conducted a cluster randomized controlled trial, enrolling primary care practices in Alberta that used Wolf or Med Access EMRs, and managed at least 50 children with asthma. The multifaceted intervention included an EMR-based pathway for pediatric asthma, Web-based education modules for physicians, and train-the-trainer sessions for practice staff to provide patient education. The control intervention was standard care. We extracted study data from participating practices’ EMRs, and standard emergency department and hospital administrative data sets. The primary and main secondary outcomes were improvement in the proportion of children prescribed and dispensed controller medications, respectively. Eleven practices were randomly assigned to each of the intervention and control groups. The intervention did not significantly change the proportion of children prescribed (mean difference 4.3%, 95% confidence interval [CI] −2.0% to 10.5%) or dispensed (mean difference −0.1%, 95% CI −7.1% to 6.9%) controller medications. Our multifaceted intervention did not improve the proportion of children in primary care who were prescribed or dispensed a controller medication for asthma. These results suggest that such interventions may require active alerts and targeting of walk-in and urgent care clinics to have a meaningful impact on clinical practice.

Post-COVID-19 condition (PCC) is defined as the persistence of symptoms, like fatigue and dyspnea, at least 3 months post-COVID infection. As dyspnea is a common symptom, we attempted to further clinically phenotype those with PCC-associated dyspnea. 1642 adults (average age of 49.6y with 63% female-predominance and BMI of 31.2 kg/m 2 ) with physician confirmed diagnosis of PCC from June 2020–April 2023 in Alberta, Canada were included. Those with dyspnea were more likely to be female (56.5%, p  = 0.005) and have higher BMI (31.3 kg/m 2 vs. 29.5 kg/m 2 ; p  = 0.0008), history of asthma (21.1% vs. 12.3%; p  < 0.001), more persistent PCC symptoms ( p  = 0.0001), more functional limitations, as well as lower quality of life ( p  < 0.0001). Multivariable-adjusted logistic regression analysis demonstrated dyspnea was independently associated with fatigue (OR = 4.20; CI = 2.71,6.59) and inversely associated with hospitalization for COVID-19 (OR = 0.53; CI = 0.32,0.91), age (OR = 0.98 per one year of age; CI = 0.96,0.99) and 6-min-walk-distance per 10 m difference (OR = 0.98, CI = 0.96,1.0). Fatigue was a predictor of dyspnea, and was associated with milder infection, higher BMI, and reduced 6-min-walk-distance despite normal pulmonary function. Reduced TLC or DLCO was associated with more severe infection and reduced 6-min-walk-distance. Thus, we speculate there are at least two dyspnea-associated phenotypes: phenotype with pronounced fatigue (normal PFT) and phenotype with pronounced pulmonary abnormalities (abnormal PFT). Improved understanding of the dyspnea-associated phenotypes may allow for better targeted rehabilitation.

ObjectiveThe aim of this qualitative study was to use a theory-based approach to understand the facilitators and barriers that impacted the implementation of the Primary Care Asthma Paediatric Pathway.DesignQualitative semistructured focus groups following a randomised cluster-controlled design.Setting22 primary care practices in Alberta, Canada.Participants37 healthcare providers participated in four focus groups to discuss the barriers and facilitators of pathway implementation.InterventionAn electronic medical record (EMR) based paediatric asthma pathway, online learning modules, in-person training for allied health teams in asthma education, and a clinical dashboard for patient management.Main outcome measuresOur qualitative findings are organised into three themes using the core constructs of the normalisation process theory: (1) Facilitators of implementation, (2) Barriers to implementation, and (3) Proposed mitigation strategies.ResultsParticipants were positive about the pathway, and felt it served as a reminder of paediatric guideline-based asthma management, and an EMR-based targeted collection of tools and resources. Barriers included a low priority of paediatric asthma due to few children with asthma in their practices. The pathway was not integrated into clinic flow and there was not a specific process to ensure the pathway was used. Sites without project champions also struggled more with implementation. Despite these barriers, clinicians identified mitigation strategies to improve uptake including developing a reminder system within the EMR and creating a workflow that incorporated the pathway.ConclusionThis study demonstrated the barriers and facilitators shaping the asthma pathway implementation. Our findings highlighted that if team support of enrolment (establishing buy-in), legitimisation (ensuring teams see their role in the pathway) and activation (an ongoing plan for sustainability) there may have been greater uptake of the pathway.Trial registration numberThis study was registered at clinicaltrials.gov on 25 June 2015; the registration number is: NCT02481037, https://clinicaltrials.gov/ct2/show/NCT02481037?term=andrew+cave&cond=Asthma+in+Children&cntry=CA&city=Edmonton&draw=2&rank=1

Objective Documenting cannabis use is important for patient care, but no formal requirements for consistent reporting exist in primary care. The objective of this study was to understand how cannabis use is documented in primary care electronic medical record (EMR) data. Results This was a cross-sectional study using de-identified EMR data from over 398,000 patients and 333 primary care providers in Alberta, Canada. An automated pattern-matching algorithm was developed to identify text and ICD-9 diagnostic codes indicating cannabis use in the EMR. There was a total of 11,724 records indicating cannabis use from 4652 patients, representing approximately 1.2% of the patient sample. Commonly used terms and ICD-9 codes included cannabis , marijuana/marihuana, THC, 304.3 and 305.2. Nabilone was the most frequently prescribed cannabinoid medication. Slightly more males and those with a chronic condition had cannabis use recorded more often. Overall, very few patients have cannabis use recorded in primary care EMR data and this is not captured in a systematic way. We propose several strategies to improve the documentation of cannabis use to facilitate more effective clinical care, research, and surveillance.

This study presents two deposits of bronze statuettes discovered in the Athenian Agora. Both groups were found with material associated with the Herulian sack ofa.d.267/8. The author proposes that these statuettes were used in the service of domestic cults. The Greek, Roman, and Egyptian deities represented illustrate the diversity of domestic cult activities current in Athens during the mid-3rd centurya.d.While the deposits provide some evidence for Roman domestic cult practices in Athens, it is clear that Greek cult practices remained the dominant tradition.

BackgroundInterstitial lung disease (ILD) is comprised of a heterogeneous group of pulmonary diseases. Oxygen therapy is used in patients with advanced lung disease; however, there are challenges associated with initiation of oxygen therapy specific to individuals with ILD. The key objectives of this study were to create a common understanding of the facilitators and barriers to oxygen therapy for patients with ILD, and healthcare professionals (HCP) caring for patients with ILD.MethodsThis qualitative study included 1 hour semistructured focus groups/interviews. An iterative and concurrent process was used for data collection and analysis to allow for supplementary development of themes and concepts generated. Data analysis used a three-phase approach: coding, categorising and development of themes.ResultsA total of 20 patients and/or caregivers and 31 HCP took part in 34 focus groups/interviews held over 3 months (November 2022–January 2023). Facilitators to oxygen therapy were identified including support from HCP and support groups, the perseverance and self-advocacy of patients, a straightforward administrative process and vendors/private industry that expedite access to oxygen therapy. There were also several barriers to accessing oxygen therapy for patients with ILD. The themes identified include rural disparity, testing requirements and qualifying for funding and the need for ILD-specific evidence base for oxygen therapy.ConclusionFurther research is needed to facilitate development of specific exertional oxygen criteria for patients with ILD, to create supports for oxygen use and monitoring and to enable providers to tailor therapy to patients. Oxygen therapy education for ILD should address the benefits and risks of oxygen therapy.

Background Asthma is a chronic respiratory disease characterized by reversible bronchoconstriction and airway inflammation. According to Statistics Canada in 2014, 8.1% of Canadians aged 12 and older reported having asthma diagnosed by a health care professional. Therefore, in 2014 there were an estimated 274,661 persons with asthma in Alberta. Most epidemiological studies estimate prevalence and incidence using survey-based data, which has limitations. The Ontario Asthma Surveillance Information System (OASIS) group has developed and validated an algorithm for epidemiologic asthma studies using provincial health databases. In Alberta, there are some studies using provincial databases, but most are restricted to emergency department visits and do not represent the entire asthma population. Using the validated asthma definition for epidemiologic studies, we performed an analysis of the Alberta Health administrative databases to investigate and report province-wide asthma prevalence, incidence and mortality in Alberta from 1995 to 2015. Methods Data from administrative databases, provided by Alberta Health, was analyzed to determine age and sex specific prevalence, incidence and mortality of the asthma population. The population cohort was all individuals residing in the province of Alberta, ages 0 to 99 from 1995–2015. Kendall’s Tau coefficient test was used to ascertain whether the observed trends were statistically significant. Results Between 1995 and 2015, the age-standardized incidence of asthma decreased by more than 50% in both males and females. Prevalence, however, increased threefold over the 20 years (for both genders) from 3.9 to 12.3% (Tau = 1.00, p < 0.0001) in females and from 3.5 to 11.6% (Tau = 1.00, p < 0.0001) in males. Thus, in 2015 there were 496,927 people with asthma in Alberta. All-cause mortality in the asthma population decreased over time, in both females (Tau = − 0.71, p < 0.0001) and males (Tau = − 0.69, p = 0.0001). For the last several years, all-cause mortality was higher in those with asthma. There were ~ 7 deaths/1000 in the population with asthma versus ~ 5 deaths/1000 in those without asthma. Conclusions The incidence of asthma decreased in both females and males while prevalence continued to increase, although at a slower rate than previously. All-cause mortality in asthma patients was higher than in those without asthma, but both decreased over time.

ObjectiveThe Respiratory Health Strategic Clinical Network (RHSCN) was launched to facilitate respiratory and sleep health through implementation of innovative, patient-centred, evidence-informed coordinated services in Alberta. In collaboration with project partners, the RHSCN aimed to determine the respiratory research priorities for Alberta.DesignThe four phases of this research prioritisation project were (1) identifying research questions from stakeholders, (2) determining which research questions had been answered in existing literature, (3) prioritising unanswered questions and (4) finalising the priorities through an inperson workshop.SettingThe study occurred in Alberta, Canada over a 2-year period beginning in March 2017.ParticipantsA total of 448 patients, clinicians and other stakeholders consented to participate in the survey.ResultsA total of 595 possible questions were submitted, with 343 unique questions identified. Of the questions, 94 were out of scope, 155 answered by existing literature and 10 were combined with others, while 83 were determined to be unanswered in the literature. Stakeholders were surveyed again to prioritise the remaining 83 questions and they were reviewed by the project’s Steering Committee (clinicians and patients). At the inperson workshop, the Steering Committee identified 17 research topics as priority areas for respiratory and sleep research in Alberta.ConclusionA stakeholder-led research prioritisation process identified optimal clinical management/follow-up, equitable access to services, and management of social, psychological and mental health issues related to respiratory/sleep health as priority research areas.

ObjectivesThe objectives of this study were to describe medication use, treatment patterns and adherence, as well as acute exacerbations of chronic obstructive pulmonary disease (AECOPD) among adults living with COPD.MethodsA retrospective observational study using administrative data (linked by unique person-level personal health numbers) between 1 April 2007 and 31 March 2018 from Alberta, Canada was performed. Individuals aged ≥35 years who had been living with COPD ≥1 year on 1 April 2017 (index date) were identified. COPD-related medication use was determined on the index date (baseline), and medication use, treatment patterns, adherence and AECOPD were measured during the 1-year postindex observation period; descriptive statistics were applied.ResultsAmong the total cohort (n=192 814), 59% were not using a COPD-related medication at baseline; among those using medication, the most common (>10%) classes were short acting bronchodilators only (29%), dual inhaled corticosteroids/long acting beta2 agonists (ICS/LABA, 27%), combined ICSs/LABA/long acting muscarinic antagonist (ICS/LABA/LAMA, 21%) and LAMA monotherapy (12%). During the observation period, those with baseline COPD medication use had low adherence (42% were adherent (medication possession ratio ≥0.80) to their baseline medication class) and AECOPD were common (13%–40%); 66% of those with ≥1 dispensation for an additional medication class had a step-up in therapy that was concordant with guideline recommendations.ConclusionsIn this population-based study, the majority of individuals identified as living with COPD were not taking any COPD-related medication, while in those who were taking medication, adherence was low, deficits in alignment to guideline-recommended therapy were observed and many had AECOPD. Strategies for earlier identification of undertreatment, consideration of guideline-based knowledge transfer strategies and mechanisms to improve long-term medication adherence may improve outcomes.