The nine Coast Salish and Nuu-Chah-Nulth nations of southern Vancouver Island have supported diabetes prevention and management with a variety of programs; however, the rate of diabetes continues to rise. Our goal is to engage with the nine First Nations communities through one-day gatherings to identify the assets, experiences, barriers, and gaps within each community, and integrate culture and language into a community-led model for diabetes prevention, treatment and management. We aim to co-create a framework for a diabetes prevention and care model that is community-driven, improves diabetes services at the local level, and supports nation-based self-determined approaches to diabetes prevention and management. It is imperative that we prioritize this work and align our efforts to explore a collaborative, decolonized approach to diabetes care. Our model will enhance the culture and resilience that is already present within our communities and bridge gaps in care to develop a diabetes strategy that can support our question of “How can we be who we are as First Nations people while integrating our Traditional knowledge with the best of Western approaches to diabetes care?”.
Nurse Practitioners (NPs) have practiced in BC since 2005, and are qualified to provide holistic primary care across the life span, similar to primary care physicians. Until 2018, NPs were health authority employees in salaried positions; in 2018 the MOH announced 200 new community NP positions and a contract payment structure option. Numerous contracted NP positions have since been introduced in Island Health. Integrating contracted NPs into an established primary care model traditionally provided by doctors has exposed unique challenges, opportunities and unintended outcomes. Although all stakeholders have generally worked well together, unanticipated conflicts and inefficient work flow impacts have arisen. Integrating inter-professional scopes of practice into an efficient and seamless system of innovative primary care in context of mixed expectations has been challenging. Published evidence suggests that full NP role optimization is affected by practice environments. We aim to develop a research plan to identify the enablers, challenges and unexpected outcomes, and determine how innovative processes enabling focused collaboration, clear scope of practice and improved teamwork can improve flow and access in primary care.
Dr. Christine Lee and her research co-lead Dr. Katharine McKeen, a primary care physician (PCP) with the Victoria Division of Family Practice (DFP), are employing a patient-oriented research (POR) approach to raise awareness and disseminate evidence of fecal microbiota transplant (FMT) to treat recurrent Clostridium difficile infection (rCDI). FMT, the administration of feces from a healthy screened donor, is demonstrated to be both safe and more effective than the usual ways to treat rCDI. Estimates from three recent Canadian studies indicate that only 1,000 rCDI patients have received FMT, yet approximately 10,000 Canadians each year are diagnosed with rCDI.
The team is proposing a distributed knowledge translation approach, one that will enable them to reach diverse stakeholders: patients, families, PCPs, and healthcare decision makers (HCMs). Using a POR approach, they will co-develop a digital story that will enable their patient partner to share her lived experience of rCDI and FMT, and then the research team will relay the evidence for FMT. This video will be used for public outreach and as an education tool. They will also engage PCPs and HCDMs through presentations at their respective networks. During this outreach, the digital story will be displayed.
The overall goal is to increase FMT access for patients diagnosed with rCDI. The objectives are to:
- Raise awareness of rCDI and FMT.
- Inform stakeholders of FMT’s safety and effectiveness.
- Engage PCPs and HCDMs in a constructive dialogue to discuss the benefits of and evidence for FMT for rCDI.
The expected outcomes and outputs are to:
- Raise stakeholder awareness of FMT and its benefits as a treatment for rCDI. Output: Production and launch of a digital story telling video on rCDI and FMT as an education and public awareness tool.
- Foster communications with PCPs and increase their awareness of regional FMT resources. Output: Share the digital story and engage PCPs in a constructive dialogue via a café scientifique style discussion at the DFP “Dine and Learn” session.
- Increase HCDMs awareness of regional FMT resources and FMTs positive contributions to the healthcare system overall. Output: Share the digital story and engage HCMs through presentations to Island Health's Medical Advisory and Clinical Practice Councils.
The team will evaluate the impact of their work by using the domains of the Canadian Academy of Health Science “Making and Impact” framework: advancing knowledge; research capacity building; informed decision making; health impact; and broad social and economic impact.
Many Canadians live with debilitating chronic gut disorders such as Crohn's or ulcerative colitis (also known as inflammatory bowel disease, or IBD), Clostridium difficile infection (CDI), or both. These disorders lead to increased morbidity and reduce quality of life and productivity for patients and their families. One in every 150 Canadians has IBD, which is the highest rate worldwide. CDI is the number one cause of health care-associated infection (HAI) in Canada, and associated costs are approximately $300 million per year. An added concern is the recent sharp increase in community-associated CDI rates in previously healthy individuals. Recurrence of CDI following treatment with antibiotics is approximately 30%, increasing to 60% after two or more recurrences.
The key reason for IBD and CDI is thought to be a major imbalance between good and harmful bacteria in the gut (also known as dysbiosis). Current treatments for these conditions are ineffective and costly, and do not establish beneficial bacteria (or microbiota) in the gut. Fecal transplantation, also known as fecal microbiota transplantation (FMT), is a promising new treatment that uses stool from a healthy screened donor to restore the healthy microbiota in the colon. However, FMT remains unavailable in most health care facilities in Canada despite high demand. Dr. Lee regularly receives phone calls and e-mails from patients with chronic gut conditions requesting FMT. FMT is not yet licensed for routine clinical use and out of desperation, some patients have explored the option of performing FMT at home using unscreened donor stools. One of the major challenges of establishing and sustaining an FMT program is the lack of suitable donors and the laboratory support to manufacture FMT. In order to improve availability and reduce cost, this program will use Lyophilized (freeze-dried) FMT, L-FMT. Dr. Lee has used L-FMT to 60 patients with CDI and its result is similar to fresh/frozen FMT.
The BCaLM (British Columbia Associated Lyophilized Microbiota Program) aims to: 1) establish the safety of L-FMT through long-term follow-up of recipients; and 2) establish an effective and safe program to deliver L-FMT across Canada. A multi-site study will evaluate the efficacy of L-FMT, and the results will be used to direct further research and establish capacity for L-FMT. The findings can offer a readily available, cost-effective, and improved treatment option for people with chronic gut disorders.