Research from a PSI Foundation–funded team has led to the development of a first-of-its-kind assessment of seniors’ biomedical and social vulnerability. The Frailty and Vulnerability Evaluation (FAVE) tool, developed by Dr. Ross Upshur and his team at Bridgepoint Active Healthcare and the Department of Family and Community Medicine in Toronto with funding from PSI Foundation, is a step towards higher quality care for seniors.

Dr. Upshur’s career has largely been focused on senior care, starting with electives as an undergraduate in medical school, followed by several years as a primary care physician in a rural area with a large senior population. In recent years of his research career, he and his team have been interested in developing tools to help physicians in family practice manage the complex health care needs of seniors.

They identified that while certain aspects of seniors’ health were becoming better understood, there was still a significant gap – social isolation. “There’s growing interest and recognition from the health system around frailty,” says Dr. Upshur. “Frailty is important, but not the whole story.” Yet, no clinical tools in primary care looked at both frailty and social vulnerability, so he and his team, with input from an expert advisory committee, developed one.

The new tool, FAVE, asks seniors about their health and functional abilities, but importantly, also asks about their social wellbeing, including their loneliness, living arrangements, feeling of safety and economic insecurity. “People are now talking about loneliness and isolation as an issue,” says Dr. Upshur. “A primary care physician might notice that a patient might have issues with loneliness and vulnerability, but collecting this information has not been systematic.”

With funding from PSI Foundation, the team validated FAVE and compared the performance to existing measures, such as the frailty score and physician judgment, to determine if it is a reliable predictor of an individual’s health and wellbeing.

More than 260 patients from 10 Family Health Teams from urban, suburban and rural practices completed the tool. Seniors completed the FAVE assessment on paper or electronically prior to an appointment with their family physician. The team also asked the family physician for an assessment of the individual’s frailty and wellbeing, blinded from the patient’s score on the tool.

They found that patients thought the survey was user friendly, and importantly, that FAVE scores correlated well with seniors’ self-reported health, as well as physician assessments and frailty scores.

To understand whether FAVE is a good predictor of an individual’s future health, the team is now looking at patients’ charts one year after they complete the tool, particularly to examine the patient’s total number of health care transitions (such as being admitted to the emergency department, long-term care or a return home), and the total number of days spent at home. The analysis is currently underway but will help determine whether FAVE, physician judgment, the frailty score, or a combination is the best predictor of a patient’s future health care transitions.

Dr. Upshur notes that PSI Foundation plays an important role in this type of research. “It can be difficult to get funding for small-scale projects that engage local partners, but PSI Foundation is a strong supporter of this type of research,” says Dr. Upshur. “They focus on research that is meaningful to clinical practice.”

As Ontario includes an already large and growing population of seniors, Dr. Upshur hopes that FAVE will help primary care physicians care for both the health and social needs of seniors. “The tool is just one component of a systematic approach for seniors in the community by primary care physicians,” he says. “It’s an important step towards more comprehensive, appropriate, compassionate and high quality care for seniors.”

A potentially practice-changing study led by a PSI Foundation-funded surgical resident has challenged long-held beliefs about care for small bowel obstructions (SBOs).

SBO, a blockage in the intestine often cause by scar tissue (or “adhesions”) from previous surgery, is a common condition, representing about 20% of all hospital admissions for abdominal pain. A small number of patients whose conditions don’t resolve with usual treatment receive surgery, but most patients, about 80%, recover from SBO through treatment with bowel rest, IV fluids and gastric decompression. These patients are considered to be successfully treated and released from hospital, yet many of them will return – sometimes as often as every few months – with a recurrence.

Dr. Ramy Behman, a surgical resident with the University of Toronto, wanted to study the long-term natural history of SBO and potentially improve treatment. “We’ve been treating SBO the same way for a long time. Some people bounce back from an SBO, but then they’re dealing with it every few months,” says Dr. Behman. “SBOs aren’t very well studied, so a better understanding of the natural history could be helpful to improve treatment.”

Dr. Behman applied for and received PSI Foundation funding, which he says was crucial to the research, especially so early in his career. “I don’t know how we would have done the study without the funding,” he says. “And having people outside of your research committee think that the research is worthwhile is very encouraging when you’re just starting off.”

With a Resident Research Grant, Dr. Behman looked at 10 years of health administrative data, identifying nearly 40,000 patients in Ontario admitted to hospital for their first SBO during that time period. They then followed how the patients were treated on that occasion and any following recurrences and tracked the outcomes. The large dataset allowed them to examine the different ways that SBOs are managed and how outcomes are affected.

“We were one of the first groups to really step back and look at the long-term disease course,” he says. “And what we found was challenging to the dogma.”

Physicians have long believed that surgery for SBO would increase the risk of recurrence by creating new adhesions and usually don’t recommended surgery for SBO unless other treatments are unsuccessful. But Dr. Behman’s research suggested that this actually isn’t the case – in fact, surgery could reduce the risk of recurrence. According to their results, patients with SBO treated with surgery – whether on the first or subsequent occurrences – cut the risk of recurrence by about half.

“Operating can take patients off the recurrence cycle. It can really change the trajectory of disease for patients,” says Dr. Behman.

Surgery does have its own risks, namely the risk of complications that could potentially have been avoided, as well as a greater upfront cost than standard treatment. Dr. Behman and his team are analyzing the cost-utility to examine whether the greater upfront costs are offset by fewer hospital readmissions due to recurrences, and he is hoping to publish the results soon.

He notes that the study may influence guidelines for SBO management and help physicians make informed decisions about how the condition can be managed.

“This isn’t a uniform prescription for every patient with SBO, but it adds to our understanding of the disease and facilitates informed decision making,” he says. “The optimal practice will be the right intervention for the right patient.”

As the child of immigrants, Dr. Shixin (Cindy) Shen has had a long-standing interest in immigrant health issues, including cancer screening. While pursuing the Public Health and Preventive Medicine Residency at the University of Toronto, she found that there was little information about the barriers to colorectal cancer screening that immigrants in Ontario may face. “Colorectal cancer is the second most common cause of cancer, and 40% of all immigrants in Canada live in Ontario,” she says. “Yet, there wasn’t much information about colorectal cancer screening in immigrants in Ontario, despite the fact that they tend to have lower screening rates.”

To address this knowledge gap, Dr. Shen and her supervisors, Dr. Aisha Lofters and Dr. Richard Glazier, looked at the immigration and non-immigration factors that influence screening rates in immigrants, in order to get a better understanding of which are the most important.

They looked at data from a number of health care administrative databases, as well as the Immigration, Refugee and Citizenship Canada’s Permanent Resident Database, which contains records of individuals who obtained immigrant status since 1985.

Dr. Shen found that within the immigrant population there were significant differences in rates of screening non-adherence, related to different factors. Among the factors related to immigration, an individual’s region of birth and the income level of that region, as well as their immigration class (economic, family or refugee) were the most important factors that predicted screening non-adherence. Among the factors not related to immigration, individuals with no or moderate use of the health care system and those not rostered to a care team were less likely to be screened.

The results emphasize the health inequalities that immigrants may face in Ontario. “Some of these factors, especially when combined, contributed to significant disparities in screening uptake,” says Dr. Shen. “For example, among refugees from low-income countries who were not rostered and who lived in low-income areas, the rate of non-adherence to screening was 71%, compared to 25% for economic immigrants from high-income countries who were rostered and lived in high-income areas.”

The study was supported by a Resident Research Grant from PSI Foundation, which was critical for allowing the team to access the multiple databases and to support Dr. Shen’s work on the study. “The funding from PSI Foundation allowed me to lead the study from beginning to end, which was a very helpful learning experience,” she says. “I was able to further develop my skills in critical thinking, problem solving, and evidence generation, which will be helpful in my career as a public health physician.”

Dr. Shen notes that the study is just the starting point in understanding the screening barriers in this population, and that further research is needed to explore these factors in more depth. Ultimately, she hopes that the research can be used to help policymakers find ways to increase screening rates in this priority population.

“We know that screening is important for reducing cancer incidence and death rates, and we know that there are social factors that lead to poorer access to services and poorer health status,” she says. “With this research, we hope to have a better understanding of the potential causes of differential access to preventive care, so that we can address them properly and bridge the gap in health outcomes. The goal is to level the playing field so that everyone can lead healthy lives.”

Health professionals agree that breastfeeding is important for long-term child health, and it has also been suggested by policymakers as a way to reduce the risk of poverty and household food insecurity (HFI). But a recent PSI Foundation–funded study has challenged the conventional wisdom regarding breastfeeding duration and HFI, suggesting that it may be more important to focus on other strategies to reduce poverty.

“The benefits of breastfeeding are well recognized, but will it protect families from household food insecurity? Maybe not,” says Dr. Peter Wong, a pediatrician in Toronto.

Because breastmilk substitutes are expensive and could take money away from a household’s food budget, policymakers have suggested that encouraging longer duration of breastfeeding can be one way to decrease the risk of HFI. No research demonstrating the effectiveness of this strategy had previously been done, although studies have shown that the presence of HFI may adversely affect the duration of breastfeeding.

With a PSI Foundation Healthcare Research by Community Physicians grant, Dr. Wong and a team of researchers led by Drs. Patricia Parkin, Jonathon Maguire, Cory Borkhoff and Catherine Birken at TARGetKids!, a research group that focuses on early childhood health, explored this question. A unique research group in Canada, TARGetKids! includes a study population of 10,000 healthy children recruited at community-based practices to provide information about their growth, development and lifestyle to help researchers answer questions about this understudied group.

Dr. Wong and his colleagues surveyed 3,000 families from TARGetKids!, asking questions about breastfeeding duration, household food insecurity and family income. Surprisingly, they did not find an association between breastfeeding duration and HFI, suggesting that shorter duration does not increase the risk of HFI in their study population.

While Dr. Wong notes that the TARGetKids! study group provided access to a large study sample, he also says that the participants were not necessarily reflective of the population where HFI is a pressing concern, which may have influenced the results. Still, the study suggests that breastfeeding on its own may not be enough to help families struggling with poverty and HFI.

“To address household food insecurity, we need a higher level, upstream strategy that addresses more societal problems,” says Dr. Wong. “We need policies that will reduce insufficient income and poor employment. That’s where we’ll make a greater difference.”

Dr. Wong and the team are now planning to examine how breastfeeding and other health-related factors might influence measures of early childhood health, such as nutrition, development and cardiometabolic health. His primary role as a practising pediatrician, as well as his interest in community engagement, public health and epidemiology, gives him unique insight into these types of research questions. “As community physicians, we interact with families and kids on a daily basis, and we have a good appreciation for their health and social challenges,” he says. “We are able to formulate research questions that really have an impact on the health of families and communities.”

And he appreciates that PSI Foundation is supportive of physicians like him who do not have access to the same resources as academic researchers. “Full-time community clinicians have a challenging time competing in the same funding pool as academic researchers,” he says. “PSI Foundation demonstrates that physicians really do care about medical research and about asking questions that address the health of Ontarians.”