Research Abstracts

• Projects to improve care which have used other methods rather than classic QI.

• Focus on improving the quality of care or patient experience.

• Relate to the improvement of the patient experience or one recognized domain of quality (Safety, Timeliness, Efficiency, Effectiveness, Equitability, Patient-Centeredness).

A resident survey identified a desire for more detailed and personalized feedback during independent on-call periods. Prior studies have shown that automated information technology tools can help to facilitate meaningful feedback. Our primary aim was to minimize barriers to feedback and improve learning experiences for on-call radiology residents.

Graduated changes were made to the on-call workflow based on A3 problem solving method with root cause analysis of factors contributing to decreased resident satisfaction on quality of on-call feedback. Changes implemented included: workflow reorganization to match the daytime workflow, use of structured report templates, and implementation of automated report comparison function. Anonymous surveys were conducted pre- and post-implementation to evaluate resident satisfaction.

22 out of 25 and 15 out of 21 residents during different academic years responded to the pre-implementation and 7-weeks post-implementation surveys, respectively. Results were overall positive. 87% agreed that the changes were beneficial to overall call experience and learning. 55% felt they received adequate on-call feedback post-implementation compared to 23% pre-implementation. 73% agreed that the report comparison function was beneficial. Post-implementation respondents identified technical barriers as the main ongoing inconvenience to case follow-up.

Use of the A3 problem solving method to identify root causes and develop targeted interventions was useful to improve residents’ satisfaction on the quality of feedback received on their on-call reports. Facilitating automated and personalized feedback will be of increased importance in the era of Competency Based Medical Education.

Although many low-risk prostate cancer (PC) patients worldwide currently receive active surveillance (AS), adherence to clinical guidelines on AS and variations in care at the population level remain poorly understood. We sought to develop system-level quality indicators (QIs) and performance measures for benchmarking the quality of care during AS.

We identified candidates for an expert panel among practising urologists and radiation oncologists across Canada. QI development involved two phases: (1) Proposed QIs were identified through a literature search and published clinical guidelines on AS and (2) indicator selection through a modified Delphi process during which each panelist independently rated each indicator based on clinical importance. QI items were chosen as appropriate measures for quality of AS care if they met prespecified criteria (disagreement index <1 and median importance of 7 or greater on a 9-point scale).

Among 42 invited expert panel members, the response rate was 45% (n=19). Expert panel members were well represented by type of physician (84% urologists, 16% radiation oncologists) and practice setting (67% academic, 33% non-academic). The expert panel endorsed 20 of 27 potential indicators as appropriate for measuring quality of AS care. The final set includes indicators covering structure of care (n=1), process of AS care (n=13) and outcomes (n=6). Two QIs were uncertain with median importance of 7 that has high disagreement index score (DI >1), and four QIs were uncertain with median importance 4-6 with DI >1.

We developed a set of QIs to measure AS care using published guidelines and clinical experts. Use of the indicators will be assessed for feasibility in healthcare databases. Reporting quality of care with these AS indicators may enhance adherence, reduce variation in care, and improve patients’ outcomes among low risk PC patients on AS.

Opioid overdoses have reached new peaks in Canada since the beginning of the COVID pandemic, continuing to merit a public health response. The ED is a key interface where people who use opioids access care and often present with opioid-related harms. One harm reduction strategy that has shown efficacy in the community is take-home naloxone.1 This project aims to assess baseline rates of dispensing take-home naloxone.

This project will be organized into a data collection and an intervention phase. The first step will be to sample current naloxone kit distribution rate in opioid overdose presenting patients at the St Joseph’s Hospital. This data will denote the baseline use of naloxone distribution and can be used as comparison data points for local Emergency Hospitals. The data collected from the chart review will then be used to determine potential avenues of improvement as part of the Plan, Do, Study, Act (PDSA) cycle method to achieve the objectives previously stated. Such elements of implementation are predicted to be adding an order set, preparing take home naloxone kit and education information for both physician and patients.

Currently in data collection/no results, here we would like to highlight some of the parts of the project that did not go as planned. We’re QI researchers can encountered several delays including data extractions and Dovetail approval due to prioritizing of secondary projects such as needed COVID vaccine distribution, and manually tracking distribution of naloxone kits from pharmacy outside of Dovetail.

In the setting of St. Joseph's Healthcare Hamilton, no baseline data exists to identify the rates at which patients who present with an opioid-related encounter, such as overdose or otherwise, are being offered take-home naloxone kits and other harm reduction strategies. This project aims to utilize quality improvement (QI) methodology to assess the need and feasibility of a take-home naloxone protocol for our patient population who use opioids.

International guidelines recommend pneumococcal pneumonia and influenza vaccination for all patients with solid organ malignancies prior to initiating chemotherapy. Baseline vaccination rates (March 2019) for pneumococcal pneumonia and influenza at our tertiary centre were 8% and 40%, respectively. The aim of this study was to increase the number of gynecologic chemotherapy patients receiving pneumococcal and influenza vaccinations to 80% by March 2020.

We performed an interrupted time series study using structured quality improvement methodology. Three interventions were introduced to address vaccination barriers: an in-house vaccination program, a staff education campaign, and a patient care bundle (pre-printed prescription, information brochure, vaccine record booklet). Process and outcome data were collected by patient survey and pharmacy audit and analyzed on statistical process control charts.

We identified 195 eligible patients. Pneumococcal and influenza vaccination rates rose significantly from 5% to a monthly mean of 61% and from 36% to a monthly mean of 67%, respectively. The 80% target was reached for both vaccines during one or more months of study. The in-house vaccination and staff education programs were major contributors to the improvement, whereas the information brochure and record booklet were minor contributors.

Three interventions to promote pneumococcal and influenza vaccination among chemotherapy patients resulted in significantly improved vaccination rates. Lessons learned about promoting vaccine uptake may be generalizable to different populations and vaccine types. In response to the global COVID-19 pandemic, initiatives to expand the program to all chemotherapy patients at our centre are underway.

RightFax™ is the digital faxing platform available at our institution. Although RightFax has been available since 2010, only 27 users have integrated it into their practice. The aim of our study was to increase the number of RightFax users within the Department of Surgery, by 50%, by March 31, 2021.

A time series analysis was performed to evaluate the impact of a virtual care onboarding initiative which included (1) streamlined onboarding instructions, (2) RightFax orientation/instructional videos, and (3) integrated RightFax-Epic™ workflows. The baseline number of users and digital faxes received prior to our interventions were obtained from IT services. Our primary outcome was the number of users onboarded. Secondary outcomes included the carbon footprint savings (calculated using the Hewlett-Packard™ carbon footprint calculator for paper), and user satisfaction.

From April 1st, 2020 to March 31, 2021, 118 new users were onboarded. A total of 137,713 pages of inbound faxes were saved, translating into a savings of 11832 kg of C02 emissions, 6000 kg of paper, and 13 thousand dollars in energy/paper costs. Nine administrative assistants were surveyed. 78% reported that RightFax was easy to use, 67% felt RightFax improved workflow and efficiency, and 89% were likely to recommend it to a colleague.

Increasing the number of digital faxing users through targeted onboarding initiatives successfully decreases an institution’s carbon footprint, costs, and improves workflow efficiency.

Improving patient access to personal health information is associated with improved: health knowledge; self-efficacy; satisfaction and communications. (HQO, 2019; Ramset et al. 2018; Rhudy et al. 2019). Baseline data showed a myHealthRecord (myHR) activation rate of 8.9%. The aim is to increase activation of myHR to 30% by Jun 2020.

Primary Outcome: Percentage of myHR activations. Process Measures: Patient usability/feedback, demographics, utilization of myHR features Balancing Measures: Staff Feedback, number of patients declined/ inactivated. A multipronged strategy of patient engagement, staff engagement, IT support, addition of features, and communications was implemented with iterative PDSA cycles to optimize myHR. Patient engagement consisted of two virtual patient focus groups and an electronic survey. Pre-pandemic, the organization planned to increase virtual care, using video visits conducted in myHR.

Patient engagement identified areas for improvement including: improved navigation, aligning clinic workflows to myHR features, interconnectivity, accessibility, and promotion of new features. Patients top 5 preferred features included: test results, health summary review, view past/upcoming appointments, plan of care review and appointment management. Gradual progressive increases in myHR activations occurred from inception with a dramatic increase to 66.7% during the pandemic with the launch of video visits to maintain ongoing access to health care.

The pandemic resulted in a culture shift regarding virtual care provision, resulting in dramatic increase in myHR activations. Substantial hospital resources were enabled to facilitate virtual care. The patient engagement will enable our team to further optimize myHR to ensure myHR meets the needs of patients to optimize patient experience.

In a rural hospital, inconsistent use of standardized admission order sets, when compounded with high staff turnover through locums and seasonal employment, leads to variability in care and potential medical error. This project’s aim was to increase the use of standardized order sets on admission to 70% over seven weeks.

Primary outcome measure: Proportion of admitted patients with a completed admission order set. Secondary outcome measures: Proportion of order sets correctly selected and completed. Process measures: Number and diversity of providers reporting confusion about order sets; diversity of providers completing order sets. Balancing measures: Staff satisfaction. A baseline audit was conducted with a review of one week’s admissions. Numerical trends were evaluated for intervention identification. Qualitative data from interviews was then used for intervention selection.

Baseline evaluation revealed a 56% completion rate on admission order sets, solely by emergency physicians, with a low uptake (16%) of appropriate diagnosis-specific order sets. Proposed interventions included: a staff meeting-based order set title review session, as physicians identified a lack of knowledge of available order sets; a transfer of care policy, as physicians identified confusion around responsibility for admission orders; and pre-printed order sets. Implementation was limited by the start of the COVID-19 Pandemic.

Shift in culture to evidence-based interventions requires engagement of diverse stakeholders. Evaluation of barriers also revealed deeper policy concerns, such as a lack of transfer of care policy. Finally, it is important to evaluate how interventions may continue in the setting of a paradigm shift, such as the COVID-19 Pandemic.

Many patients with diabetes also live with advanced kidney disease requiring hemodialysis. It can be overwhelming for patients with multiple comorbidities to attend numerous appointments to receive care. This initiative aimed to develop an outreach diabetes care program lead by a Certified Diabetes Educator (CDE) at London Health Sciences Centre. 

We conducted a baseline needs assessment for diabetic patients receiving in-centre hemodialysis at the Kidney Care Centre (KCC) as of August 1, 2019. Once gaps were elicited, our team developed project aim statements. These included improvements to blood glucose self-monitoring, treatment adherence, episodes of hyperglycemia and hypoglycemia, and frequency of regular eye and foot care. We performed a root cause analysis to identify critical drivers of gaps and conceptualized diabetes supports for our outreach intervention.

Process, outcome and balancing measures were captured using run charts. Since December 2020, our CDE has provided outreach support every 1-2 months to 51 patients with diabetes, in-person and remotely, during the pandemic. Upon completing our program in the summer of 2021, we will formally analyze data using SPC software. Our outreach program appears to be improving the proportion with professional foot care, adequately self-monitoring sugars, and the mean number of blood sugars above 11. 

We have successfully implemented an outreach diabetes support program at the KCC. Our program appears to be improving glycemic control, regularity of foot and eye care, and disease knowledge in patients with diabetes undergoing hemodialysis.

Falls occur annually in one-third of those over the age of 65. Falls predict hospitalization, functional decline and the need for long-term care. Falls occur frequently in inpatient dialysis patients. By March 2021, the aim was to decrease inpatient falls in hemodialysis patients on the Nephrology ward by 50%.

To better understand the circumstances and precipitating, we completed a retrospective chart review of all falls on the inpatient Nephrology ward between January to November 2019. This was followed by informal interviews with frontline staff for qualitative feedback. With this information, we completed a root cause analysis and explored change ideas that included patient, physician, nursing and environmental interventions.

We decided to focus on intervention that could be physician-led. Patients who fell were either on high falls-risk medications or delirious. Our aim was to change prescribing practices on the inpatient ward to reduce the incidence of delirium and falls. We attempted to obtain baseline data on inpatient prescribing practices from Dovetale. However, despite multiple requests and attempts, we were unable to obtain this crucial information. Therefore, we were not able to proceed further.

Barriers we faced prompted us to wonder if others pursuing QI projects in an academic hospital setting had similar experiences. There is a research gap in barriers and facilitators to pursuing QI projects in this setting. We are in the process of completing a qualitative study to explore this topic.

Residual neuromuscular blockade (NMB) after general anesthesia is a risk factor for postoperative respiratory complications, detectable only by quantitative NMB assessment, but often unrecognized by the anesthesiologist. The 2020 Guidelines to the Practice of Anesthesia of the Canadian Anesthesiologists’ Society, mandates the use of neuromuscular monitoring whenever NMB agents are administered. However, at our institution, NMB and reversal management predominantly relies on the anesthesiologist’s subjective assessment and clinical judgment. The OBISPO initiative intends to address this practice gap for improving our current standard of care.

1. Increasing quantitative NMB monitoring in PACU to > 80% in fast-track cardiac surgery patients, to reduce the incidence of residual NMB after anesthesia to < 20% by December 2021. 

2. Increasing continuous NMB monitoring during anesthesia to > 90% in cardiac surgery patients, for reducing residual NMB incidence after skin closure to < 10% by December 2022. 

Plan-Do-Study-Act (PDSA) improvement model. Outcome measure: incidence of residual NMB after general anesthesia (train-of-four ratio < 0.9 by electromyography). Process measure: NMB assessments rate in fast-track cardiac surgery patients; Fidelity: NMB assessments in > 70% patients per PDSA cycle. Balancing measures: trends of NMB and reversal agents dosing, PACU length-of-stay, time-to-extubation, adverse respiratory events, and staff satisfaction, per PDSA cycle.

COVID-19 safety precautions makes informed decision-making a more challenging process for patients. This is an opportunity for healthcare providers to integrate patient decision aids into practice, an intervention to enhance patient experience. This study explores whether video-based patient decision aids (VBPDA) can facilitate patient decision making in the cataract surgery consent process.

Before the clinical encounter, patients watched the VBPDA, which outlined the process of cataract surgery and the decisions to be made (ie. biometry, intraocular lens, and focus). During the clinical encounter, patients had a consultation with an ophthalmologist and engaged in shared decision making. At the end of the encounter, all patients completed a questionnaire assessing the effects of COVID-19 safety precautions on their appointment. Patients proceeding with surgery also completed the Decisional Conflict Scale (DCS).

For patients proceeding with cataract surgery (n=111), the median DCS score was 9.4 (0-54.7, min-max) on a scale of 0 to 100 (low to high decisional conflict). Of these, 76 participants (68.5%; 95% CI: 0.60-77.0%) scored < 25, 30 participants (27.0%; 19.0-36.0%) scored between 25-37.5, and 5 participants (4.5%; 1.5-10.0%) scored > 37.5, representing low, medium, and high decisional conflict, respectively.

COVID-19 health precautions have made it more difficult to communicate the decisions that patients need to make before their cataract surgeries, presenting challenges to the consent process. Our study found that VBPDAs to be an effective tool to enhance the patient decision making process for cataract surgery.

Potentially to include video based methods of patient education in other predictable procedures as well, as it makes the encounter both more efficient and effective. Patients are more satisfied and the efficiency decreases their risk of exposure in COVID. Beyond COVID, efficiency will be necessary to allow patients to receive care in a timely manner.

Research indicates 34% of Canadian family physicians caring for patients receiving hemodialysis do not receive any reporting from nephrologists. Locally, reports are sent to family physicians monthly, requiring significant nephrologist time and effort. This audit aimed to examine the use and value of these reports to primary care providers.

We conducted a survey study of family physicians who care for patients receiving hemodialysis in the Queen’s University nephrology program. The survey evaluated the percentage of family physicians who reviewed the report monthly and found its content useful for patient care. Based on expected current performance of 50% for both metrics and desired performance of >80%, a target sample of 12 physicians was required to demonstrate a quality of care gap.

Thirteen family physicians completed the survey. 84% (11/13) indicated they always review the report and 15% (2/13) indicated they review the report over 50% of the time. Additionally, 77% (10/13) of respondents view the report as very (23%, 3/13) or somewhat (54%, 7/13) useful. All respondents included medication lists as the most important content of these dictations. Further, 85% (11/13) listed role delineation (e.g., primary responsibility for depression management, cancer screening, etc) as valuable content.

Contrary to our expectation based on prior informal feedback, reports were reviewed by primary care physicians regularly (i.e., every 4-6 weeks). This supports the nephrologist effort being dedicated to current practice. Instead, improvement is needed in dictation content, particularly listing medications and clearly delineating primary responsibilities for different care tasks.

eFax is the process when an electronic medical record generates a paperless prescription and electronically transmits to an Ontario outpatient pharmacy’s fax machine. eFax is to promote efficient workflows to support healthcare workers, reduce patient safety risks (e.g. photocopying) and keep patient information secure (e.g. non-authorized interception, anti-forgery microfont). eFax is a patient centred functionality improving the patient experience, enabling virtual care and social distancing during the pandemic.

Pilot scope included 8 Ambulatory Nephrology areas between June 16th – July 9th 2020. Users were Prescribers with the support of Clerical Staff to manage eFax Rx Notice Pool which showed the status of sent eFaxes. Only prescribers have the authority to dual authenticate (eSign) and send eFaxes. The eFax workflow consists of 4 process steps in contrast to the 9-10 faxing process steps.

Between June 16th – July 9th 2020, 631 eFax prescriptions were sent with a 98.1% successful transmissions rate. The eFax process saved 35 seconds to print & sign prescription and 87 seconds to travel & fax prescription. It is projected to save the department 40.14 hours / month. Prescription can be prepared before a patient arrives to pharmacy saving patient time and providing convivence. User feedback included the process being user friendly, fast and efficient and they liked the ability to work remotely.

For patients, eFax means less stress and waiting at the pharmacy especially if their health is not great and less exposure to infection for immunocompromised patients. For prescribers, efficiencies mean more time to spend on patient value-add tasks including the opportunity to see more patients within a day. eFax secured workflows including the addition of a destination pharmacy, a microfont line and dual authentication. In contrast, printed prescriptions for faxing can be intercepted by non-authorized users at the printer or fax machine and paper copies need to be managed appropriately.

Appendicitis accounts for 7-10% of acute abdominal pain cases presenting to the emergency department. Nursing directives in the ED have previously been shown to decrease ED length of stay, time to imaging, and improve pain control. An advanced nursing directive could expedite the diagnostic workup for children with suspected appendicitis.

Inclusion Criteria: Children aged 3-17 years presenting with ≤4 days of abdominal pain, right lower quadrant (RLQ) pain with walking or jumping and tenderness or guarding on palpation. Exclusion Criteria: Chronic GI/GU illness or neurodevelopment disorder. Statistical Analysis: Categorical variables were summarized using frequencies, proportions, and rates. Continuous variables were summarized using means, medians, and standard deviations. For differences in proportions, we conducted a χ2 test and for continuous variables we used student t-test

Nurse-initiated investigations for suspected pediatric appendicitis patients had a mean reduction in time from ED presentation to all diagnostic and therapeutic ED flow parameters when compared to MD-initiated standard of care. There was no significant difference in proportion of patients who had a surgical appendectomy between those who were investigated using the nursing directive (32.8%) and those who were MD-initiated (30.0%) (Pearson’s chi square 0.185, p-value 0.758).

A nursing directive selects intermediate to high risk patients for appendicitis & empowers nurses to begin the diagnostic work-up. Nurse-initiated investigations for suspected pediatric appendicitis had quicker diagnostic and therapeutic outcomes and did not result into an increase in resource utilization.

More than 45 million people globally are affected by chronic liver disease (CLD) - with incidence expected to rise. CLD results in a complex immunocompromised state, leaving patients defenceless in the face of infection and at a 4-fold risk of mortality. Immunization remains our best line of defence. The National Advisory Committee on Immunization Practices recommends special immunization considerations for patients with CLD against vaccine-preventable disease, including vaccination against hepatitis A virus (HAV), hepatitis B virus (HBV), pneumococcal pneumonia, and influenza. The degree of successful implementation of vaccine programs in response to guidelines for CLD patients is not well understood.

The aim of this quality assessment study examine rates and timing of vaccine administration in patients with CLD, in an effort to mitigate potential disparities in coverage and the potential harm of vaccination delay.  Problem description 3.5 Aim 1

Patients with CLD who received care at a large, primary care academic center in Ontario between January 1, 2010 and June 30, 2020 were identified using diagnostic codes. Demographics, etiology, and vaccination data pertaining to influenza, pneumococcus, HAV, and HBV were collected utilizing the electronic medical record and Canadian Primary Care Sentinel Surveillance Network database. 

Of 23, 021 patients registered, a total of 150 patients were identified to have CLD.  The average age of the cohort was 55 and 25.3% (n = 38) were older than 65 at time of diagnosis. 58.7% (n = 88) were male. Overall, 32% (n = 48) of patients with CLD received at least 1 vaccination following their diagnosis. The rate of having at least 1 influenza vaccine after diagnosis was 28% (n = 42), of which 66.7% (n = 28) were vaccinated within 1 year after diagnosis. The rate of having at least 1 lifetime pneumococcal vaccine was 26% (n = 39), of which 12.8% (n = 5) were within 1 year after diagnosis.  Analysis revealed that 6% (n = 9) of patients initiated vaccination against HAV, of which 44.4% (n = 4) initiated the series within 1 year after diagnosis.  55.6% (n = 5) completed the full schedule. 10% (n = 15) of the total cohort initiated vaccination against HBV, with 4.7% (n = 7) having initiated the series within 1 year after diagnosis. Only 2 patients completed the full schedule for HBV vaccine. Another 10 patients (6.7%) initiated dual-HepA/B vaccination, of which 3 patients (30%) did so within 1 year following diagnosis. Only 3 patients (30%) completed the full series. 

Gender and racial minority representation in academic leadership in Canadian Departments of Obstetrics and Gynecology (OBGYN) and Divisions of Gynecologic Oncology (GO) has not been previously described. Our objective was to examine gender and ethnic diversity in departmental leadership roles.

Institutional websites were queried in 01/2021 to compile a list of faculty members of academic departments. Subjective gender was assigned based on photographs and pronouns. Visible minorities were identified from photographs. Descriptive statistics were used to summarize faculty characteristics. Logistic regression analysis was performed to examine prognostic factors for leadership roles.

355(33.7%) male and 698(66.3%) female academic OBGYNs were identified across 16 Canadian institutions; no physicians of non-binary gender were identified. Visible minorities comprised 18.3% of academic OBGYNs. Men were more likely than women to reach full professorship (p-value<0.00001) and to be appointed to leadership positions including Chair of OBGYN (p-value=0.0004) or subspecialty Division Head (p-value<0.00001). Visible minority physicians were less likely to have attained full professorship (p-value=0.002), but there was no statistical difference in ethnic representation in leadership roles. Within GO, 97 academic physicians were identified: 68(70.1%) were female, 17(17.5%) were visible minorities. Seven departments (44%) did not have visible minority representation. Factors associated with leadership positions on univariate analysis (Department Chairs, Division Heads, Fellowship, Residency and Undergraduate Program Directors) were academic title (odds ratio [OR]=2.91,95%CI=1.19-7.11,p-value=0.019 for Professor/Associate Professor vs Assistant Professor/Lecturer) and year of fellowship completion (OR=0.95,95%CI=0.91-0.99,p-value=0.014). Gender or being from a visible minority were not significant factors. On multivariable analysis, only year of completion of fellowship was predictive of leadership roles in GO. 

This is the first study to describe gender and ethnic representation in the Canadian OBGYN landscape. Despite underrepresentation of women in leadership and full-professor positions, and visible minority underrepresentation in full-professorship in OBGYN, no such difference was observed amongst academic Gynecologic Oncologists.

Oral anticoagulants (OACs) are commonly prescribed and highly effective medications, but a leading cause of serious medication-related adverse events. High-quality OAC management, has become more complex now that there are several direct-acting OACs (DOACs). This study aimed to identify barriers and facilitators for optimal OAC management using qualitative research methods.

Using a qualitative descriptive study design, we conducted five focus groups, three with patients and caregivers and two with health care providers, in two health regions in Southwestern Ontario. An expert facilitator led the discussions using a semi-structured interview guide. Each session was digitally recorded, transcribed verbatim and anonymized. Transcripts were analyzed in duplicate using conventional content analysis, consistent with a qualitative descriptive approach.

42 informants, including 19 patients, 7 caregivers, and 16 providers, participated in the discussions. Data analysis organized codes describing barriers and facilitators into 4 main themes - medication-related, patient-related, provider-related, and system-related. Barriers highlighted were problems with medication access due to cost, patient difficulties with adherence, knowledge and adjusting their lifestyles to OAC therapy, and provider expertise and time for adequate communications. Facilitators addressed these barriers

Many barriers to optimal OAC management exist even in the era of DOACs, many of which are amenable to facilitators of improved care coordination, patient education, and adherence monitoring. Since there is not yet high quality evidence that interventions to address these barriers actually improve clinical outcomes in a cost-effective manner, further research is required before policies can be created.