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Maximizing Value and Reducing Waste: Identifying Suboptimal Prescription Drug Dispensations in Alberta
No full textThis dissertation represents the first application of the health technology reassessment (HTR) model for outpatient prescription drugs. The objectives of this work were to develop and apply an approach to identify candidate outpatient prescription drugs for HTR in Alberta. This thesis includes three distinct projects. First, the approach to the identification of candidate prescription drugs for HTR in Alberta was developed. The approach embodies the process attributes of data-driven, routine and replicable, actionable, enabling broad collaboration, and offering high return on investment. Initial identification of candidate technologies should include all candidate technologies and clinical areas to minimize clinician disengagement and compare outcomes of proposed changes in use. Second, funnel plots were quantitatively compared across Anatomic Therapeutic Chemical (ATC) classes at the fourth level stratified by prescriber specialty. We used variation in prescription dispensation rates between prescribers to estimate three outcomes: the number of prescribers affected, the number of patients affected, and the potential budgetary impact. Combinations of ATC class and prescriber specialty were ranked in descending order for each of these outcomes, with dispensation rates above and below the mean considered separately. The top ATC classes for each outcome showed high similarity above and below the mean, with minimal overlap between outcomes. Third, patients with dispensations of the ATC classes with the highest potential for reducing budgetary impact were compared to identify formulary management levers for policy action. Administrative data were used to evaluate the presence of variation in effective care, variation in supply sensitive care, and variation in preference sensitive care. Based on this work, suggested policy actions supported were broad, such as aggressive price negotiation, and the pursuit of alternatives such as biosimilars to reduce price. Overall, high-level assessment of variation held much promise for HTR of prescription drugs due to the low up-front efforts, but focusing on relative variation also created distance from meaningful clinical context. Other methods of technology identification based on absolute standards may be more likely to maintain clinical relevance. This would come at the cost of increased efforts during technology identification
Proceedings from the 2024 precision public health research symposium: advancing health equity through precision public health
No full textRapid Itch Improvement and Skin Clearance with Upadacitinib Versus Placebo (Measure Up 1 and Measure Up 2) and Versus Dupilumab (Heads Up): Results from Three Phase 3 Clinical Trials in Patients with Moderate-to-Severe Atopic Dermatitis
No full textAbstract Introduction Achievement of stringent outcomes (e.g., ≥ 90% improvement from baseline in Eczema Area and Severity Index [EASI 90] or minimal-to-no itch on the Worst Pruritus Numerical Rating Scale [WP-NRS 0/1]) is associated with a substantial improvement in quality of life among patients with atopic dermatitis (AD). Using stringent outcomes, we evaluated the efficacy of upadacitinib vs placebo and vs dupilumab on rapid itch improvement and skin clearance in patients with moderate-to-severe AD in three phase 3 clinical trials. Methods Patients received orally administered upadacitinib 15 mg (UPA15), 30 mg (UPA30), or placebo once daily for 16 weeks in Measure Up 1 and Measure Up 2 and orally administered UPA30 once daily or subcutaneously administered 300 mg dupilumab every 2 weeks (after a 600 mg loading dose) for 24 weeks in Heads Up. Key outcomes included the proportion of patients achieving WP-NRS 0/1, WP-NRS 0, EASI 90, and EASI 100, as well as the proportion of patients achieving composite outcomes (EASI 90 and WP-NRS 0/1; EASI 100 and WP-NRS 0). Patients assessed WP-NRS daily for the first 16 weeks and at scheduled visits thereafter, and investigators assessed EASI at scheduled visits. Results A greater proportion of patients receiving upadacitinib vs placebo and vs dupilumab achieved WP-NRS 0/1 at week 16 (nominal p < 0.001 vs placebo) and week 24 (nominal p < 0.001 vs dupilumab), with differences as early as the day after treatment initiation (day 2; nominal p < 0.05 vs placebo and vs dupilumab), as well as WP-NRS 0 at week 16 (nominal p < 0.001 vs placebo) and week 24 (nominal p < 0.001 vs dupilumab), with differences as early as day 8 (nominal p < 0.01 vs placebo; nominal p < 0.001 vs dupilumab). A greater proportion of patients receiving upadacitinib vs placebo and vs dupilumab achieved EASI 90 at week 16 (p < 0.001 vs dupilumab), with differences as early as week 1 (nominal p < 0.01 vs placebo; nominal p < 0.05 vs dupilumab), as well as EASI 100 at week 16 (p < 0.001 vs placebo) and week 24 (nominal p < 0.001 vs dupilumab), with differences as early as week 4 (nominal p < 0.001 vs placebo and vs dupilumab). A greater proportion of patients also achieved EASI 90 and WP-NRS 0/1 by week 2 (UPA15: 2.7%, UPA30: 6.7% vs placebo: 0%, nominal p < 0.001; UPA30: 7.1% vs dupilumab: 1.2%, nominal p < 0.001) and EASI 100 and WP-NRS 0 by week 4 (UPA15: 1.6%, UPA30: 3.9% vs placebo: 0.2%, nominal p ≤ 0.01; UPA30: 4.7% vs dupilumab: 0.6%, nominal p < 0.01) through all evaluated time points. Conclusions Patients with moderate-to-severe AD treated with upadacitinib rapidly achieved stringent itch improvement and skin clearance targets compared with those receiving placebo or dupilumab, with responses sustained through weeks 16 (Measure Up 1 and Measure Up 2) and 24 (Heads Up). Clinical Trial Registration ClinicalTrials.gov; NCT03569293 (Measure Up 1), NCT03607422 (Measure Up 2), and NCT03738397 (Heads Up).Plain Language Summary Patients with atopic dermatitis, also known as eczema, can have skin signs and symptoms, such as redness, itchiness, and dryness, that affect their quality of life. Patients value treatments that quickly help them achieve little-to-no itch and clear or almost clear skin, but clinical trials are not always designed to use these important treatment goals as targets. This analysis looked at results from three previous clinical studies of people with moderate or severe atopic dermatitis to see if upadacitinib, a tablet taken once a day by mouth, helped patients achieve little-to-no itch and clear or almost clear skin more quickly than placebo or another treatment (dupilumab). The results of this analysis showed that more patients who took upadacitinib had little-to-no itch as soon as the day after they received their first 15 or 30 mg of upadacitinib vs placebo or when they received 30 mg of upadacitinib vs 300 mg of dupilumab. These differences continued to the end of all three studies: 16 weeks vs placebo and 24 weeks vs dupilumab. More patients had clear or almost clear skin with upadacitinib vs placebo and vs dupilumab starting at week 1 of treatment and continuing to the end of all three studies. These findings show that upadacitinib led to rapid itch improvement and clearer skin, two outcomes considered most important by patients with moderate or severe atopic dermatitis
Exploring the experiences of mothers of children with type 1 diabetes in Northern Alberta: a qualitative descriptive study
No full textAbstract Objectives Canada has one of the highest rates of Type 1 diabetes in children. Management of their diabetes and prevention of poor health outcomes often falls on mothers who are often the primary caregiver. The caregiving demands can result in substantial responsibility and stress. Mothers report career sacrifices, sleep deprivation, stress, grief, anxiety, and low mood. While globally Canada has a high rate of type 1 diabetes, studies on the caregiving experience within a Canadian context have not been conducted. This study explored the experiences of mothers of children with type 1 diabetes in northern Alberta, Canada. Methods Utilizing a qualitative descriptive approach, we interviewed 16 mothers (average age = 37.1 ± 6) with children with type 1 diabetes who were under the age of 18. We also drew upon a caregiver engagement in research approach to create a Community Advisory Committee of three mothers of children with diabetes. Advisory members collaborated with us and offered invaluable insight and feedback throughout the study. Results Using reflexive thematic analysis, six interrelated themes were identified: (a) “I am the organ”: a sense of constant vigilance, (b) accepting a new normal, (c) grief underlying a rollercoaster of emotions, (d) caregiving as an isolating experience, (e) the continuous glucose monitor is a champion, and (f) finding the positives. Mothers face constant vigilance and anxiety, often feeling like their child’s “organ” for survival. They view caregiving as an isolating experience with limited understanding and assumptions from people without children with type 1 diabetes. Grief persists several years post diagnosis, intertwined with concerns and worries for the health and future of their children. New routines revolved around caretaking duties result in the acceptance of lifestyle changes and shifts in priorities. Conclusions Caring for a child with type 1 diabetes presents many stressors for mothers. Over time, mothers gain confidence about their abilities as caregivers. They find relief in online networks and access to continuous glucose monitors, which alleviate some anxiety and sleep deprivation but also present challenges. Our findings highlight the importance of improving access to affordable technology, psychological support, and respite care to improve loss of personal time and the need for constant vigilance
Finite Element-Based Machine Learning for Modeling and Prediction of Manufacturing Processes: Applications in Rolling and Milling
No full textThe global transition toward smart manufacturing is increasing the demand for modeling approaches that can estimate process parameters with high accuracy and computational efficiency. Conventional methods, including physical experimentation, empirical or analytical formulations, and finite element (FE) simulations, remain essential but are often costly, time-consuming, or limited in their generalizability. These limitations can hinder rapid process optimization and adaptive decision-making in modern manufacturing. This thesis develops machine learning (ML) frameworks that combine FE simulations with domain knowledge to enhance predictive performance and reduce reliance on repetitive physical testing and large-scale numerical simulations. Two representative processes are investigated in depth: wire rod rolling and milling. In wire rod rolling, a dimensionless ML framework is proposed to predict the lateral spread after each rolling stand which is a critical parameter governing roll-pass design and process optimization. FE simulations are employed to generate a diverse dataset that captures the influence of geometric, material, and process variables. Through a physics-based feature design that ensures dimensionless inputs and outputs, the trained ML models achieve high accuracy and consistent generalization across the studied rolling stands. The results demonstrate that the framework can serve as a transferable and data-efficient alternative to conventional empirical or resource-intensive simulation methods. In milling process, chatter vibrations are a primary barrier to productivity. Manufacturers often adopt conservative cutting conditions to avoid chatter, which limits material removal rates. Although chatter stability lobe analysis can improve performance, its dependence on complex measurements limits its industrial application. This thesis proposes two complementary ML approaches that reduce measurement requirements while maintaining predictive capability. The first develops ML models trained on FE data to estimate milling force coefficients, minimizing the need for table dynamometers and extensive cutting tests. The second introduces an ML-based substructure coupling framework that predicts tool tip dynamics and chatter stability through a combination of simulation data and limited experimental input, allowing rapid tool tuning and selection of stable cutting parameters. Validation results show that both models achieve accurate predictions for their respective tasks
Uncertainty, loss, ambivalence, and connection: Conversations with older adults about social isolation during COVID-19 physical activity program closures
No full textGroup physical activity (PA) creates opportunities for social connection, social support, and regular PA, contributing to older adults’ well-being. Public health restrictions during the COVID-19 pandemic limited in-person programming, which led to social isolation and provided an opportunity to understand the contribution such programmes make to well-being. This study explored older adults’ (≥55 years old) experiences of changes to their PA behaviours, programme participation, and social connections as they transitioned from limited opportunities for in-person PA programming during the pandemic to more opportunities as restrictions eased. The experiences of older adults (N = 29; Mage = 68.14 years) were explored using interviews and analysed using reflexive thematic analysis. Three themes were identified: (a) navigating uncertainty and loss; (b) emotional ambivalence about reconnecting; and (c) heightened awareness of the interconnection between the body, PA, and social connection. Restrictions on PA programmes created a sense of loss as programmes were a source of social connection, leading older adults to cope with adversity in various ways. Eagerness to resume participation was often accompanied by apprehension and hesitancy to re-engage in social settings. When participation resumed, participants had heightened awareness of how their physical abilities could affect their physical and social activity. The loss and isolation participants experienced call attention to the value of qualitative interviews, which provided a meaningful opportunity to share their experiences. While disruptions to group PA programmes had negative implications for many older adults, the uncertainty and loss they experienced reinforced the value of group PA for their well-being.The work was supported by the Brawn Family Foundation
Breaking the Cycle: Mental Health Courts as a Pathway to Treatment
No full textMental health courts are specialized judicial systems designed to divert individuals with mental health issues away from incarceration and toward treatment and rehabilitation. These courts address a critical gap at the intersection of mental health and criminal justice, where individuals with mental health issue are significantly overrepresented. Traditional justice processes often fail to account for the underlying causes of criminal behaviour linked to untreated mental health issues, resulting in high rates of recidivism and worsening mental health outcomes.
By offering a more therapeutic and rehabilitative approach, mental health courts have demonstrated effectiveness in reducing recidivism and improving individual well-being. However, the reliance on courts to redirect individuals into treatment highlights broader systemic failures in Canada’s mental health care system. Mental health issue is in health domain, and ideally, it should be addressed within the health care system before individuals come into contact with the justice system.
To address these systemic issues, this paper presents three key policy recommendations. First, mental health courts should be expanded to provinces and territories where they are not yet established, ensuring equitable access to therapeutic justice across Canada. Second, national guidelines for mental health courts should be developed in collaboration with provincial and territorial governments, mental health experts, and Indigenous communities. These standards would promote consistency while accommodating regional needs and cultural contexts. Third, significant investments are needed in community-based mental health services to ensure individuals receive appropriate care before, during, and after any involvement with the justice system
Political Ecology of Protected Area Governance and Livelihood Concerns vis-à-vis Bengal Tiger Conservation in Bangladesh’s Sundarban Mangroves
No full textThis qualitative political ecology case study analyzes how formal and informal power dynamics shape trade-offs and synergies between protected area conservation politics and local livelihood governance in Bangladesh’s Sundarban mangrove region. Firstly, it explores how discursive framings and policy measures surrounding the narrative constructions of flagship species Bengal tigers create hegemonic rationalities and undermine local social-cultural-historical framings and alternative imaginaries. Secondly, the empirical insights illustrate how unchecked state power and authority can exploit local mangrove dwellers, meddle with rural power dynamics and informal actors in the region, and create a culture of localized corruption and shadow economy in a world of parallel de facto governance. Thirdly, it argues that the protected area governance has resulted in privileged access for rural political-economic actors, rent-creation and extra-legal management opportunities for the local-level state-agency with ever-rising harvesting restrictions, fatalities and pricing competitions for already marginalized forest dwellers. Fourthly, this study reviews Bangladesh’s climate-carbon approach (national REDD+ strategy) as a techno-bureaucratic neoliberal process emerging under strong donor support with implications for carbon co-benefits, social safeguards and co-management in the Sundarban. In summary, this study critiques the intentions and efficacy of the regional protected area model’s multi-layered harvesting bans, stricter enforcement, sanctions, regulatory approach and (under)reporting practices of tiger fatalities as dominant technologies of mangrove governance that create new environmental subjects in a legal-illegal dichotomy. The study concludes with concerns that the protected area framework has become counterproductive in the Sundarban mangroves. Local livelihood governance is plagued by disenfranchisement of mangrove dwellers, their resource access and customary rights, based on extended exploitation built from colonial legacy, fortress-style forest governance and top-down environmental politics of tiger-centric regulations vis-à-vis contrasting de facto material practices on the ground. Highlighting these inherent design flaws in Sundarban’s resource governance, this study recommends a radical shift in discursive and material practices to dismantle the structural inequity and hierarchical power relations and move from band-aid solutions to a system change from within and across the governance to address systemic corruption, historical injustice, multi-faceted livelihood insecurity and conservation challenges in the Sundarban and beyond
Alberta Pre-Service Teachers’ Preparedness for Student Diversity: A Mixed Methods Approach Informed by Critical Race Theory
No full textThe study “Alberta Pre-Service Teachers’ Preparedness for Student Diversity: A Mixed Methods Approach Informed by Critical Race Theory” attempts to clarify Alberta B.Ed. (secondary school) pre-service teacher candidates’ perception of preparedness for the challenges of working with English Language Learners (ELLs). Applying critical race theory (CRT), as well as the related racial literacy, the study poses the research question: How prepared are White pre-service teachers and non-White / mixed-race pre-service teachers (according to participants’ self-identification) respectively, to meet the needs of ELLS? Twenty-nine Alberta B.Ed. candidates participated in a survey that elicited their CRT and racial literacy-related values; six of these candidates completed interviews. The research process was thus mixed methods—a mainly quantitative survey, and qualitative semi-structured interviews. Each survey item, including selected participant comments, is included, as are each interview question and relevant responses to them. My findings show that Alberta pre-service teachers’ values are in general accordance with both CRT and, even more so, with racial literacy (particularly in the case of English / Social Studies teachers). Certain items had higher accordance with the values of White participants or with non-White / mixed-race participants. Stemming from the interviews, specific challenges and strategies used in working with ELLs were noted by participants, including classroom translation and the values of patience and compassion. Only half of participants received advice from mentor teachers about how to work with ELLs; despite this, participants expressed surprising confidence in their own abilities to do so. I conclude by offering suggestions about the future of teacher training in Alberta in view of ELLs
Optimal cerebrovascular reactivity thresholds for the determination of individualized intracranial pressure thresholds in traumatic brain injury: a CAHR-TBI cohort study
No full textAbstract It has been demonstrated that patient-specific intracranial pressure (ICP) thresholds are possible to derive using the function intersectionality between ICP and cerebrovascular reactivity (CVR). Such individualized ICP (iICP) thresholds represent a potential personalized medicine approach to neurocritical care management. However, it is currently unknown how various CVR thresholds compare in regard to deriving iICP. Here we attempt to identify the CVR thresholds that are best suited for iICP derivation. Leveraging 365 patient data sets from the CAnadian High-Resolution TBI (CAHR-TBI) Research Collaborative, iICP was derived using three ICP-based CVR indices: the pressure reactivity index (PRx); the pulse amplitude index (PAx); and the RAC index, and thresholds ranging from − 1 to + 1, in 0.05 increments. Patients were dichotomized based on 6-month outcome scores into Alive vs. Dead and Favorable vs. Unfavorable outcome. 2 × 2 tables were created for each threshold, grouping patients by outcome and whether their mean ICP was greater or less than their calculated iICP. Chi-squares were calculated for each table and subsequently plotted. The thresholds that produced the largest Chi-square values were identified as those able to derive the iICP with the greatest ability to predict outcomes. Next, Spearman rank correlation testing was used to evaluate associations between iICP, for each threshold, and measures of cerebral physiologic insult burden. With consideration of yield data, ability to predict outcome, and association with cerebral physiologic insult burden, a threshold of + 0.05 was identified for PRx. No optimal threshold could be identified for PAx or RAC