Research ArticleOriginal Research

Health TAPESTRY Ontario: A Multi-Site Randomized Controlled Trial Testing Implementation and Reproducibility

Dee Mangin, Larkin Lamarche, Doug Oliver, Gord Blackhouse, Sivan Bomze, Sayem Borhan, Tracey Carr, Rebecca Clark, Julie Datta, Lisa Dolovich, Jessica Gaber, Pamela Forsyth, Michelle Howard, Sarah Marentette-Brown, Cathy Risdon, Samina Talat, Jean-Éric Tarride, Lehana Thabane, Ruta Valaitis and David Price
The Annals of Family Medicine March 2023, 21 (2) 132-142; DOI: https://doi.org/10.1370/afm.2944

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    CONSORT flow diagram of participants.

    CONSORT = consolidated standards of reporting trials.

    a All randomized individuals were included in the intention-to-treat analysis even if they did not receive follow-up.

Tables

  • Table 1.

    Comparison of Interpretation and Implementation of Initial and Current Trials

    Attribute of ImplementationInterpretation & Implementation: Initial TrialInterpretation & Implementation: Current Trial
    Core elements of the Health TAPESTRY intervention
    Trained community volunteers

    • Volunteers were age 18 years or in university

    • Volunteers were coordinated by 1 dedicated Volunteer Coordinator at a local nonprofit senior center

    • Volunteers ranged in age, and visited patients in younger-older pairs when possible

    • Volunteers were trained with a standard presentation and practice session that included use of standardized patients, and an online Virtual Learning Centre with video and quiz modules. Ongoing learning included Lunch and Learn sessions of interest or identified need to volunteers.

    • Volunteers had same age criteria

    • Across the 6 sites, there were 5 dedicated Volunteer Coordinators, 4 employed by a national organization and 1 (who managed 2 sites) by a local nonprofit

    • Volunteers ranged in age, visited patients in pairs, without specific age pairings

    • Volunteers were trained with a standard presentation (altered slightly by site) and practice session that included role play, and an online Virtual Learning Centre with video and quiz modules. Ongoing learning was the same as initial trial.

    Interprofessional primary health care teams

    • 2 clinical sites of 1 well-resourced FHT took part

    • Huddle teams ranged in size during the implementation: 1 site had approximately 7 members, the other had approximately 4

    • A research team member joined the huddle to keep the teams up to date on the intervention

    • 6 individual FHTs took part (including the group from the initial trial)

    • Huddle teams ranged in size (3-8 members) based on clinical resources and capacity (described in Supplemental Table 1)

    • No research team member joined the huddle

    Technology

    • Used the initial version of the TAP-App (TAP-App 1.0)

    • Volunteer Coordinators set volunteer visits with the TAP-App

    • Volunteers entered patient survey data into the TAP-App

    • TAP-App automatically created TAP-Reports which were uploaded to the huddle team and primary care team members EMR inboxes

    • Used the same TAP-App (TAP-App 1.0)

    • Volunteer Coordinators set visits in the same way

    • Volunteers entered patient survey data the same way

    • The TAP-App automatically created TAP-Reports and sent them to a care provider dashboard where they could view and download the reports

    Community engagement and connections

    • List of community-based health and social services was created for the 1 community

    • Health team members and volunteers were encouraged to help connect patients to community services

    • Lists of community-based health and social services were created for each community

    • Health team members were encouraged to help patients connect to community services, and volunteers were in most communities

    Additional contextual elements
    Community setting

    • Took place in 1 community

    • Took place in 6 communities across Ontario (including the initial community)

    Program structure

    • Volunteers conducted home visits for the initial surveys, then did a follow-up visit with more surveys 3 months later

    • Research outcomes were collected by the research team

    • Volunteers conducted home visits for the initial surveys, then did a follow-up visit with more surveys 6 months later

    • Research outcomes were collected by the volunteers

    • EMR = electronic medical record; FHT = family health team; TAP-App = web-based application on a tablet computer; TAP-Reports = reports automatically generated by the TAP-App and transmitted to clinics.

  • Table 2.

    Baseline Characteristics of Participants by Group

    CharacteristicInterventionControl
    Age, mean (SD), ya  77.5 (5.8)  77.5 (5.9)
    Female, No. (%)b153 (62.7)161 (67.6)
    European or White ethnicity, No. (%)c,d224 (92.6)217 (91.6)
    Marital status, No. (%)b
      Married or common law119 (48.8)112 (47.1)
      Divorced, separated, widowed, never married125 (51.2)126 (52.9)
    Household income, No. (%)e
      ≤$20,000  19 (8.6)  23 (10.4)
      $20,001 to $50,000  92 (41.4)  97 (43.7)
      $50,001 to $70,000  50 (22.5)  47 (21.2)
      $70,001 to $100,000  35 (15.8)  36 (16.2)
      $100,001 to $150,000  19 (8.6)  13 (5.9)
      >$150,000    7 (3.2)    6 (2.7)
    Charlson Comorbidity Indexf, mean (SD)a 1.3 (1.7) 1.5 (1.6)
    Asthmag chronic lung disease, chronic bronchitis, or emphysema, No. (%)h  43 (17.7)  40 (16.7)
    Cancer,g No. (%)h  40 (16.5)  43 (17.9)
    Diabetes,g No. (%)i  34 (14.1)  37 (15.5)

    • Note: Charlson Comorbidity Index range from 0-29, with higher scores representing higher comorbidity burden.

    • ↵a Intervention group n = 257, control n = 255

    • ↵b Intervention group n = 244, control n = 238

    • ↵c Intervention group n = 242, control n = 237

    • ↵d Black, Indigenous, and other people of color were under represented.

    • ↵e Intervention group n= 222, control n = 222

    • ↵f Obtained from chart audits, not self-report

    • ↵g The 3 most prevalent comorbidities, not a complete list

    • ↵h Intervention group n= 243, control n = 240

    • ↵i Intervention group n = 241, control n = 239

  • Table 3.

    Patient-Reported and Health Care Utilization Outcomes Related to Effectiveness

    VariableIntervention (n = 257)Control (n = 255)Effect Estimate (95% CI)
    Baseline6-MonthBaseline6-Month
    No. hospitalizations, mean (SD)a0.14 (0.45)0.13 (0.44)0.18 (0.50)0.17 (0.43)IRR = 0.79 (0.48-1.30)
    Total physical activity, median (Q1, Q3), mina1,646 (692, 3,329)1,386 (558, 2,592)1,689 (693, 3,261)1,278 (438, 3,013)MD = −0.26 (−1.18 to 0.67)
    No. ED or urgent care visits, mean (SD)0.33 (0.99)0.30 (1.12)0.26 (0.59)0.19 (0.55)IRR = 1.18 (0.74-1.88)
    No. primary care visits, mean (SD)3.49 (3.49)4.51 (3.68)3.47 (2.92)3.63 (3.16)IRR = 1.18 (1.01-1.37)b
    No. medications, mean (SD)4.54 (3.51)4.63 (3.93)4.48 (3.55)4.54 (3.50)IRR = 0.99 (0.91-1.09)
    Walking, median (Q1, Q3), min225 (90, 420)210 (90, 420)210 (103, 420)180 (90, 420)MD = −0.21 (−0.44 to 0.03)c
    Sitting, median (Q1, Q3), h6 (5, 9)7 (5, 10)6 (5, 8)6 (5, 8)MD = 0.08 (−0.01 to 0.16)c
    Moderate-vigorous physical activity, median (Q1, Q3), min1,160 (555, 2,310)960 (480, 1,680)1,260 (620, 2,160)1,060 (480, 1,935)MD = −0.02 (−0.83 to 0.80)d
    Patient enablement score, mean (SD)3.86 (3.60)2.89 (3.39)3.36 (3.38)2.58 (3.29)MD = 0.13 (−0.41 to 0.67)
    Quality of life score, mean (SD)0.79 (0.17)0.79 (0.18)0.78 (0.17)0.79 (0.17)MD = −0.01 (−0.03 to 0.02)
    Treatment burden score, median (Q1, Q3)0 (0, 5)0 (0, 5)2.5 (0.0, 7.5)0 (0, 5))MD = 0.10 (−0.14 to 0.34)
    Disease burden score, median (Q1, Q3)7 (4, 11)7 (4, 12)9 (5, 14)7 (4, 12)MD = 0.05 (−0.10 to 0.20)
    No. falls, mean (SD)0.06 (0.23)0.09 (0.32)0.08 (0.27)0.05 (0.22)IRR = 1.73 (0.84-3.56)

    • ED = emergency department; IRR = incidence rate ratio; MD = mean difference; MET = metabolic equivalent of task; Q1 = first interquartile range point; Q3 = third interquartile range point.

    • Note: Physical activity reported in MET minutes. Patient enablement scores ranged from 0-12; higher scores represent higher patient enablement or better ability to cope with or have control over their health as a result of health visits. Quality of life scores ranged from -0.148 to 0.949; higher scores represent higher quality of life. Treatment burden scores ranged from 0-100; higher scores represent higher burden (ie, a patient’s effort needed to take care of oneself). Disease burden scores ranged from 0-130; higher scores represent higher burden (ie, burden of multimorbidity).

    • ↵a Co-primary outcomes

    • ↵b P <.005

    • ↵c Log transformed data

    • ↵d Cube-root transformed data

  • Table 4.

    Sensitivity Analysis (Efficacy): Co-Primary Outcomes at the Lead Implementation Site

    VariableIntervention (n = 100)Control (n = 104)
    Baseline6-MonthBaseline6-Month
    No. hospitalizations, mean (SD)0.21 (0.58)0.09 (0.36)0.12 (0.36)0.16 (0.43)
    ED or urgent care visits, mean (SD)0.30 (0.97)0.10 (0.37)0.22 (0.54)0.23 (0.54)
    No. primary care visits, mean (SD)2.76 (3.39)3.64 (3.15)3.41 (2.97)3.49 (3.13)
    Total physical activity, median (Q1, Q3)a1,724 (642, 3,199)1,733 (570, 2,813)1,386 (695, 3,013)1,980 (528, 3,721)
    Quality of life score, mean (SD)0.80 (0.15)0.82 (0.14)0.81 (0.15)0.81 (0.17)

    • ED = emergency department; MET = metabolic equivalent of task; Q1 = first interquartile range point; Q3 = third interquartile range point.

    • Note: The lead implementation site recruited a larger portion than intended of the sample due to low recruitment at other sites.

    • ↵a Physical activity is in MET minutes.

  • Table 5.

    Descriptions of the 6 Participating FHTs and Key Outcomes Across Ontario

    CharacteristicMcMaster FHTNiagara North FHT
    Urban/rural (rostera size, No.)Urban (35,000)Rural (15,000)
    Co-location of cliniciansYesNo
    ControlInterventionControlIntervention
    Months    0    6    0    6    0    6    0    6
    No. hospitalizations, mean (SD)    0.12
        (0.36)    		    0.16
        (0.43)    		    0.21
        (0.58)    		    0.09
        (0.36)    		    0.16
        (0.37)    		    0.06
        (0.24)    		    0.19
        (0.51)    		    0.11
        (0.32)
    No. ED or urgent care visits, mean (SD)    0.22
        (0.54)    		    0.23
        (0.54)    		    0.30
        (0.97)    		    0.10
        (0.37)    		    0.32
        (0.67)    		    0.06
        (0.24)    		    0.38
        (0.59)    		    0.44
        (1.25)
    No. primary care visits, mean (SD)    3.41
        (2.97)    		    3.49
        (3.13)    		    2.76
        (3.39)    		    3.64
        (3.15)    		    3.42
        (2.67)    		    3.61
        (3.52)    		    4.32
        (2.96)    		    5.67
        (3.34)
    Total physical activity, median (Q1, Q3), MET min1,386
    (695, 3,013)    		1,980
    (528, 3,721)    		1,724
    (642, 3,199)    		1,733
    (5.0, 2,813)    		1,782
    (231, 4,286)    		661
    (378, 1,662)    		2,420
    (696, 3,950)    		1,134
    (762, 1,831)
    CharacteristicSuperior FHTWindsor FHT
    Urban/rural (rostera size, No.)Rural (7,300)Urban (6,300)
    Co-location of cliniciansYesYes
    ControlInterventionControlIntervention
    Months    0    6    0    6    0    6    0    6
    No. hospitalizations, mean (SD)    0.08
        (0.28)    		    0.36
        (0.81)    		    0.27
        (0.59)    		    0.07
        (0.27)    		    0.06
        (0.24)    		    0.06
        (0.24)    		    0.04
        (0.20)    		    0.04
        (0.20)
    No. ED or urgent care visits, mean (SD)    0.54
        (0.78)    		    0.27
        (0.90)    		    0.80
        (1.61)    		    1.43
        (3.72)    		    0.06
        (0.24)    		    0.00
        (0.00)    		    0.12
        (0.33)    		    0.12
        (0.33)
    No. primary care visits, mean (SD)    3.15
        (1.68)    		    3.36
        (3.07)    		    5.93
        (4.17)    		    6.57
        (4.24)    		    3.44
        (2.42)    		    3.50
        (2.68)    		    3.76
        (2.67)    		    4.15
        (3.07)
    Total physical activity, median (Q1, Q3), MET min431
    (201, 1,299)    		750
    (314, 1,033)    		1,371
    (668, 2,845)    		990
    (570, 1,404)    		1,386
    (585, 3,592)    		1,169
    (495, 3,049)    		1,878
    (864, 3,252)    		1,289
    (553, 2,237)
    CharacteristicHarrow Health CentreDufferin Area FHT
    Urban/rural (rostera size, No.)Rural (6,400)Rural (47,000)
    Co-location of cliniciansYesNo
    ControlInterventionControlIntervention
    Months    0    6    0    6    0    6    0    6
    No. hospitalizations, mean (SD)    0.19
        (0.47)    		    0.19
        (0.47)    		    0.03
        (0.17)    		    0.24
        (0.75)    		    0.33
        (0.76)    		    0.20
        (0.40)    		    0.09
        (0.30)    		    0.19
        (0.45)
    No. ED or urgent care visits, mean (SD)    0.19
        (0.52)    		    0.03
        (0.18)    		    0.18
        (0.46)    		    0.21
        (0.48)    		    0.34
        (0.66)    		    0.30
        (0.71)    		    0.45
        (1.34)    		    0.46
        (0.85)
    No. primary care visits, mean (SD)    3.47
        (2.67)    		    4.31
        (3.18)    		    3.56
        (3.29)    		    4.24
        (3.26)    		    3.68
        (3.46)    		    3.55
        (3.30)    		    3.58
        (3.84)    		    5.42
        (4.62)
    Total physical activity, median (Q1, Q3), MET min3,066
    (892, 3,686)    		1,257
    (332, 2,867)    		2,172
    (1,186, 4,066)    		1,413
    (657, 2,300)    		2,329
    (1,081, 3,166)    		1,075
    (619, 2,397)    		1,169
    (674, 2,453)    		992
    (367, 2,371)

    • ED = emergency department; FHT = family health team; MET = metabolic equivalent of task; Q1 = first interquartile range point; Q3 = third interquartile range point.

    • ↵a Roster = number of patients registered with a physician within the primary care practice regardless of age.

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