2019 of Medicine Review - Find out about the new ARCH Calgary program at PLC.

2019 of Medicine Review - Find out about the new ARCH Calgary program at PLC.
2019                   Review

       of Medicine

       Find out
       about the
       new ARCH
       at PLC.

2019 of Medicine Review - Find out about the new ARCH Calgary program at PLC.
2019 Review                                                                                                                    DIVISION
                                                                        DEPARTMENT OF MEDICINE                                                                                                         PROFILES
                                                                        UNIVERSITY OF CALGARY AND
                                                                        ALBERTA HEALTH SERVICES                                                                                                        Message from
                                                                                                                                                                                                       Department Head

                                                                        2018-19 REPORT                                                                                                                 PAGE


                                                                                                                                                                                                       Endocrinology & Metabolism

                                                                        “We have worked hard to provide                                                      44,069 outpatient clinical               Gastroenterology &
                                                                                                                                                              referrals received by Central
                                                                          reports and information that highlight                                              Access & Triage (CAT).

                                                                          the Department's important clinical,                                                PAGE                                     General Internal Medicine
                                                                                                                                                              60                                       PAGE

                                                                          educational, academic, and administrative                                                                                    68
                                                                          activities and accomplishments in the                                               PHYSICIAN PROFILES                       Geriatric Medicine
                                                                                                                                                              Meet two members of the Department       PAGE

                                                                          2018-19 Fiscal Year.”                                                               of Medicine, Dr. Jane Lemaire and        70
                                                                        Dr. Richard Leigh                                                                     Dr. Habib Kurwa, and see how each,       Hematology & Hematological
                                                                        Professor and Head, Department of Medicine                                            in their own ways, are working to        Malignancies
                                                                                                                                                              improve health care for all Albertans.


                                                                                                                                                              36                                       Infectious Diseases


                                                                                                                  RE-THINKING HOW WE                          QUALITY IMPROVEMENT                      Nephrology
                                                                                                                  PROVIDE CARE                                INITIATIVES                              PAGE

                                                                                                                  Learn about several collaborative,          In 2018-19, many of our Divisions        76
                                                                                                                  multidisciplinary programs that             collaborated with Primary Care           Respiratory Medicine
                                                                        $29,991,365.87 in total                   provide care outside of a traditional       and Strategic Clinical Networks on       PAGE

                                                                        annual research revenue,                  health care or hospital setting,            QI initiatives. The changes made         78
                                                                                                                  tailor care to meet patients’ specific      because of these initiatives have        Rheumatology
                                                                        including $6.88 Million in
                                                                                                                  needs, and meet patients ‘where             allowed the Department to provide        PAGE

                                                                        CIHR revenue and $16 Million              they’re at’.                                better, and more timely care for         80
                                                                        in clinical research revenue.             PAGE
                                                                                                                                                              all Albertans.                           Our Community
                                                                                                                  4                                                                                    PAGE

                                                                        PAGE                                                                                  PAGE

                                                                        58                                                                                    46

                                                                                                                  INNOVATIONS IN
                                                                                                                  CLINICAL RESEARCH                                                                    OPERATIONS
                                                                                                                  From ‘bench to bedside’: Find out                                                    Department Organization

             The Department of            Foothills Medical Centre
             Medicine is located in the   (FMC) and UCalgary
                                                                                                                  about some of our recent innova-
                                                                                                                  tions in clinical research and how
                                                                                                                                                              The Department of Medicine               86
                                                                                                                                                              consists of 431 primary
scope        Alberta Health Services
             – Calgary Zone and at
                                          Foothills Campus, Peter
                                          Lougheed Centre (PLC)
                                                                                                                  Department of Medicine members
                                                                                                                  are working to improve the health           members and 66 cross-
                                                                                                                                                                                                       Department Demographics

             the Cumming School of        and Sunridge Landing,         PARENT ORGANIZATIONS                      and lives of Albertans.                     appointed members.
             Medicine, University of      Rockyview General Hospital    The Department of Medicine exists as                                                                                           Awards
                                                                                                                  PAGE                                        PAGE

             Calgary. The Department      (RGH), South Health           a Department within both Alberta Health
                                                                        Services (AHS) and the University
                                                                                                                  24                                          88                                       PAGE

             serves a catchment of        Campus (SHC), Richmond
             2.4 million residents        Road Diagnostic and           of Calgary (UCalgary). To reflect this                                                                                         Patient Data
             of Southern Alberta,         Treatment Centre (RRDTC),     unique dual-organizational structure,     “Physician wellness is when you’re not                                              PAGE

                                                                        both AHS’ and the UCalgary’s logos                                                                                             92
             Southeastern British
             Columbia and Southwestern
                                          Sheldon M. Chumir Health
                                          Centre, and the Associate     and colour palettes are featured in
                                                                                                                    just surviving in your work, but you’re
             Saskatchewan. Department     Clinic, Gulf Canada Square.   balance throughout this Report.             thriving in your work, so that you can be                                          PAGE

             Members are located at                                                                                                                                                                    93
             7 medical sites across                                                                                 at your very best and deliver excellent                                            Revenue
             Calgary, including the
                                                                                                                    patient care. Because that’s really what                                           PAGE

                                                                                                                    our work is as physicians.”                                                        Physician List
                                                                                                                  Dr. Jane Lemaire
                                                                                                                  Vice Chair, Physician Wellness & Vitality

2019 of Medicine Review - Find out about the new ARCH Calgary program at PLC.
                                                                                                                                                the next
                                                                                                                                                Our Mandate is to identify
                                                                                                                                                and mentor trainees who
                                                                                                                                                have potential to become
                                                                                                                                                academic leaders in
                                                                                                                                                medicine and related fields:
                             powerful        One of the core tenets of
                                             the Department of Medicine
                                                                           and Oncology, as well
                                                                           as with the six Calgary
                                                                                                                                                identify them, mentor and
                                                                                                                                                support them, provide them
                             partnerships    is that collaborative,
                                             multidisciplinary teams
                                                                           and Area Primary Care
                                                                           Networks (PCNs). Our
                                                                                                                                                with the opportunities to be
                                                                                                                                                competitive for academic
                                             are essential for providing   members are also exten-
                                                                                                                                                faculty positions, and ulti-
                                             outstanding medical care      sively involved within
                                                                                                                                                mately recruit them as the
                                             to all Albertans. We have     Alberta Health Services’
                                                                                                                                                medical leaders of tomorrow.
                                             close working relationships   sixteen provincial Strategic
                                             with other Departments,       Clinical Networks (SCNs).
                                             including Community
                                             Health, Cardiac Sciences,

6 THINGS YOU                                                                                                                                                                              impactful           Department Members             as well as within W21C,
                                                                                                                                                                                                              conduct world-class            a research and innova-

                                                                                                                                                                                          research            translational and health       tion initiative based in the

                                                                                                                                                                                                              outcomes research              University of Calgary and
                                                                                                                                                                                                              within all seven Research      Calgary Zone of Alberta
                                                                                                                                                                                                              Institutes at the University   Health Services.

ABOUT THE                                                                                                                                                                                                     of Calgary’s Cumming
                                                                                                                                                                                                              School of Medicine

OF MEDICINE                                                                                                                      innovation     In collaboration and
                                                                                                                                                partnership with PCNs
                                                                                                                                                                                Other innovative programs
                                                                                                                                                                                we have developed include

                                                                                                                                 to improve     and SCNs, the Department
                                                                                                                                                has established numerous
                                                                                                                                                                                the Geriatrics Fracture
                                                                                                                                                                                Liaison Service, COPD

                                                                                                                                 patient care   Clinical Care Pathways and
                                                                                                                                                Specialist Link services,
                                                                                                                                                                                Initiative, Lung Cancer
                                                                                                                                                                                Screening Program, Home
                                                                                                                                                which have reduced wait         Dialysis Program, Diabetes
                                                                                                                                                lists for specialist services   in Pregnancy Clinic, Health
                                                                                                                                                and allowed more patients       Analytics Working Group
                                                                                                                                                to receive quality care in      (HAWG), and the Calgary
                                                                                                                                                the medical home.               Zone Medical Services
                                                                                                                                                                                Clinical Safety Committee

                                            improving            Our members are
                                                                 committed to improving
                                                                                                 both lead innovative clinical
                                                                                                 and research programs to

                                            public               Public Health for the benefit
                                                                 of all Albertans. Dr. John
                                                                                                 improve patient care for
                                                                                                 vulnerable populations,

                                            health               Conly, who is the current
                                                                 Medical Director for W21C
                                                                                                 including refugees and
                                                                                                 patients with substance
                                                                 and former Head of the          use disorders. Dr. Cheryl
                                                                 Department of Medicine,         Barnabe, Vice Chair of
                                                                 conducts groundbreaking         Indigenous Health in the
                                                                 research on antimicrobial       Department of Medicine,
                                                                 resistance and stewardship.     is helping to drive work to
                                                                 Dr. William Ghali is the        improve health outcomes
                                                                 Institute Director for
                                                                 the O’Brien Institute for
                                                                                                 for Indigenous patients.
                                                                                                                                                   our                          We are one of the
                                                                                                                                                                                largest Departments in
                                                                                                                                                                                                              appointments in the
                                                                                                                                                                                                              Department of Medicine
                                                                 Public Health. Drs. Gabriel
                                                                 Fabreau and Prabh Lail                                                            membership                   the Cumming School of
                                                                                                                                                                                Medicine and Calgary
                                                                                                                                                                                                              or Division of Cardiology
                                                                                                                                                                                                              (Cardiac Sciences),
                                                                                                                                                                                Zone, and have grown to       and 66 members with
                                                                                                                                                                                just under 500 members        cross-appointments to the
                                                                                                                                                                                in 2018-19, including 431     Department of Medicine.
                                                                                                                                                                                members with primary

2   DEPARTMENT OF MEDICINE                                                                                                                                                                                                                                 2018-19 ANNUAL REPORT   3

                                       roviding health care to
                                                                                                                                                              Dr. Parabhdeep (Prabh) Lail               THE PATIENT NEARLY DIES. He or she
                                                                                                                                                              General Internal Medicine Specialist,
                                                                                                                                                                                                      is admitted to hospital with complica-
                                                                                                                                                              Medical Director, Addiction Recovery
                                                                                                                                                              and Community Health (ARCH) Calgary     tions from liver disease. They have

                                       thousands of Calgarians is a
                                                                                                                                                                                                      gastrointestinal bleeding with massive
                                                                                                                                                                                                      varices—veins that are enlarged and
                                                                                                                                                              ADDICTION                               swollen. The patient is resuscitated,

                                       huge and complex undertaking.                                                                                          RECOVERY AND
                                                                                                                                                                                                      the varices are banded and appropriate
                                                                                                                                                                                                      medication is administered.

                                                                                                                                                              COMMUNITY                                   When the clinician digs deeper

                              The Department of Medicine, AHS, and                                                                                            HEALTH (ARCH)
                                                                                                                                                                                                      to explore the cause of the liver
                                                                                                                                                                                                      disease, they may find the patient
                                                                                                                                                                                                      has longstanding alcohol use disorder.

       Dr. Parabdheep
       (Prabh) Lail           UCalgary are constantly working together                                                                                        AT PLC
                                                                                                                                                              Delivering front-line acute care
                                                                                                                                                                                                      In that case, the doctor will likely tell
                                                                                                                                                                                                      the patient to stop drinking or face
                                                                                                                                                                                                      certain death. But Dr. Prabh Lail

                              to find ways to improve how to provide
       Dr. Karmon Helmle
       Dr. Julie McKeen                                                                                                                                                                               says the patient needs more than a
                                                                                                                                                              is demanding work, and it’s
       Dr. Michelle Grinman                                                                                                                                                                           directive, they need counselling and
       Olive Wiley
                                                                                                                                                              an extra challenge to provide           information on treatment options in
       Winnie Smith
       (patient)              better care.                                                                                                                    support for the many patients
                                                                                                                                                              who suffer from addictions.
                                                                                                                                                              Now, a special team at the
                                                                                                                                                                                                      order to stop drinking.
                                                                                                                                                                                                          That’s where the new Addiction
                                                                                                                                                                                                      Recovery and Community Health
                                                                                                                                                              Peter Lougheed Center is                (ARCH) consultation service comes in.
       Endocrinology &
                              In some cases, change starts when one individual person               And you’ll read about a program that serves to bridge                                                 “Often the reason for admission or
                                                                                                                                                              helping give wraparound care
       General Internal
                              who is paying close attention notices a gap in care for their     acute care hospitals with people in the community who need                                            a hospital visit is a consequence of or
       Medicine                                                                                                                                               to patients with addictions.            directly because of a substance use
                              patients. In this chapter you will read about how a resident in   lower acuity care, by bringing hospital-quality care home.
                              the Department started asking questions that led, eventually,         We are dedicated to providing health care that supports                                           disorder. There has been very little being
                              to scores of people from the Department, AHS and UCalgary         the entire person—not just a single illness or condition.                                             offered in acute care for these patients,
                              working together to close that gap and dramatically improve       To ensure we do this we work collaboratively; bringing                                                so there certainly was a gap,” says
                              care for people with diabetes who are admitted to hospital.       different disciplines and partners together to develop new                                            Lail, the medical director of the ARCH
                                  Sometimes we start to re-think the way we’ve always           programs that provide better care in the hospital and                                                 program at Calgary’s Peter Lougheed
                              done things when we see colleagues outside our jurisdiction       beyond into the community.                                                                            Centre, a specialist in substance
                              making changes and improving care by finding new ways to                                                                                                                use disorders and a former Canada
                              tackle old problems. In this chapter we also bring you a story                                                                                                          Addiction Medicine Research Fellow.
                              about a new team that’s emulating a program that began
                              in Edmonton to provide wraparound care to people with
                              addictions who are admitted to the Peter Lougheed Centre.

4   DEPARTMENT OF MEDICINE                                                                                                                                                                                          2018-19 ANNUAL REPORT      5
“In terms of
                                                                                                                                                                 room visits,
                                                                                                                                                                 one-third of
                                                                                                                                                                 not more—
                                                                                                                                                                 have some sort
                                                                                                                                                                 of substance
                                                                                                                                                                 use disorder.”
                                                                                                                                                               Dr. Prabh Lail

    ARCH has operated at the Royal        harm reduction and creating efficien-       workers, especially in cases where a          PREVIOUS PAGE
                                                                                                                                    Peer Support Worker
Alexandra Hospital in Edmonton since      cies in the system by improving health      patient’s immediate needs are housing
                                                                                                                                    Catherine MacAllister
2014 as part of the Inner City Health     outcomes and health care access.            and food. Many patients don’t even
                                                                                                                                    takes Kari High, a
and Wellness Program. It launched in      “Addiction is a disease that doesn’t dis-   have photo identification.                    patient in the ARCH
Calgary in November 2018 and has a        criminate,” says Lail. “Anyone from any         Lail says many of her colleagues are      Calgary program,
team of 12 physicians on rotation, two    socio-economic background can have          eager to learn more about ARCH while          outside for a coffee
                                                                                                                                    and conversation in the
social workers, two addictions coun-      a substance use disorder and they can       others may be critical of the service
                                                                                                                                    sunshine – part of the
sellors, two peer support workers, an     end up being very vulnerable.” ARCH         and its patients. “We try to have open
                                                                                                                                    “full wrap-around care”
outreach worker, a nurse practitioner,    patients may also be socially vulnera-      and honest conversations, no matter           that ARCH provides.
a registered nurse, a clinical nurse      ble; many are homeless.                     how difficult they are, with the goal of
                                                                                                                                    PAGE 6
educator, an administrative assistant,        ARCH provides what Lail calls           educating and working towards a culture
                                                                                                                                    Top left:
and a pharmacist.                         “full wrap-around care.” It starts with     change that needs to happen in acute          Dr. Prabh Lail, the
    Demand for the ARCH’s services        ensuring basic patient needs are met:       care.” Lail and her team are working on       Medical Director for the
has been steady. “We have seen close      food, clothing and shelter. The next        breaking down the considerable stigma         ARCH Calgary program,
                                                                                                                                    speaks with Catherine
to 1,000 patients at our site alone. It   step is inquiring about housing status      surrounding addictions, one patient and
                                                                                                                                    MacAllister. The ARCH
motivates me to think that we certainly   and testing for sexually transmitted        one conversation at a time.
                                                                                                                                    Team meets for rounds
need to expand this to other sites as     infections, diabetes and dyslipidemia           ARCH has become a vital resource          every day to review
well,” she says. “When we think of the    (abnormal levels of lipids in the blood),   in Alberta, particularly in light of the      patients currently in
visits to emergency rooms, on average     screening for colon cancer and pap          rising fentanyl crisis—front-line staff are   the program.

one-third of patients—maybe more—         smears for women.                           seeing cases of opioid use disorder and       Bottom left:
also have addiction issues.”                  Intake forms are completed along        related issues more frequently than ever      All patients in the
    ARCH sees people with addictions      with full assessments of substances,        before. Lail is hoping to dedicate time to    ARCH Program receive
                                                                                                                                    Naloxone Kits. These
from every walk of life; focusing on      primarily alcohol, tobacco, opioids,        training more clinicians in addictions so
                                                                                                                                    kits are available free
                                          cannabis, stimulants and benzodiazap-       ARCH is able to expand across Calgary
                                                                                                                                    of charge to anyone at
                                          ines—depressant drugs that include          and help more patients once they leave        risk of opioid overdose.
                                          sleeping pills and tranquilizers. This      the hospital; preventing readmissions         Family and friends can
                                          assessment helps the ARCH team know         and medical complications.                    also get a kit.

                                          what they’re dealing with in terms of           “The philosophy of our program
                                          intoxication and withdrawal symptoms.       is to meet patients where they’re at,”
                                              Nurses initiate many of the consul-     says Lail. “We don’t set the goal for
                                          tations because they’re on the front        the patient. We work with patients to
                                          line and recognize when patients with       set their goals and we support them
                                          substance use issues would benefit          in achieving those goals.”
                                          from ARCH services. Addictions coun-
                                          sellors become involved as do social

6      DEPARTMENT OF MEDICINE                                                                                                                                            2018-19 ANNUAL REPORT   7
“Addiction      “There was very
                                                                                                                                                                                       is a disease     little being
                                                                                                                                                                                       that doesn’t     offered in acute
                                                                                                                                                                                       discriminate.” care for these
                             PROVIDING SUPPORT                                                   PREVIOUS PAGE
                                                                                                 Top right:
                                                                                                                            Bottom right:
                                                                                                                            Drs. Prabh Lail and Kate
                                                                                                                                                         PAGE 8 AND 9
                                                                                                                                                         Brad Johnson and
                                                                                                                                                                                      Dr. Prabh Lail
                                                                                                                                                                                                        patients so
                                                                                                                                                                                                        there certainly
                             Brad Morrison is one                Instead, everyone who           In the Emergency           Colizza review the list      Dr. Prabh Lail visit with

                             of the ARCH support              comes through the ARCH             Department, Dr. Kate       of consult requests for      James Galant, another
                                                              program receives wrap-             Colizza, ARCH Assistant    patients with substance      patient who is bene-
                             workers who meets
                             with and helps people
                             who have addictions
                                                              around care. And the peer
                                                              support workers play a
                                                              pivotal role in that care;
                                                                                                 Medical Director, speaks
                                                                                                 with Brad Morrison,
                                                                                                 the program’s other
                                                                                                                            use issues who would
                                                                                                                            benefit from ARCH
                                                                                                                            services. Many of these
                                                                                                                                                         fitting from the ARCH
                                                                                                                                                         Calgary program.
                                                                                                                                                                                                        was a gap.”
                                                                                                 Peer Support Worker,       consult requests are
                                                                                                                                                                                                        Dr. Prabh Lail
                             when they’re admitted            acting as a trusted bridge         while Kai Johnson, RN      initiated by nurses in the

                             to the Peter Lougheed            between the person with            prepares a Naloxone Kit.   Emergency Department.

                             Centre in Calgary.               addictions and the health
                                                              care professionals and
                             Brad Morrison has a deep         provide “a warm handover.”
                             understanding of the ten or
                             so people he meets every         “He felt,
                             day in his role as ARCH peer
                             support worker at the PLC.         for the first
                             Morrison struggled with his        time, that
                             own addiction issues for
                             decades and spent years            somebody
                             trying to get clean and sober.
                             He started working with            finally got
                             ARCH when it launched in           it, and that
                             November, 2018 and so
                             far, the program has helped        he wasn’t
                             more than 1,500 people.
                                  One of them really stands     going to be
                             out in his memory—a 60             stigmatized
                             year old man with alcoholism
                             who had been admitted to           and sent
                             the emergency department
                             about 80 times in the year         away without
                             prior. “He couldn’t stop           any help
                             drinking,” says Morrison.
                             “He would do his best. He’d        or under-
                             come to emerg, they would
                             rehydrate him, hold him for        standing.”
                             four to six hours and then         Brad Morrison
                             discharge him.” The man
                             would be sent on his way             “Typically with the way
                             with advice to go to detox       these patients have been
                             and quit drinking.               treated, they don’t really trust
                                  When inevitably, the man    the staff in any health care
                             came back to the hospital,       setting,” he says. “I reassure
                             Morrison sat with him and        the patient that we are there
                             shared a bit about his own       for them. Then I go to the
                             story before telling him how     staff and let them know what
                             ARCH was going to help           the patient’s going through,
                             him. “He held his blanket to     what their fears are and why
                             his face and started crying.     they’re here.”
                             He felt, for the first time,         Morrison sees a bit of
                             that somebody finally got        himself in every patient he
                             it, and that he wasn’t going     meets. And he’s thrilled
                             to be stigmatized and sent       he can help them.
                             away without any help or             “You know, some Sundays
                             understanding.”                  I can’t wait to get here
                                                              Monday morning because
                                                              I love my job that much.”

8   DEPARTMENT OF MEDICINE                                                                                                                                                                                        2018-19 ANNUAL REPORT   9
INITIAL                                                                     “Residents
                                                                                                                                                                                                                WHAT IS BBIT?

                                                                                              OBSERVATION                                                                                                       BASAL INSULIN

                                                                                              Dr. Karmon Helmle,              The questions asked about                     knew how                            Basal insulin is intermediate
                                                                                                                                                                                                                or long acting and mimics the

                                                                                                                                                                            to best treat
                                                                                              clinical assistant professor,   the clinicians’ comfort level                                                     background insulin typically
                                                                                              Department of Medicine,         with managing patients’                                                           produced by the pancreas in
                                                                                              was in her first year of        diabetes and whether they                                                         people without diabetes.
                                                                                              residency in Calgary when
                                                                                              she noticed the care given
                                                                                              to patients with diabetes on
                                                                                                                              felt they needed more
                                                                                                                              training or information.
                                                                                                                                  The results of the
                                                                                                                                                                            diabetes in                         BOLUS INSULIN
                                                                                                                                                                                                                Bolus insulin is short or
                                                                                              the medical teaching unit
                                                                                              didn’t always line up with
                                                                                                                              survey—“We are very com-
                                                                                                                              fortable treating diabetes.                   hospital, but                       rapid acting and it balances
                                                                                                                                                                                                                the carbohydrates consumed

                                                                                                                                                                            in reality,
                                                                                              the guidelines that suggest     We’re very comfortable with                                                       at meals.
                                                                                              doctors use BBIT.               different insulins in different
                                                                                                  So, for her first year      complex scenarios. We                                                             INSULIN CORRECTION
                                                                                              resident’s research project,
                                                                                              she surveyed her colleagues
                                                                                              about diabetes management.
                                                                                                                              know that we should be
                                                                                                                              treating people with BBIT
                                                                                                                              strategies and not using the
                                                                                                                                                                            actual treatment                    Insulin correction is another
                                                                                                                                                                                                                short-acting insulin that
                                                                                                                                                                                                                makes small corrections and
                                                                                              She asked clinicians to fill
                                                                                              out a questionnaire about
                                                                                                                              sliding scale”—did not line
                                                                                                                              up with what Dr. Helmle was                   didn’t match                        brings blood glucose back to
                                                                                                                                                                                                                target, if needed.

                                                                                                                                                                            with what
                                                                                              how they order insulin for      observing in the hospital.
                                                                                              their patients and manage a                                                                                       TITRATE
                                                                                              variety of complex scenarios.                                                                                     Ensure blood glucose is

                                                                                                                                                                            we knew we                          monitored four times daily
                                                                                                                                                                                                                and insulin doses are
                                                                                                                                                                                                                adjusted regularly to meet

                                                                                                                                                                            should                              Diabetes Canada targets.

                                                                                                                   Dr. Helmle
Dr. Karmon Helmle
Clinical Assistant Professor,
                                                  ONE OF FIVE adults admitted to
                                                the hospital in Alberta has diabetes.
                                                                                                                   decided to dive                                          be doing.”
Department of Medicine
Physician Champion, Provincial Diabetes         These patients are usually admitted                                in further                                              Dr. Karmon Helmle
Inpatient Management Initiative,                for a different medical reason but their
Diabetes Obesity Nutrition Strategic
                                                diabetes creates complex issues and
Clinical Network
                                                can dramatically slow their recovery.
Dr. Julie McKeen
Clinical Assistant Professor,                       People with diabetes are often
Department of Medicine                          experts in managing their chronic

Physician Lead, Provincial Diabetes Inpatient
                                                condition day-to-day, but that becomes
Management Initiative, Diabetes Obesity
Nutrition Strategic Clinical Network            difficult when they’re in the hospital and
                                                they have little control over their diet,
                                                physical activity and other factors.
USING                                               Basal bolus insulin therapy (BBIT)
                                                is a proactive way to give insulin that
                                                mimics the body’s natural production
TRANSLATION                                     of the hormone. Research shows that
                                                BBIT is a better way to treat people with               For her second year              difficult to actually order

TO IMPROVE                                      diabetes while they’re in the hospital
                                                than using sliding scale insulin (SSI),
                                                                                                        residency research project,
                                                                                                        Dr. Helmle looked at old
                                                                                                                                         the sequence of insulin in
                                                                                                                                         Calgary’s hospital’s software

INPATIENT                                       where a patient is administered insulin                                                                                                  DIABETES AFFECTS
                                                                                                        electronic health records        system, Sunrise Clinical                        AN ESTIMATED 1 IN 20
                                                depending on their blood sugar levels.                  to see whether the records       Manager (SCM). They                             CANADIANS.

DIABETES                                        SSI is not individualized to the patient,
                                                can result in large blood glucose fluctu-
                                                                                                        aligned with the results
                                                                                                        from her first-year survey.
                                                                                                                                         needed an order set—a
                                                                                                                                         group of pre-packaged
MANAGEMENT                                      ations over the day which can increase
                                                morbidity, mortality and length of stay.
                                                                                                        The records supported her
                                                                                                        observation that clinicians
                                                                                                                                         instructions that allow clini-
                                                                                                                                         cians to order BBIT for their
In 2007, a medical resident in                      The BBIT program was developed to                   were not, in fact, using BBIT    patients in just a few clicks.
Calgary started asking questions                make it easier for clinicians to follow the             to treat their patients with     Dr. Helmle worked with a few
                                                necessary steps of ordering insulin for                 diabetes in hospital.            colleagues in IT to develop
about how people with diabetes
                                                their patients with paper order sets, or                    When Dr. Helmle started      an order set and they saw
receive care in the hospital. Those             in Calgary hospitals within the Sunrise                 asking her colleagues            an uptake in clinicians in
initial questions have informed                 Clinical Manager (SCM) software.                        why they didn’t use BBIT,        Calgary using BBIT.
a province-wide initiative that’s                                                                       they told her it was really
standardizing and improving care
for patients with diabetes.

10      DEPARTMENT OF MEDICINE                                                                                                                                                                                    2018-19 ANNUAL REPORT      11
$13b                                                                         “It became a
                                                                                                                                                PAGE 10 AND 11
                                                                                                                                                Dr. Karmon Helmle
                                                                                                                                                and Dr. Julie McKeen

                                                                                       question of
                                                                                                                                                review analytical data
                                                                                                                                                for the BBIT.ca and
                                                                                                                                                KTToolkit.ca websites.

                    CANADA’S HEALTH CARE
                                                                                       how to take                                              PAGE 13
                                                                                                                                                The Improved Glycemic
                                                                                                                                                Management core team

                                                                                       best evidence
                    BUDGET CONTRIBUTES                                                                                                          meets at the Richmond
                    $13 BILLION A YEAR
                                                                                                                                                Road Diagnostic and
                    FOR 2 MILLION PEOPLE
                    WITH DIABETES.                                                                                                              Treatment Centre

                                                                                       and translate it
                                                                                                                                                (RRDTC) to review the
                                                                                                                                                status of the Provincial
                                                                                                                                                In-Patient Diabetes
                                                                                                                                                Management Initiative.

                                                                                       into practice—
                                                                                       the knowledge
                                Dr. Helmle had                                          Dr. Julie McKeen

                                identified a care
                                gap for people
                                with diabetes in
                                hospital                                                                                           The DON SCN
                                                                                                                                   core committee
                                                                                                                                   identified diabetes
                                                                                                                                   in hospitals as
                                                                                                                                   a priority for

                                Meanwhile, the Diabetes,
                                Obesity and Nutrition
                                Strategic Clinical Network
                                (DON SCN) did a patient
                                survey evaluating patient
                                                                   DON SCN received
                                                               feedback from 672 patients
                                                               who have diabetes and
                                                               were admitted to an Alberta
                                                               hospital in 2014. Those
                                                                                                    An Improved Glycemic
                                                                                                Management core team was
                                                                                                assembled. And it quickly
                                                                                                identified that about a third
                                                                                                of patients with diabetes had
                                                                                                                                                                           20% 4th
                                                                                                                                                                           ABOUT 20% OF ADULTS
                                                                                                                                                                           ADMITTED TO ALBERTA
                                                                                                                                                                                                 DIABETES IS THE
                                                                                                                                                                                                 FOURTH MOST COMMON
                                                                                                                                                                           HOSPITALS HAVE        CO-MORBIDITY IN
                                perceptions of diabetes        patients with diabetes           blood sugar levels that were                                               DIABETES.             PATIENT CHARTS.
                                care in hospital. DON          were less satisfied with         well above the recommended
                                SCN, one of 16 SCNs in         their care in hospital than      guidelines. Further, the team
                                Alberta, is a network of       people without the disease.      found patients with diabetes
                                health care providers,         The patients with diabetes       stayed in hospital about 40
                                patients, researchers and      identified three areas of less   per cent longer compared to
                                policy makers with expertise   satisfaction: blood sugar        those without. The team also
                                in specific areas. SCNs        control, nutrition and finally   verified, provincially, that the
                                identify care gaps and find    their relationships with their   use of BBIT was low and cli-
                                innovative ways to deliver     care providers and the rela-     nicians were using outdated
                                care and provide better        tionship between hospital        SSI to treat their patients,
                                outcomes for Albertans.        care providers.                  confirming a widespread,
                                                                                                complex problem.

12   DEPARTMENT OF MEDICINE                                                                                                                                                                                           2018-19 ANNUAL REPORT   13
MAPPING                                                                                                                                                                  EARLY
                                                                         A STRATEGY                                                                                                                                                               ADOPTER
                                                                                                                                                                                                                  Moving from
                                                                         Implementing BBIT order
                                                                         sets and basic diabetes
                                                                                                             importance of hypoglycemia
                                                                                                             and its management, but                                                                              best practices
                                                                         education was only one              equally important, the                                                                               to common                       Beginning in early 2016,           led the change, mindful of          The DON SCN group
                                                                         piece of a complex puzzle to        recognition and treatment                                                                                                            ten early adopter sites            the barriers at that specific   facilitated baseline and
                                                                                                                                                                                                                  practice                        started implementing the           site and armed with specific    audit data for 18 months.
                                                                         improve the care of patients        of hyperglycemia.

                                                                         with diabetes in hospital.              Together, the transforma-                                                                                                        knowledge translation plan         tools to overcome them.         The group gave the sites
                                                                         The team developed a                tive project was called the                                                                                                          toward changing clinical           While initial education was     targeted feedback, provided
                                                                         comprehensive strategy that         Provincial In-Patient Diabetes                                                                                                       practice from SSI to BBIT.         important, tools to promote     information and knowledge
                                                                         included nine other support-        Management Initiative. The                                                                                                           After a few months, the sites      and sustain change involved     translation tools to share
                                                                         ing initiatives, identified their   overall goal was to improve                                                                                                          gave feedback around what          much more than just ongoing     with frontline staff and
                                                                         internal AHS sponsors and           glycemic management in                                                                                                               was working well to address        education. Champions            helped re-evaluate barriers
                                                                                                                                                                                                                                                  their barriers, and what           worked to influence their
                                                                         set out timelines.                  hospital, better aligning with                Revising                                                                                                                                                  to address any practice
                                                                              These other collaborative      guidelines, available literature                                                                                                     new barriers had emerged.          peers and share successes       drift, quickly and early.
                                                                         initiatives included everything     and how patients are taught
                                                                                                                                                           order                                                                                  The early adopter sites            while on the lookout for            There was consistent
                                                                         from developing appropriate         to manage their diabetes                      sets when                        IMPLEMENTING                                          implemented in a staggered         emerging barriers. With         and sustained increase
                                                                                                                                                                                            PROGRAMS FOCUSED
                                                                         nutritional support, ways           outside of hospital.                          needed                           ON TREATING                                           fashion, with each site con-       support from their admin-       in ordering of BBIT which
                                                                         to manage patient-specific              Team members identified                                                    HYPERGLYCEMIA SAW                                     tributing to the knowledge         istrators, audit data was       led to improved glycemic
                                                                                                                                                                                            A 450% RETURN ON
                                                                         dispensing of insulin as well       a number of outcomes and                                                       INVESTMENT.                                           and tools available to the         collected and shared to         control, decreased episodes
                                                                         as policies and guidelines          pulled together to reach them.                                                                                                       next site.                         support and sustain the         of hyperglycemia and no
                                                                         for highlighting not only the                                                                                                                                                At each of the early           change from SSI to BBIT.        increase in hypoglycemia.
                                       Identifying                                                                                                                                                                                                adopter sites, physician,          The early adopter sites
                                                                                                                                                                                                                                                  nursing, pharmacy and              collaborated and solved

                                                                                                                                                                                                                                                  administrative champions           problems together.

        Research begins                                                                                                                         DEVELOPING                        KNOWLEDGE
        into how other
        sites implemented                                                                                                                       ORDER SETS                        TRANSLATION
        BBIT                                                                                                                                    When it came to developing        Identifying best practice is        The Improved Glycemic
                                                                                                                                                the order sets—the specific       one thing. Having people        Management team worked
                                                                                                                                                                                                                                                                       DON SCN IMPROVED GLYCEMIC
                                                                                                                                                instructions about ordering       adopt them is another matter    with knowledge trans-                                MANAGEMENT TEAM
                                                                         IN ALBERTA, PATIENTS                                                   BBIT for a patient—the team       altogether. Even when there’s   lation experts and the                               Dr. Julie McKeen
                                                                         WITH DIABETES STAY IN
                                                                                                                                                looked at all the order sets      ample evidence and whole-       Alberta SPOR Support                                 Physician Lead
                                                                         HOSPITAL 40% LONGER
                                                                         THAN THOSE WITHOUT.                                                                                                                                                                           Dr. Karmon Helmle
                                                                                                                                                available in the published        hearted support for changing    Unit (SUPPORT = Support                              Physician Champion
                                                                                                                                                and unpublished literature        a clinical practice, the        for People and Patient-                              Leta Philp
                                                                                                                                                across Canada as well as          process of establishing and     Oriented Research and                                Clinical Practice Lead

        IDENTIFYING                                                                                                                             hospitals and jurisdictions
                                                                                                                                                across the country that had
                                                                                                                                                                                  sustaining the new patterns
                                                                                                                                                                                  of care can be challenging.
                                                                                                                                                                                                                  Trials) to develop a three
                                                                                                                                                                                                                  stage knowledge transla-
                                                                                                                                                                                                                                                                       Glenda Moore
                                                                                                                                                                                                                                                                       Past Project Lead
                                                                                                                                                                                                                                                                                                                     TEN EARLY
                                                                                                                                                                                                                                                                                                                     ADOPTER SITES
                                                                                                                                                                                                                                                                       Rhonda Roedler
        BARRIERS                                                                                                                                already implemented order
                                                                                                                                                sets for BBIT.
                                                                                                                                                                                      That’s where the science
                                                                                                                                                                                  of knowledge translation
                                                                                                                                                                                                                  tion plan to promote the
                                                                                                                                                                                                                  change to BBIT. It identified
                                                                                                                                                                                                                                                                       Provincial Pharmacy
                                                                                                                                                                                                                                                                                                                     −− Chinook Regional
                                                                                                                                                                                                                                                                       Edwin Rogers
        The core team undertook            The core team found                                                                                      Leveraging insights from      comes in. It closes the gap     and addressed barriers                               AHS, Analytics                                −− Canmore General
        a national environmental        that while each site had its                                                                            those that had already imple-     between ‘what we know’          and offered a deliberate                             Naomi Popeski                                    Hospital
        scan, collecting information    own unique culture, many                                                                                mented BBIT order sets, a         and ‘what we do’—so called      approach to help teams                               Assistant Scientific
                                                                                                                                                                                                                                                                       Director, DON SCN                             −− Oilfields General Hospital
        from dozens of acute care       barriers and facilitators were                                                                          unified provincial BBIT order     ‘knowledge to action gaps’      adopt BBIT into their
                                                                                                                                                                                                                                                                       Gabreille Zimmerman                           −− Calgary Urban Hospitalist
        sites across Canada that        shared amongst sites. The                                                                               set was developed. AHS            or K2A. These gaps can be       daily routines.                                      Program Coordinator,
        had implemented order sets      Alberta team concluded                                                                                  Human Factors supported a         responsible for variations                                                           Knowledge Translation                            Program at Foothills
                                                                                                                                                                                                                                                                       and Implementation                               Medical Centre, Peter
        for BBIT. The Alberta team      that to overcome these                                                                                  usability assessment and the      in practice and big discrep-                                                         Science, AB SPOR
        focused on the barriers the     many shared barriers, an                                                                                order set was revised where       ancies in patient outcomes,                                                          Support                                          Lougheed Centre,
        hospitals had encountered       organized, evidence-informed                                                                            needed. The SCM BBIT              quality and safety of care,                                                                                                           Rockyview General
                                                                                                                                                                                                                                                                       DON SCN LEADERSHIP
        and what helped implemen-       approach was required.                                                                                  Order Set was updated to          efficiency and cost.                                                                 Petra O'Connell
                                                                                                                                                                                                                                                                                                                        Hospital, and South
        tation of BBIT order sets                                                                                                               align with the provincial order                                                                                        Senior Provincial                                Health Campus
        at each site.                                                                                                                           set. Once implemented,                                                                                                                                               −− University of Alberta
                                                                                                                                                                                                                                                                       Dr. Peter Sargious
                                                                                                                                                feedback was sought from                                                                                               Senior Medical Director                          Hospital
                                                                                                                                                early adopter sites, and                                                                                                                                             −− Grey Nuns Community
                                                                                                                                                further revisions were made.                                                                                                                                            Hospital
                                                                                                                                                The order set is now on its                                                                                                                                          −− Queen Elizabeth II
                                                                                                                                                sixth iteration.                                                                                                                                                        Hospital

14   DEPARTMENT OF MEDICINE                                                                                                                                                                                                                                                                                            2018-19 ANNUAL REPORT    15
                                                                                                                                                                                NCE SCORE

                                                                                                                                                                  Basal B
                                                                                                                                                                            olus Ins
                                                                                                                                                                                         ulin The
                                                                                                                                                                                                    rapy Pro
                                                                                                                                                                 The BBIT                                       gram
                                                                                                                                                                             initiative g
                                                                                                                                                                                          ets top m
                                                                                                                                                                                                    arks for im
                                                                                           “This is a road                                                     inpatient d
                                                                    PAGE 16
                                                                                                                                                                            iabetes m                           proving
                                                                    Dr. Karmon Helmle
                                                                    reviews data on the                                                                         Basal Bolu                         nt by supp
                                                                                                                                                                           s Insulin T                         orting

                                                                                             map now.
                                                                    BBIT website with
                                                                                                                                                                                         herapy ord
                                                                    Core Team members                                                                                                                ering prac
                                                                    Gabrielle Zimmerman,                                                                       GOAL                                              tices.
                                                                    Edwin Rogers, and

                                                                                             We’ve created a
                                                                    Leta Philp.                                                                                Improve B
                                                                                                                                                                           BIT orderi
                                                                                                                                                              in hospita              ng
                                                                                                                                                                         l                           Overall, B
                                                                                                                                                                                                                BIT orderi

                                                                                             process of how
                                                                                                                                                                                                      2.5x from

                                                                                                                                                            Improve ra
                                                                                                                                                                       tes of

                                                                                             to implement                                                   hyperglyc
                                                                                                                                                                      emia                         15% fewe
                                                                                                                                                                                                             r days wit
                                                                                                                                                                                                             or worse

                                                                                             this complex
                                                                                                                                                                    and contin
                                                                                                                                                          use of BB            ued

                                                                                             practice change.
                                                                                                                                                                    IT                           97% of sit
                                                                                                                                                                                                             es “satisfi
                                                                                                                                                                                                 or “very s              ed”
                                                                                                                                                                                                            atisfied” w
                                                                                                                                                                                                implemen                it h
                                                                                                                                                                                                            tation. 95

                                                                                             BBIT site imple-                                                                                   sites repo             %   of
                                                                                                                                                                                                           rt BBIT us
                                                                                                                                                                                               “frequentl              e d
                                                                                                                                                                                                          y” or “alw
                                                                                                                                                                                               after imple            ays”

                                                                                                                                                       BBIT orde
                                                                                                                                                                  ring adop
                                                                                                                                                       at all AHS           ted
                                                                                                                                                                  sites                        Of 106 ho
                                                                                                                                                                                                          spital site

                                                                                             guidelines have                                                                                  in Alberta              s
                                                                                                                                                                                                         , 71 have
                                                                                                                                                                                                        ted the BB
                                                                                                                                                                                            protocol,                 IT

                                                                                             been created
                                                                                                                                                                                                       with an ad
                                                                                                                                                                                            9 sites in              d itional

                                                                                             and are shared
                                                                                             on our BBIT
                                                                                            Dr. Julie McKeen

        5.3%                               9.6%                                                               BBIT
                    THIS BBIT APPROACH
                    REDUCED THE FREQUENCY
                    OF HYPERGLYCEMIC
                                             THE BBIT APPROACH
                                             SAW A 9.6% REDUCTION
                                             IN LENGTH OF STAY AT
                    PATIENT-DAYS BY 5.3%     THE CALGARY ZONE                                                  There are 106 acute care          has been developed to               barriers to BBIT imple-
                    THE FREQUENCY OF         FOUR SITES.                                                       sites in Alberta. And most        help other sites provincially,      mentation, and links to the
                    HYPOGLYCEMIA.                                                                              of them are either in the         nationally, and internationally     evidence-informed tools
                                                                                                               process of implementing           move to BBIT and improve            targeted to each. All
                                                                                                               BBIT order sets or have           their patient care. Anyone          tools have been made
                                                                                                               already done so. Well             can access the “BBIT Site           publicly available.
                                                                                                               beyond Alberta’s borders,         Implementation Guidelines”              As well as improving care
                                                                                                               other acute care sites            at BBIT.ca and tailor them to       for patients with diabetes in
                                                                                                               are contacting the people         work in their own specific site.    Alberta hospitals, the whole
                                                                                                               who were involved in the              A second website,               process of implementing a
                                                                                                               project to gain insights          www.KTToolkit.ca, guides            change in practice to BBIT
                                                                                                               to lend to their own BBIT         users through the process           may serve as a road map for
                                                                                                               implementation.                   of identifying cultural,            other complex interventions
                                                                                                                   A website, www.BBIT.ca,       awareness and capability,           in the province.
                                                                                                               containing all of the education   communication, system,
                                                                                                               and implementation guidelines     resource, and patient-related

16   DEPARTMENT OF MEDICINE                                                                                                                                                                          2018-19 ANNUAL REPORT      17
Dr. Michelle Grinman                      FOR 89 OF HER 90 YEARS, Olive Willey      in CCH or stay as an inpatient at the      PAGE 18
Medical Lead, Complex Care Hub                                                                                                 Top Left:
                                        had never spent a night in hospital.        hospital. Those who choose CCH are
Division of General Internal Medicine                                                                                          Dr. Michelle Grinman
                                        Even after her visit to the emergency       sent home where they receive daily         meets with the Complex
                                        department at Rockyview General             care and monitoring from a team that
                                                                                                                               Care Hub team at RGH.
                                        Hospital (RGH) last spring, she spent       is overseen by a General Internist/
                                                                                                                               Bottom Left:
                                        just one day in a hospital bed thanks       Hospitalist, Clinical Assistant and
HUB BRINGS THE                          to the new Complex Care Hub                 Nurse Navigators. The team collabo-
                                                                                                                               Dr. Michelle Grinman
                                                                                                                               and Kirsten Proceviat,
                                        (CCH) program.                              rates with the Mobile Integrated Health
                                                                                                                               Manager of Transition
                                            This innovative program is a            Service, also known as the Community       Services for Rockyview
                                                                                                                               General Hospital (RGH)
                                        “virtual inpatient unit that allows         Paramedics in the Calgary Zone who
Patients enjoy the benefits of          eligible patients to receive the same       serve as the eyes and ears of the
                                                                                                                               and South Health
                                                                                                                               Campus (SHC).
home with hospital-quality care.        kind of care and treatment they would       physicians in patients’ homes. Rigorous
                                        in hospital, but within the comfort of      safety protocols ensure patients have
                                                                                                                               Barb Leteta, Nurse
                                        their own home.” Says Dr. Michelle          a direct line to their care team should    Navigator, and
                                        Grinman, a General Internal Medicine        questions or concerns arise while          Dr. Azadeh
                                        specialist at RGH and originator of         they’re at home. Tests and lab work can    Motehayerarani,
                                        CCH in the Calgary Zone.                    be ordered with the same priority as       Clinical Assistant
                                                                                                                               – members of the
                                            It serves as a bridge between           inpatients. The CCH Nurse Navigators
                                                                                                                               Complex Care Hub
                                        acute care sites and the community,         report to Transition Services and are      (CCH) team – review
                                        she adds. Patients who come into the        able to access home care services,         a CCH patient’s chart.
                                        emergency department or who are             which enables them to leverage
                                                                                                                               PAGE 19
                                        admitted to inpatient wards at RGH or       existing pathways for comprehensive        Drs. Grinman and
                                        South Health Campus (SHC) requiring         geriatric assessments provided by the      Motehayerarani see
                                        lower acuity care that would otherwise      Geriatric Consult team, physiotherapy,     Benjamin Predella at
                                        require hospitalization are admitted        occupational therapy and social work.      the Rockyview General
                                                                                                                               Hospital, a patient who
                                        to the CCH program. These patients              Dr. Grinman and her team have
                                                                                                                               is also participating in
                                        receive daily, sometimes twice daily,       also fostered relationships with Primary   the Complex Care
                                        visits to manage their acute issues         Care in order to enhance transitions of    Hub program.
                                        as they would under a conventional          care from CCH to the health home.
                                        hospital admission. But unlike tradi-           The Calgary West Primary Care
                                        tional inpatients, CCH patients aren’t      Network (PCN) has hired two nurses to
                                        transferred to a unit in the hospital to    liaise with the CCH Nurse Navigators in
                                        recover – instead they sleep at home.       order to expedite transition of patients
                                            Patients who meet the program’s         back to the PCN and to support them in
                                        criteria are given a choice – participate   implementing their complex care plan.

18      DEPARTMENT OF MEDICINE                                                                                                                            2018-19 ANNUAL REPORT   19
PAGE 20 AND 21
                                                                                                                                  Complex Care Hub
                                                                                                                                  patients, like Benjamin
                                                                                                                                  Predella, can also be
                                                                                                                                  monitored and seen by
                                                                                                                                  the team at either RGH
                                                                                                                                  or SHC when they come
                                                                                                                                  to either site for medical
                                                                                                                                  tests or procedures.

                              The East Family Care Centre has also             “You’re in your own bed, you can
                              partnered with CCH to re-roster patients     go have coffee with friends – you’re not
                              that require home visits or intensive        stuck in a hospital bed the whole time,”
                              primary care services upon discharge         say Willey. “When the doctor gave me
                              from the program. This comprehensive         the option to stay in hospital or go home,
                              team approach not only benefits patients     it was an easy decision to make.”
                              by allowing them to recover within the           Daughter Dianne Arnott says she
                              comfort of their home, it also improves      felt confident about her mom’s choice:
                              the healthcare system through more           “There were no concerns for mom’s
                              efficient use of resources.                  care whatsoever. It was a logical
                                  “We know that hospital-at-home           choice, really. She wasn’t sick enough
                              services have been shown to reduce           to stay in hospital, but she’s still getting
                              visits to emergency departments and          the care she needs when she needs
                              provide flexibility during crises or surge   it, whether it’s from her community
                              situations,” says Dr. Grinman. “Older        paramedic or the doctor at Rockyview.
                              adults treated within this model are also    The attention has been very fast and
                              less likely to have functional decline       thorough. We’re very impressed.”
                              and need long-term care or assisted              Winnie Smith, another patient in the
                              living one year later.                       program, also shared why she made
                                  “Multiple systematic reviews and         the decision to receive hospital-level
                              meta-analyses of Hospital at Home            care at home through the Complex
                              programs around the world have shown         Care Hub. “Privacy. Like having
                              reduced morbidity and mortality when         somebody else next to you moaning
                              hospital-level care is delivered for the     and crooning and everything you know.
                              right population of patients,” she says.     I [would] rather be at home where I
                                  “When a senior comes to the              have peace and quiet,” says Winnie.
                              hospital and receives meals in bed
                              and isn’t walking around, they’re
                              more likely to deteriorate quicker than
                              patients being treated at home who
                              remain active and independent.”
                                  For Willey and her family, the CCH
                              means quality of life isn’t sacrificed for
                              quality of care.

20   DEPARTMENT OF MEDICINE                                                                                               2018-19 ANNUAL REPORT             21
                                                                                 “Privacy. Like                                        ORECARD

                                                                                   having somebody                    Complex Car
                                                                                                                                     e Hub Progra
                                                                                   else next to you                  Data collected by
                                                                                                                                       Complex Care H
                                                                                   moaning and                       17-month period
                                                                                                                                                        ub staff over a
                                                                                                                                     (Feb 2018 – July
                                                                                   crooning and                     the considerable
                                                                                                                                                       2019) confirms
                                                                                                                                     success of the pr
                                                                                   everything you                                                      ogram to date:
                                                                                                                   PROGRAM MEASUR
                                                                                   know. I [would]                                ES
                                                                                                                   QUALITY OF
                                “After going         PAGES 22 AND 23              rather be at home                          CARE

                                                                                                                   Percentage of pa
PROGRAM ANALYSIS                                      The Complex Care                                                               tients (n=66) wh
Preliminary economic              through this        Hub allowed Olive
                                                      Willey (page 22, top)
                                                                                   where I have                   reported that th
                                                                                                                  from the Comple
                                                                                                                                   e care they rece
                                                                                                                                    x Care Hub staff
analyses of the beginning
                                  program,            and Winnie Smith
                                                      (page 22, bottom; page
                                                                                   peace and quiet.”              was good or ex
of the program suggest                                                                                           REGAINING
                                                                                  Winnie Smith, CCH patient
that providing care for CCH       I realized          23) the opportunity to                                               FUNCTION

                                                                                                                 AND INDEPE
                                                      remain at home while                                                  NDENCE
patients may cost less than                                                                                      Percentage of pa
for inpatients matched by         how much            receiving hospital-level
                                                      care from a compre-                                        reported that Co
                                                                                                                                   tients (n=68) wh
                                                                                                                                  mplex Care Hub
age, gender and diagnosis.
Responses from both
                                  I never knew        hensive team including
                                                      physicians, nurses, and
                                                                                                                helped them rega
                                                                                                                independence qu
                                                                                                                                   in their function
                                                                                                                                  ite a bit or comple
patients and staff to date        about my            community paramedics
                                                      like Lou Labrash.                                         PATIENT INVO
have been very positive.                                                                                                                T
                                  patients and
                                                                                                                Percentage of pa
    Data collected by CCH                                                                                                         tients (n=69) wh
                                                                                                                reported always                    o
                                                                                                                                 or usually being
staff over a 17-month period
show the program is a hit
                                  that my care                                                                 involved as muc
                                                                                                                                 h as they wanted
                                                                                                               to be in decision
with patients:                    was never                                                                    and treatment
                                                                                                                                s about their care
−− On average, patients
    rated their overall expe-     complete.                                                                    DAYS OF AC
                                                                                                                          UTE CARE PR
                                                                                                                                      OV      IDED

                                                                                                               From Feb 2018
    rience of the care they
    received on the Complex
                                  I feel this                                                                 received care th
                                                                                                                                – July 2019, 141
                                                                                                                               rough the Comple
                                                                                                                                                 x Care
    Care Hub 9.5 out of 10        program is                                                                  Hub, resulting in
                                                                                                              days of acute ca
                                                                                                                                an estimated 1,59
                                                                                                                               re provided
−− 96% of patients
   reported that the care
   they received from the         and gives
   Complex Care Hub staff
   was good or excellent          us an oppor-
−− 84% of patients reported
   always or usually being
                                  tunity to
   involved as much as            help people
   they wanted to be in
   decisions about their          in what they
   care and treatment
−− 81% of patients reported
   that the Complex Care          need.”
   Hub helped them regain        Anonymous Complex
   their function and inde-      Care Hub physician
   pendence quite a bit
   or completely
    An anonymous CCH
physician remarked, “After
going through this program,
I realized how much I never
knew about my patients
and that my care was never
complete. I feel this program
is wonderful and gives us an
opportunity to help people in
what they actually need.”
    While these are early
positive signals, the team
is embarking on a rigorous
evaluation of the program
as it is maturing.

22     DEPARTMENT OF MEDICINE                                                                                                                                             2018-19 ANNUAL REPORT   23

                                            edical research and innova-
                                                                                                                                                                    Dr. Andrew Daly                                   AN EXCITING NEW cancer treatment,
                                                                                                                                                                    Division Head and Zone Clinical Section Chief
                                                                                                                                                                                                                    chimeric antigen receptor (CAR)
                                                                                                                                                                    for Hematology & Hematological Malignancies
                                                                                                                                                                    Former Director of the Alberta Blood and Bone   T-cell therapy, is opening up a world

                                            tion are fundamental to the
                                                                                                                                                                    Marrow Transplant Program                       of potential for treating certain forms
                                                                                                                                                                    Clinical Associate Professor,
                                                                                                                                                                                                                    of cancer and providing hope for
                                                                                                                                                                    Cumming School of Medicine
                                                                                                                                                                                                                    people where, in many cases, there

                                            Department of Medicine,                                                                                                 CHIMERIC ANTIGEN
                                                                                                                                                                                                                    was little before. Essentially, CAR
                                                                                                                                                                                                                    T-cell therapy strengthens the body’s
                                                                                                                                                                                                                    immune system and pushes it harder
                                                                                                                                                                    RECEPTOR T-CELL
                              UCalgary, and AHS. Researchers acquire                                                                                                (CAR T-CELL)
                                                                                                                                                                                                                    to fight cancer cells.
                                                                                                                                                                                                                        The type of genetic immunother-
                                                                                                                                                                                                                    apy re-engineers a patient’s own cells

        Dr. Andrew Daly
        Dr. Kara Nerenberg
                              evidence and improve—or discover—                                                                                                     THERAPY
                                                                                                                                                                                                                    from their immune system, giving them
                                                                                                                                                                                                                    instructions to attack cancer cells, and
                                                                                                                                                                                                                    injects them back into the body. The

                              treatments that help people here in Alberta
        Liz Deneer                                                                                                                                                  Clinical trials are underway in                 process creates what is essentially
        Sandra Burk
        (patient)                                                                                                                                                   Calgary to use immunotherapy,                   a living drug—one that’s individually
                                                                                                                                                                    a sort of “living drug,” to target              customized for each patient.

                              and around the world.

        Hematology &                                                                                                                                                certain blood cancers.                              The first CAR T-cells were
        Hematological                                                                                                                                                                                               developed in the 1980s but it has
                                                                                                                                                                                                                    taken tremendous time and effort to
        General Internal
        Medicine                                                                                                                                                                                                    make them work says Dr. Andrew
                              Every year, UCalgary and AHS support thousands of new                   These mothers are at a higher risk for heart attack and                                                       Daly, Division Head and Zone Clinical
                              and ongoing studies that use UCalgary and AHS facilities,           even premature death. In this chapter you will read about                                                         Section Chief for Hematology and
                              patient data and systems. In fact, Alberta has a higher             an innovative research, new clinics and telephone health                                                          Hematological Malignancies in the
                              clinical trial enrolment rate than the national average.            coaching program that is helping reduce women’s long-term                                                         Department of Medicine, former
                                  In this chapter you will read about new clinical trials that    risk factors of having high blood pressure during pregnancy.                                                      director of the Alberta Blood and
                              are testing an innovative and exciting immunotherapy to treat           As members of the Department pursue their research                                                            Bone Marrow Transplant Program
                              some types of cancer. Chimeric Antigen Receptor T-Cell              and perform clinical trials, the Department, UCalgary and                                                         and Clinical Associate Professor with
                              therapy is a type of “living drug” that is able to strengthen the   AHS work with them, helping these world-class researchers                                                         the Cumming School of Medicine and
                              patient’s own immune system, pushing it to work harder and          translate their discoveries from ‘bench to bedside’ and improve                                                   Arnie Charbonneau Cancer Institute
                              target certain blood cancers.                                       the health and lives of people who live in Alberta and around                                                     at the University of Calgary.
                                  Women who have high blood pressure when they’re                 the world.
                              pregnant often think their issues go away after their baby is
                              born. But researchers have determined that they’re likely to
                              continue to have problems long after they’ve had their babies.

24   DEPARTMENT OF MEDICINE                                                                                                                                                                                                      2018-19 ANNUAL REPORT     25
“We’ve been
                                                                                                                               leaders in stem
Dr. Andrew Daly
discusses CAR T-cells
                                        Clinical trials have been happening
                                    in various locations for the past few
                                                                                     Daly is a recognized leader in
                                                                                 stem cell therapy and transplantation.
                                                                                                                               cell transplants
                                                                                                                               for years, and
                                    years. Now, Daly and his team have           He made headlines in May 2019 after
with a patient on the
Hematology Unit at the              started clinical trials that will help       performing a stem cell transplant for
Foothills Medical Centre.           advance CAR T-cell therapy and provide       Revée Agyepong. She was the first
Dr. Daly and his team
have started clinical trials
that will help advance
                                    renewed hope and improve the lives of
                                    Albertans. “There are two established
                                    indications for CAR T-cells right now,”
                                                                                 adult in Alberta whose sickle cell
                                                                                 anemia was cured with this treatment,
                                                                                 freeing her from the debilitating disease
                                                                                                                               so this is a
CAR T-cell therapy.

PAGE 26:
Jillian de Groot, a
                                    he says. “One is relapsed, or refractory,
                                    acute lymphoblastic leukemia, or ALL.
                                                                                 that caused excruciating pain and was
                                                                                 slowing killing her major organs. This
                                                                                                                               new opportu-
                                                                                                                               nity to look at
                                    That’s the childhood type of leukemia,       success was the latest to reinforce
Registered Nurse on
Unit 57 at the Foothills            and then the indication in adults is         Alberta’s leadership in stem cell
Hospital, begins to                 relapsed or refractory aggressive            research and cancer treatment. Now,
prepare a patient for an
infusion of CAR T-cells,
a process similar to a
                                    non-Hodgkin lymphoma.”
                                        Daly and his colleagues at
                                    Alberta Children’s Hospital have
                                                                                 Daly is applying the expertise to CAR
                                                                                 T-cell research, making advancements
                                                                                 that will open the doors to more “firsts”
                                                                                                                               a different type
blood transfusion.

PAGE 27:
After the CAR T-cells
                                    begun clinical trials treating children
                                    who have ALL and he hopes to treat
                                                                                 in Alberta health care.
                                                                                                                               of transplant
                                    adults with non-Hodgkin lymphoma on          PUSHING THE BOUNDARIES
are created and multi-
plied in Alberta Public             similar trials. “My estimate is thirty or    OF MEDICAL SCIENCE
Laboratory’s Cellular               forty patients per year would have a         In addition to trials in leukemia and
Therapy Lab, they                   disease that is eligible for CAR T-cells.    lymphoma, Daly is collaborating on           Dr. Andrew Daly
are cryopreserved in
                                    Not every patient is going to be well        a clinical trial in a different blood
liquid nitrogen.
                                    enough to get them,” he says.                cancer, multiple myeloma. “In multiple
                                        Daly specializes in the transplan-       myeloma, the CAR T-cell actually
                                    tation of hematopoietic stem cells           targets something different compared
                                    – bone marrow cells that have the            to what’s being targeted in the other
                                    remarkable ability to develop into white     two diseases that are treated.” His
                                    blood cells, red blood cells or platelets.   colleague Dr. Nizar Bahlis, Clinical
                                    “We have an improved understand-             Associate Professor with the
                                    ing of how to engineer cells plus an         Cumming School of Medicine and
                                    improved understanding of how the            member of the Division of Hematology
                                    immune system works,” he says.               & Hematological Malignancies, is
                                    “Those are two very powerful tools           principal investigator of the multiple
                                    that are coming together and leading         myeloma project.
                                    to better treatments for patients.”

26         DEPARTMENT OF MEDICINE                                                                                                                 2018-19 ANNUAL REPORT   27
                                                                                                                                                                                                                                HOW IT WORKS

                                                                                                                                                                                                                                Chimeric antigen
                                                                                                                                                                                                                            3   receptor (CAR) T-cell
                                                                                                                                                                                                                                therapy is a new,
                                                                                                                                                                                                                                individualized cancer
                                                                                                                                                                                                                                treatment that boosts
                                                                                                                                                                                                                                the patient’s own
                                                                                                                                                                                                                                immune system to fight
                                                                                                                                                                                                                                cancer cells. Here’s
                                                                                                                                                                                                                                how it works:

                                                                                                                                                                                                                                STEP 1
                                                                                                                                                                                                                                Collect the patient’s T-cells
                                                                                                                                                                                                                                from their immune system.

                                                                                                                                                                                                                                STEP 2
                                                                                                                                                                                                                                Load the chimeric antigen
                                                                                                                                                                                                                                receptor (CAR) onto the
                                                                                                                                                                                                                                surface of the T-cells
                                                                                                                                                                                                                                creating CAR T-cells with

“Making CAR                                                                                                                                                            “Because we                                    1   4   instructions to look for
                                                                                                                                                                                                                                certain cancer cells.

  T-cells work                                                                                                                                                            have a really                                         STEP 3
                                                                                                                                                                                                                                Multiply the CAR T-cells
                                                                                                                                                                                                                                in the lab.

  clinically took                     Daly and his team are also looking
                                  to take part in another study that
                                                                                                                           “Some people may look at the prospect
                                                                                                                           of a two week hospitalization, being
                                                                                                                                                                          good name         PAGE 28
                                                                                                                                                                                            Once the patient’s
                                                                                                                                                                                            T-cells have been
                                                                                                                                                                                                                                STEP 4

  a lot of work.                                                                                                                                                          in cancer
                                  involves manufacturing CAR T-cells                                                       away from home, possibly ending up                                                                   Give the patient chemother-
                                                                                                                                                                                            collected, the chimeric
                                  “in house”. Due to the complexity of                                                     with really serious toxicity and say,                                                                apy to reduce the number of
                                                                                                                                                                                            antigen receptor (CAR)
                                  the CAR T-cell manufacturing process,                                                    ‘You know, that’s not for me.’”                                  is loaded onto the                  cancer cells in their body.

  They’ve been                    most of these products are manufac-
                                  tured by the pharmaceutical industry,
                                  which adds to the cost of treating
                                                                                                                               That’s because roughly one-third
                                                                                                                           of those who receive CAR T-cells
                                                                                                                           require hospitalization in intensive
                                                                                                                                                                          clinical trials   surface of the T-cells,
                                                                                                                                                                                            creating the CAR
                                                                                                                                                                                            T-cells, on this machine
                                                                                                                                                                                                                                Put millions of CAR
                                                                                                                                                                                                                                T-cells into the patient’s

  doing clinical                                                                                                                                                          in general,       in the Alberta Public               blood stream.
                                  patients. Daly’s team has joined forces                                                  care for a week or more. Because of                              Laboratory’s Cellular
                                  with researchers at the University of                                                    this consideration, Daly estimates their                         Therapy Lab at the                  The CAR T-cells will

  trials with CAR                                                                                                                                                         people are
                                  Alberta and the University of Ottawa                                                     capacity will be 26 to 30 patients per                           Foothills Medical Centre.           continue to multiply in
                                  in order to develop the expertise                                                        year to begin with. “We’re planning to                                                               the blood stream.
                                                                                                                                                                                            PAGE 29
                                  necessary to manufacture CAR T-cells              Daly is excited to think of a day      keep people in hospital for about two                            Dr. Andrew Daly on

  T-cells for the                 in Alberta Public Laboratory’s Cellular
                                  Therapy Lab, located in Calgary. The
                                  Calgary team was approached to take
                                                                                when CAR T-cell therapy may even be
                                                                                applied to cancers in which the immune
                                                                                system doesn’t play such a central role,
                                                                                                                           weeks, and in order to be respectful of
                                                                                                                           the other areas of the hospital, and the
                                                                                                                           other resources in the hospital, we’re
                                                                                                                                                                          starting to       Hematology Unit 57
                                                                                                                                                                                            at the Foothills
                                                                                                                                                                                            Medical Centre.
                                                                                                                                                                                                                                STEP 5
                                                                                                                                                                                                                                The CAR T-cells look
                                                                                                                                                                                                                                for and set out to destroy

  last five or                    part because of the existing equipment
                                  and expertise made possible by the
                                                                                such as cancer of the colon or kidney.
                                                                                He points out that while these are
                                                                                                                           going to start off by treating one patient
                                                                                                                           every two weeks,” he says. “So we will
                                                                                                                                                                          look at us                                        5
                                                                                                                                                                                                                                cancer cells that have a
                                                                                                                                                                                                                                specific antigen.

  six years.”                                                                                                                                                             now as a place
                                  strength of the research partnership of       challenging to treat with immunother-      try not to have more than one patient                                                                After receiving CAR T-cell
                                  Alberta Health Services, Alberta Public       apy, “people are trying to develop CAR     getting CAR T-cells in the hospital at                                                               therapy, patients stay in
                                  Laboratories, Cumming School of               T-cells that actually function in those    any one time.”                                                                                       the hospital and are
     Dr. Andrew Daly              Medicine and the University of Calgary.
                                      Alberta’s international reputation as a
                                  leader in cancer clinical trials makes this
                                                                                environments, and when that happens
                                                                                this field will explode.”
                                                                                                                               Over the years, Daly and other
                                                                                                                           researchers have made tremendous
                                                                                                                           progress exploring the intricacy and
                                                                                                                                                                          to do CAR                                             monitored and treated for
                                                                                                                                                                                                                                any side effects.

                                  province a logical place for this sort of
                                  cutting edge research. “We have a fairly
                                                                                THE CHALLENGES
                                                                                While the potential for living drug
                                                                                                                           complexity of the human body to
                                                                                                                           understand how CAR T-cell therapies
                                                                                                                                                                          T-cell studies                                        CAR T-cells may stay active
                                                                                                                                                                                                                                in the body and prevent the

                                                                                                                                                                          as well.”
                                  small population and we’re really spread      therapy is very exciting, CAR T-cells      can work and they are continuing to                                                                  cancer from returning.
                                  out,” he says. “But what we’ve done           have an unfortunate element in             push the boundaries and learn new
                                  is we’ve really gotten out there, sold        common with other cancer treatments:       knowledge that will save lives.
                                  ourselves, developed the infrastructure,      it can make patients extremely ill.                                                      Dr. Andrew Daly
                                  developed the standard operating pro-         Daly says some patients may even
                                  cedures, and because we have a really         turn away the treatment. “Not every
                                  good name in cancer clinical trials in        patient is going to want to receive them
                                  general, people are starting to look at us    because of the toxicity and because of
                                  now as a place to do CAR T-cell studies.”     the unpredictable journey,” he says.

28       DEPARTMENT OF MEDICINE                                                                                                                                                                                                    2018-19 ANNUAL REPORT        29
“Women in
                                                                                                                                                                    Canada are
                              Dr. Kara Nerenberg
                              Associate Professor,
                              Division of General Internal Medicine
                                                                        UP TO ONE IN 10 Canadian women
                                                                      will experience a high blood pressure
                                                                                                                    She received funding through Heart
                                                                                                                    and Stroke and CIHR as one of the
                                                                                                                                                                    starting to         indicate how many women have their
                                                                                                                                                                                        cholesterol and diabetes blood tests
                                                                                                                                                                                                                                             PAGE 30
                                                                                                                                                                                                                                             Dr. Kara Nerenberg,
                                                                                                                                                                                                                                             who received funding

                                                                                                                                                                    have heart
                              Cumming School of Medicine              disorder in pregnancy (HDP), making           recipients of the Women’s Heart and                                 and the results.
                                                                                                                                                                                                                                             from the Heart and
                                                                      them two to five times more likely to         Brain Health Chairs awards, a program                                    This information will provide vital             Stroke Foundation
                                                                      have a heart attack or stroke before the      designed to generate new knowledge                                  insight into the best ways to reach
                              PROGRAM TO
                                                                                                                                                                                                                                             and CIHR as one of

                              IMPROVE THE
                                                                      age of 40 and die before they reach 60.
                                                                      Even more troubling is that roughly half
                                                                      of Canadian physicians are not aware
                                                                                                                    that improves awareness, prevention
                                                                                                                    and understanding of how biology and
                                                                                                                    socio-cultural factors affect women’s
                                                                                                                                                                    attacks and         women after they’ve had their babies. It
                                                                                                                                                                                        begins with improving clinic attendance.
                                                                                                                                                                                             Nerenberg’s research indicates 25
                                                                                                                                                                                                                                             the recipients of the
                                                                                                                                                                                                                                             Mid-Career Women’s
                                                                                                                                                                                                                                             Heart and Brain Health

                              HEART AND                               of this risk, so they aren’t able to inform
                                                                      their patients.
                                                                                                                    heart and brain health. The funding also
                                                                                                                    allowed Nerenberg to bring together 17
                                                                                                                                                                    stroke even in      per cent of new moms don’t show up
                                                                                                                                                                                        for their first post-partum visit and that
                                                                                                                                                                                                                                             Chair awards, leads the
                                                                                                                                                                                                                                             IMPROVE program.

                                                                                                                                                                                                                                             PAGE 31

                              BRAIN HEALTH                                                                                                                          their 30s and
                                                                          Dr. Kara Nerenberg is determined to       other post-partum clinics from across                               grows to 50 per cent for later follow-up
                                                                                                                                                                                                                                             Calgary mom Sandra
                                                                      give young women the tools they need          the country and form a national network                             visits. “There’s quite a big gap for these           Burke was referred to

                              OF POST-PARTUM                          to take charge of their health through        that’s developing best practices for                                women in terms of follow-up because                  the IMPROVE clinic in

                              CANADIAN WOMEN
                                                                      the new clinic IMPROVE (Identifying
                                                                      Methods for Postpartum Reduction
                                                                      Of Vascular Events). She focuses on
                                                                                                                    managing women’s cardiovascular
                                                                                                                    health after pregnancy.
                                                                                                                         “Specialized follow-up clinics for
                                                                                                                                                                    they’re dying       it falls between the fields of obstetrics,
                                                                                                                                                                                        primary care and internal medicine,”
                                                                                                                                                                                        says Nerenberg. “To bridge that gap
                                                                                                                                                                                                                                             June, 2018.

                              Research, new clinics and
                              a telephone health coaching
                                                                      finding the best ways to prevent heart
                                                                      attacks and strokes in young women
                                                                                                                    women after pregnancy across Canada
                                                                                                                    have started working together to share
                                                                                                                                                                    in their 50s.       we’ve done a couple things here in
                                                                                                                                                                                        Calgary such as starting a clinic called

                                                                                                                                                                    We can’t wait
                                                                      who were diagnosed with high blood            clinic information so we can find out if                            PreVASC, a post-partum cardiovascu-
                              program for new moms are
                                                                      pressure in pregnancy—roughly seven           specialty clinics work better than usual                            lar risk reduction clinic, as well as our
                              helping to reduce women’s               per cent of all pregnancies in Alberta.       care clinics at finding and treating the                            IMPROVE post-partum clinic.”
                              long-term risk factors of
                              having high blood pressure
                                                                      For example, preeclampsia, a condition
                                                                      which includes high blood pressure, dis-
                                                                      appears shortly after a woman delivers
                                                                                                                    heart and stroke risk factors,” says
                                                                                                                    Nerenberg. “These specialists will also
                                                                                                                    help us develop and test tools to help
                                                                                                                                                                    until they’re 40         But these clinics can’t help if
                                                                                                                                                                                        women aren’t showing up for their
                                                                                                                                                                                        appointments. New moms can face

                                                                                                                                                                    to 50 to start
                              during pregnancy.
                                                                      her baby. But new research shows that         doctors take better care of their patients.                         a number of challenges to get to the
                                                                      the blood vessel damage that occurred         If these tools work, we can test these                              clinic—caring for a little child can

                                                                      during pregnancy, causing stiffening can      tools in different clinics across Alberta                           make it difficult to travel to a medical
                                                                      lead to accelerated atherosclerosis—          as another starting point.”                                         appointment and they may not have
                                                                      hardening of the arteries.                         Nerenberg is leading the very first                            the money to pay for child care or the
                                                                          “Women in Canada are starting to          study to examine where, when and               Dr. Kara Nerenberg   additional expenses associated with
                                                                      have heart attacks and stroke even in         why women visit their doctors after                                 travelling such as fuel and parking.
                                                                      their 30s and they’re dying in their 50s,”    pregnancy. This involves accessing                                       After conducting surveys of new
                                                                      says Nerenberg. “So we can’t wait             health databases that already collect                               moms, it made sense to create a
                                                                      until they’re 40 to 50 to start treat-        information on women in Alberta and                                 program that would bring help to them.
                                                                      ments. We have to start in their 30s.”

30   DEPARTMENT OF MEDICINE                                                                                                                                                                                                          2018-19 ANNUAL REPORT           31
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