Continuing health professions education (CHPE) is an important policy intervention for the opioid epidemic. Besides effectiveness or impact, health policy implementation should be studied to understand how an intervention was delivered within complex environments. Implementation outcomes can be used to help interpret CHPE effects and impacts, help answer questions of “how” and “why” programs work, and inform transferability. We evaluated Safer Opioid Prescribing (SOP), a national CHPE program, using implementation outcomes of reach, dose, fidelity, and participant responsiveness.We conducted a retrospective quantitative implementation evaluation of the 2014–2017 cohorts of SOP. To measure reach and dose, we examined participation and completion data. We used Ontario physician demographic data, including regulatory status with respect to controlled substances, to examine relevant trends. To measure fidelity and participant responsiveness, we analyzed participant-provided evaluations of bias, active learning, and relevance to practice. We used descriptive statistics and measures of association for both continuous and categorical variables. We used logistic regression to determine predictors of workshop participation and analysis of covariance to examine variation in satisfaction across different-sized sessions.Reach: In total, there were 472 unique participants, 84.0% of whom were family physicians. Among Ontario physician participants, 90.0% were family physicians with characteristics representative of province-wide demographics. Dose: Webinar completion rate was 86.2% with no differences in completion based on rurality, gender, or controlled substance prescribing status with medical regulatory authorities. Fidelity and participant responsiveness: Nearly all participants rated the three webinars and workshop as balanced, and each element of SOP was also rated as highly relevant to clinical practice.This evaluation demonstrates that Safer Opioid Prescribing was implemented as intended. Over a short period and without any external funding, the program reached more than 1% of the Ontario physician workforce. This suggests that the program may be a good model for using virtual CHPE to reach a critical mass of prescribers. This study represents a methodological advance of adapting evaluation methods from health policy and complex interventions for continuing health professions education. Future studies will assess effectiveness and impact on opioid prescribing and utilization within evaluation models of complex interventions.The online version contains supplementary material available at 10.1186/s12909-021-02529-7. Health policies are often characterized as complex interventions and continuing health professions education (CHPE) programs share many similar distinguishing features: they involve the actions of people, include a complex chain of steps, are embedded in social systems shaped by context, and are dynamic, open systems subject to change , 2. ThisOpioid-related harms such as overdose and death continue to mount throughout high-income North America. In the United States more than 232,000 people died between 1999 and 2018 from opioid overdoses involving prescription opioids, with death rates more than four times higher in 2018 compared to 1999 . While iContinuing health professional education (CHPE) without industry involvement has been considered an important rectifying intervention as identified by a variety of national and regional policy documents –12, editIn a recent systematic review of the effectiveness of interventions to reduce opioid-related harms, Furlan et al.  identifiMoore et al.’s CHPE outcomes framework , 27 provWith this framework of opioid prescribing CHPE as a health policy intervention, we aimed to conduct a comprehensive implementation evaluation of a national Canadian program called Safer Opioid Prescribing (SOP). SOP was fully redeveloped from a previous program that has been delivered by the College of Physicians and Surgeons of Ontario (CPSO) to address remediation needs for physicians for whom this medical regulator had identified instances of inappropriate controlled substance prescribing. SOP continued to address this remediation need for the CPSO, as well as medical regulators in other Canadian provinces, but aimed primarily to provide high quality continuing education for health professionals without any regulatory involvement. In this study, we specifically assessed the implementation outcomes of reach, dose, fidelity and participant responsiveness. Study questions, implementation outcomes and corresponding CPD outcome level are summarized in Table We conducted a quantitative retrospective cohort evaluation of SOP between 2014 and 2017 using registration and participant evaluation data. Ethical approval for this study was granted by the University of Toronto Research Ethics Board.contextualize CHPE within the specific circumstances of the Canadian contemporary opioid epidemic and the range of other policy options for addressing it; b) involve the target audience for the intervention in program planning; and, c) conceptualize and categorize specific implementation and effectiveness outcomes during the initial design stages  effectiveness to identify and incorporate best practices in education for achieving practice change and improvement in patient outcomes –47, inclThe first of the three webinars focused on the multimodal management of chronic pain; the second on the details of opioid prescribing ; and the third on situations in which prescribing can be more challenging . The workshop addressed challenging cases and communication issues, focusing on skills and competencies particularly suited for a live workshop as compared to a synchronous webinar. Webinar participation was a pre-requisite for workshop participation. Each webinar and the workshop had specific pre-work and post-work to prime learning and to facilitate integration into practice, respectively. The program was accredited for a total of 27 credits of learning: 9 credits for the webinars and an additional 18 credits for the workshop.The study population included all SOP participants from January 1, 2014 through June 14, 2017. This study period was chosen because the program had fully launched in its current form by January 2014 and the content of the program was substantially redeveloped after June 2017 based on the release of new Canadian guidelines for opioid prescribing . We inclParticipation data was collected from the registration system of Continuing Professional Development at the University of Toronto which administers SOP. Registration data included dates of participation, practice location, profession and specialty. For Ontario physicians, these registration data were linked with gender, graduating medical school and dates of Ontario licensure from the public register of the CPSO. Prior authorization from the CPSO to access these data was obtained. The Ontario Medical Association’s (OMA) Rurality Index of Ontario was used to determine a rurality score based on practice postal code. This Index has been used in other program evaluations as a measure of rurality for Ontario physicians . For datWe collected both participation and satisfaction data to assess for the implementation measures of reach, dose, fidelity and participant responsiveness . We defiHewing closely to the definition of dose as “how much of the original program has been delivered”  or Canadian medical graduate (CMG) status and the likelihood of workshop participation. We used the Hosmer–Lemeshow test to assess the goodness of fit for the logistic regression model and the outcomes are reported as odds ratios. We used analysis of covariance to assess for variability in adequacy of active learning time and clinical relevance across different size groups and program types (webinar or workshop). All tests were two-sided and mean = 47.5). Workshop participation ranged from 14 to 26 (mean = 24.2). The response rate for anonymous post webinar evaluations was between 51 to 53% and for post workshop evaluations was 91 to 99%.During this study period, the SOP series of three webinars was offered 11 times. The workshop was offered 8 times as a standalone program in Toronto, Ontario, Canada at a University-affiliated conference centre. The number of participants per webinar ranged from 26 to 74 (n = 10) were excluded from this analysis. We combined data for registrants who participated in the program more than once (n = 20) into a single record. We excluded 18 medical residents (3.5%) and also excluded an additional 17 registrants (3.3%) due to incomplete registration or participation data.There were 517 unique registrants for this program. Participants who only participated in the workshop . Two hundred and fifty-nine (64.8%) were Canadian medical graduates, which was significantly lower than the proportion of 70.5% for physicians in the entire province (p < .0001). The mean number of years of practice was 19.2 (SD = 14.0) and ranged from 0.0 to 50.0. There was a clear bimodal distribution with a peak in the 0–10 year range consisting of nearly even female and male participants and another peak in the 30–35 years in practice range consisting mostly of male participants .We analyzed the Ontario physician participants with respect to their status regarding controlled substance prescribing with the provincial medical regulatory college Table . We founp = 0.001). Family physicians with a focused practice in emergency medicine (n = 25) had a completion rate of 68.0%, which was closer to other medical specialists than to other family physicians (not shown). Likewise, Ontario participants had a significantly higher completion rate of 87.7% compared to the non-Ontario rate of 75.0% (p = .009). However, participants from jurisdictions below a two-hour time difference from Ontario  had completion rates similar to Ontario at 85.2% (p = .753), while those at a two-hour or greater time difference from Ontario  had a significantly lower completion rate of 65.5% (p = .0005).Of the 472 webinar participants, 407 completed all three webinars for a completion rate of 86.2% Table . There wp = .003). We conducted a multivariate logistic regression to determine predictors of workshop participation for Ontario physician participants. Webinar completers were 5.1 times more likely to participate in the workshop  than non-completers. Those who had medical regulatory involvement were 4.1 times more likely than those with no involvement to participate in the workshop . Urban practitioners were 2.2 times more likely than rural practitioners to participate in the workshop, but this finding was not statistically significant . There was no difference between urban and non-major urban participants . Gender, years in practice, or country of medical school graduation also did not predict workshop participation.Of the 472 webinar participants, 177 (37.5%) participated in the workshop. Ontario participants were more likely to participate in the workshop than were participants from other provinces .Close to 100% of the participants rated the three webinars and workshop as balanced and unbiased Table . Each elp = .178).All elements of the program were rated as having adequate time for active learning Table . An analSOP was designed as a policy intervention for the Canadian opioid crisis, using best practices in CHPE as a means for driving meaningful change at multiple levels of outcomes. This evaluation strongly suggests that through 2014–2017, SOP was delivered as intended along multiple implementation outcomes including reach, dose, fidelity and participant responsiveness.Family physicians, who are responsible for the majority of long-term and high-dose opioid prescribing, were disproportionately represented in the program. Likewise, participation in the program was representative of the geographic spread of physicians in Ontario, despite the program being delivered virtually from a major urban academic medical centre. This was accomplished in the context of Ontario’s vast geography and known issues of poor access to high-speed internet in rural and remote communities . OverallThe program was rated as highly relevant to practice, which may partly explain the very high engagement and completion rates. The slightly lower completion rates amongst specialist physicians and family physicians with focused practices, such as in emergency medicine, may in part be driven by lower relevance to practice ratings. It should be noted, however, that completion rates amongst these groups was still very high compared to internet-delivered CHPE norms –61. AnotOut of province completion rates were also high at 75.0%, though not as high as Ontario participants. This may be driven by lower relevance to practice as some of the program content is focused on epidemiological and practice issues specific to Ontario. However, a more practical reason for this difference may be because of time zone differences making it challenging for working professionals to participate in the webinars.While not formally assessed as part of this implementation evaluation, scalability of the program  is suggeAs CHPE evaluation has moved increasingly towards outcome-based approaches  with a pTo our knowledge, this study is one of few examples of an opioid prescribing CHPE evaluation that has formally assessed implementation outcomes using an evaluation framework for complex interventions together with a CHPE outcome model. Barth et al.  describeOverall this implementation evaluation adds further support to the feasibility of delivering multicomponent CHPE programs virtually to increase reach, scalability and thus potentially effectiveness and impact –73. ThisThere are several important limitations to this study. First, this study was of a single program and was conducted retrospectively using data that were collected for both evaluative purposes but also for administrative purposes, such as for tracking participation for accreditation reporting. We did have to exclude 17 participants (3.2%) due to incomplete participation data. This was a small enough number that it was unlikely to significantly bias results. Likewise, demographic data was for the most part complete. We could not, for example, determine rurality for only two of the 400 Ontario physician participants. Also, it is important to note that the evaluative data collected (e.g. relevance to practice and amount of interactivity) was defined prior to the delivery of the program and did reflect attempts to assess underlying program theory. The second data limitation relates to the anonymous nature of the evaluative data. These were kept anonymous as per norms in CHPE to allow participants to freely share their evaluative assessments. However, this did not allow us to link evaluative statements to particular participants and then analyze by demographic factors. This could be rectified in future evaluations by using, for example, a linking identifier that blinds the scientific planning committee to the identity of participants but allows evaluators to link evaluations to the demographic characteristics of de-identified program participants. Likewise, the webinar evaluation data response rates were moderate at 51% which would introduce an unknown bias to these data. Since these responses were anonymous, it is not possible to further assess the nature of this possible bias. However, the consistency of these evaluative responses between the webinars and the consistency of the responses with the workshop data which had an excellent response rate provides confidence that these data are reflective of the entire participant population. Third, the available data did not allow for a direct inquiry into the posited mechanism for change, namely that the SOP structure facilitates the creation of a virtual community of learning and practice. Qualitative inquiry using interviews or focus groups of program participants and facilitators would be well suited to better assess this aspect of the program. As noted above, this evaluation did not study patient- or population-level outcomes, which will be a priority for future study.This evaluation demonstrates that Safer Opioid Prescribing was implemented as intended. Over a short period and without any external funding, the program reached more than 1% of the Ontario physician workforce. This suggests that Safer Opioid Prescribing may be a good model for using virtual continuing health professions education to reach a critical mass of prescribers. This study represents a methodological advance of adapting evaluation methods from health policy and complex interventions for continuing health professions education. This implementation evaluation will be used to inform further effectiveness and impact evaluations of Safer Opioid Prescribing.Additional file 1.Additional file 2.Additional file 3.


The aim of this study is to investigate if there are educational level and birthplace related differences in joint-related pain, health-related quality of life (HRQoL), willingness to undergo joint surgery, walking difficulties, physical activity level, fear-avoidance behavior before, as well as three and 12 months after participation in a structured self-management program for hip and knee osteoarthritis. Differences in adherence to and use of knowledge from the program were also investigated. An observational national register-based study was performed with a prospective longitudinal design using patient and physiotherapist-reported data on 22,741 complete cases from the National Quality Register for better management of patients with osteoarthritis (BOA) during years 2008–2017. At baseline and after three and 12 months follow-up, higher educational level and being domestic-born was associated with less joint-related pain, better HRQoL, lower willingness to undergo joint surgery, fewer walking difficulties, higher physical activity level, and less fear-avoidance behavior. Foreign born individuals demonstrated higher adherence to exercise and reported better use of the self-management program. The BOA self-management program may require further pedagogical refinement to suit participants of different sociodemographic backgrounds and health literacy. A more patient-centered delivery, sensitive to educational, ethnic, and cultural differences may potentially reduce inequalities in future outcomes. Today, osteoarthritis (OA) is the fastest growing disability, causing disease globally and affecting over 40 million people in Europe ,2. AccorIn light of this background, a Swedish national care program for the better management of patients with osteoarthritis (BOA) was launched in 2006 with the intention that all patients in Sweden with symptomatic hip and knee OA should be offered this treatment ,8,9,10.Disparities in the patient reported frequency of OA-related symptoms and self-efficacy to manage symptoms have previously been reported in the Swedish context based on social determinants, such as educational level and domestic/foreign birthplace ,11,12. AForeign born individuals make up 19.1% of Sweden’s population . In a crTheoretical frameworks propose that social determinants are likely to play a role in OA outcomes . FurtherThe aim of this study is to investigate if there are educational level and birthplace differences in joint related pain, HRQoL, willingness to undergo joint surgery, walking difficulties, physical activity level, fear-avoidance behavior before, as well as three and 12 months after participation in a structured self-management program for hip and knee osteoarthritis. Adherence to and use of knowledge from the program were also investigated.This is an observational national register-based study with prospective longitudinal design for routine collected outcomes of the BOA Swedish national care program. The BOA self-management program has been described elsewhere  and is on = 94,798) were eligible. The BOA register prospectively includes patients who have sought treatment for hip and/or knee pain in all the 21 regions of Sweden, and after a confirmed OA diagnosis  have been referred to the BOA self-management program. The following exclusion criteria for participation in the BOA self-management program and registration in the BOA register are applied: suspicion of or confirmed tumor, rheumatoid arthritis, sequel hip fracture, chronic pain or fibromyalgia, TJR within the past 12 months or other knee or hip joint surgery within the past 3 months and inability to read or understand the Swedish language.All patients from the BOA register, with a first registration (baseline) between 01,012,008–31,122,017 . Those who had undergone TJR or decided to drop out for any other reason for surgery were also excluded . In a final step, participants with missing data from any of the covariates, dependent and independent variables in the present study were excluded . This was done to facilitate a complete case analysis [A flow-chart for defining the selection and size of the analytic sample for this study is illustrated in d n = 15,5. In a fPatient-reported outcome measures are collected and entered in the BOA registry when the patient visits the physiotherapist at baseline and at 3-months follow-up. Patients also receive a final questionnaire by mail or email after 12 months which is entered into the BOA registry. Health care quality process indicators are reported by the responsible physiotherapist or occupational therapist at baseline and after 3 months. The following variables were extracted from the BOA registry for the current study and are outlined in -Which is the highest level of education that you have obtained ?-Were you born in Sweden (yes/no)?Independent VariablesCovariates2) was calculated based on patient’s self-assessed weight (kilograms) and length (centimetres).All analyses were adjusted for age, sex, and levels of BMI. Age and sex are self-administered variables by the BOA-register, retrieved by the patient’s personal identity number in the baseline questionnaire. BMI , ranging from 0–10  .-The EQ-5D-3L is a standardised self-reported generic measurement of health. It covers five aspects of health: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 3 levels: no problems, some problems, extreme problems, resulting in 243 possible health states. In this study we used the United Kingdom value set, diverging from −0.594 to 1, where a value of 1 means that a person has no problems with any of the five health domains, and value of 0 means that the person has extreme problems with all five health domains .-Do you suffer so much impairment from any joint that you are willing to undergo surgery (yes/no)?-Does your pain cause you difficulties with walking (yes/no)?-Being physical active more than 150 min per week (yes/no)? This was originally an ordinal variable with seven answer options (spanning from 0 min to more than 300 min). Categories 150–300 min and more than 300 min were recoded into “yes”, and all other categories into “no”. This because at least 150 min of physical activity weekly is recommended to prevent all-cause mortality and chronic disease .-Fear-avoidance behaviour: Are you afraid that exercise or physical activity will be harmful to your joints (yes/no)?-Participation in theory lessons was assessed by a single question assessed by the physical or occupational therapist, namely “has the patient participated in the theory sessions” (yes/no)?-Number of supervised exercise sessions the patient participated in, assessed and reported by the physical or occupational therapist. This variable had five answer categories spanning from no session to more than 12. But to make the variable easier to overview, responses were categorized into: no exercise session, 1–9 sessions, and 10 or more.-How often do you use knowledge acquired from the self-management program? Originally the variable had six categories but for the purpose of interpretation the variable was recoded into two categories. One category included responses like “every day or several times daily” while the other category included responses like “every week, month, never, or don’t know”.Dependent VariablesAs a first step in the analyses, we explored the distribution of the sample across the sociodemographic characteristics and outcomes. The results are presented in terms of means and standard deviations for the continuous indicators and numbers and percentages for the categorical indicators.In the next step, we analyzed the associations between the exposure to sociodemographic factors  and the BOA self-management program outcomes using multivariate analyses.The continuous outcomes (EQ-5D-3L and NRS pain) were analyzed by analysis of covariance (ANCOVA) with Bonferroni corrections for multiple comparisons. The results are presented in terms of adjusted means with 95% confidence intervals (CI). Educational level or domestic/foreign country of birth were analyzed as in separate ANCOVA models, where they were used alternatively as a fixed factor or covariate.The dichotomous outcomes were analyzed using binary logistic regressions. The reported degree of participation in exercise session (3 categories) was analyzed using multinomial logistic regression in order to account for nonlinearities in the associations. The results from these analyses are presented in terms of adjusted odds ratios (OR) with 95% CI.In addition to the main exposures, education and birthplace, all statistical analyses were also adjusted for age, BMI and the baseline score of the outcome. All statistical analyses were conducted using SPSS for Windows, version 25 on a secure online data access (SODA) service provided by the Centre of Registers, Västra Götaland, Sweden where the BOA national registry is housed.The study was approved by the Regional Ethical Review Board Gothenburg (entry number: 986-17). All participants in the register are informed by the responsible physiotherapist that their participation will be registered in BOA and may be used in research.Descriptive sociodemographic characteristics for the analytical sample are described in Longitudinal outcomes comparing educational levels showed statistically significantly higher levels of HRQoL and physical activity at baseline, three and 12 months, regular use of learned content from the self-management program after three and 12 months and higher levels of participation in 1–9 exercise sessions in participants with higher level of education. Furthermore, statistically significant less NRS pain and willingness for joint surgery at baseline and three and 12 months, as well as less walking difficulties and less fear-avoidance behavior after three and 12 months was observed among participants with a higher level of education.A comparison of country of origin showed statistically significant higher levels of HRQoL and physical activity at baseline and three and 12 months among domestic born participants. Significantly less NRS pain, walking difficulties and fear-avoidance behavior were reported at baseline, three and 12 months in the domestic born groups. Furthermore, significantly less willingness for joint surgery at baseline, less regular use of learned content from the self-management program after three and 12 months, as well as lower levels of participation in exercise sessions was reported in the domestic-born group.In line with the study’s aim, investigation of registry data from before the BOA self-management program start, after three months follow-up, and after 12 months follow-up could confirm statistically significant differences in outcomes according to education and domestic/foreign country of birth, adjusted for known confounders. Self-reported pain, HRQoL, levels of physical activity, and walking difficulty showed a persistent pattern where participants with higher education and domestic-born participants reported better outcomes from the BOA self-management program over time.Our findings that participants with lower educational attainment reported more pain and lower HRQoL at baseline and maintained a higher willingness to undergo joint surgery despite participation in the BOA self-management program is in line with earlier research ,14,24.Foreign born participants reported a greater willingness to undergo joint surgery at baseline than domestic born participants, but this difference had vanished at the three and 12-month follow-ups. One possible reason for this could be that foreign-born participants in the BOA cohort on average reported higher levels of OA-related pain. This finding is similar to previous literature from Swedish cohorts for TJR , and musForeign-born participants participated in more exercises sessions and were more likely to utilize what they have learned from the BOA self-management program when compared to domestic-born participants. This may appear contradictory since, in the current study and similar to previous literature ,12, foreBoth participants with lower levels of education and those foreign-born reported increasingly higher odds for fear-avoidance behavior at all follow-up’s even though all participants receive the message that physical activity and exercise are safe for the joints. Since earlier research  has showThe BOA self-management program is one of Sweden’s biggest public health interventions, with the potential to diminish sociodemographic inequalities in health. However, sociodemographic inequalities in OA-related health exists after participation in the BOA self-management program. This suggests that the educational intervention within the BOA self-management program may require further pedagogical refinement to suit participants of different sociodemographic background and health literacy, as a more personalized delivery of OA self-management care has been recommended in the current literature ,29.To our knowledge, this study provides the largest study sample to date for evaluating non-surgical measures to affect OA health in relation to participants sociodemographic background. This is also the first large cohort study to show that foreign/domestic birthplace is associated with varying adherence to an OA management program. In addition, only two prior studies have assessed if educational level is associated with adherence to OA-related rehabilitation ,30. HoweSelf-reported variables over multiple measurements imply an inherent possibility of response-shift and social desirability bias that one must also take into consideration. Another possible limitation was that knee/hip OA were not analyzed separately, as research has shown that patients with hip OA are less likely to respond to nonsurgical treatment . It is nThe BOA self-management program may require further pedagogical refinement to suit participants of different sociodemographic backgrounds and health literacy. A more patient-centered delivery sensitive to educational, ethnic, and cultural differences may potentially reduce inequalities in future outcomes.


Furthermore, positive LVI was associated with shorter overall survival (OS) (p = 0.014) and was an independent risk factor of poor OS. Although there was no association between LVI status and lymphangiogenesis, epithelial-mesenchymal transition (EMT), or metastasis-related genes, Gene Set Enrichment Analysis revealed a strong association with cell-proliferation-related gene sets such as mitotic spindles  = 1.76, p = 0.016) and G2/M checkpoints , as well as with transforming growth factor beta (TGF-beta) signaling , which is a known mechanism of metastasis in PDACs. In conclusion, positive LVI was an independent risk factor of poor OS in PDACs. We found that PDACs with LVI were possibly associated with accelerated cell proliferation and enhanced TGF-beta signaling independent of lymphangiogenesis. Transcriptomic profiling elucidates more precise tumor biology of LVI-positive PDACs.Lymphovascular invasion (LVI) is an aggressive pathologic feature and considered a risk factor for distant metastasis. We hypothesized that pancreatic ductal adenocarcinomas (PDACs) with LVI are associated with shorter survival, as well as aggressive cancer biology and lymphangiogenesis in transcriptomic analysis. Utilizing the cancer genome atlas (TCGA)-PDAC cohort, we found that positive LVI was significantly associated with positive perineural invasion (PNI) ( Pancreatic ductal adenocarcinoma (PDAC) will become the second leading cause of cancer-related deaths in the United States by 2030 ,2. The eThere have been multiple studies reporting an association between clinical outcome and pathological features, such as LVI and PNI in patients with PDAC ,7,14,15.p = 0.023, p = 0.318, p = 0.085, p = 0.017, p < 0.001, Out of 154 patients in the TCGA cohort, 130 (84.4%) and 123 79.9%) had LVI and PNI information available, respectively. Among these patients, the number of PDACs with positive LVI and PNI were 85 (65.4%) and 109 (89.1%), respectively, similar to the previous reports 9.9% had . The prop = 0.069, p = 0.014, p = 0.021), adjuvant radiation (p = 0.002), and positive LVI status (p = 0.011) were associated with OS. Multivariate analysis revealed that positive LVI was independently associated with shorter OS  compared with patients without LVI , tumor inflammation, metabolism, cell proliferation, cancer stem cell maintenance, and several other important signaling pathways in PDACs. As Jones et al. reported that there were several core signaling pathways altered in most PDACs, including transforming growth factor beta (TGF-beta), Notch signaling, WNT-beta catenin, and Hedgehog pathways , we suspTo our knowledge, this is the first study evaluating the association between pathologically proven LVIs and transcriptomic information in a PDAC cohort. Some of the pathological information, such as LVI or PNI, is not included in clinicopathological data in the TCGA cohort. However, with the Text Information Extraction System (TIES), we were able to access the de-identified original pathology reports on each TCGA patient and link pathological information to the transcriptomic data manually. This methodology enabled us to complete this study.Similar to our previous study on the association between enhanced vascularity in PDACs and better survival, we investigated the association between LVI-positive PDACs and lymphangiogenesis and ECM degradation, utilizing transcriptomic profiling analysis. We found that PNI status and AJCC T and N categories were associated with LVI status in the PDACs. Using the TCGA cohort, we confirmed that positive LVI status was significantly associated with poor survival in PDAC and an independent risk factor for OS, echoing the previous reports ,15. FurtWe found that that positive LVI tumors were associated with a higher AJCC T category and increased lymph node metastases, which is in agreement with previous studies ,7,14. EpTGF-beta signaling was associated with positive LVI status in the present study. TGF-beta signaling is one of several core signaling pathways commonly altered in PDACs , and enhThese novel findings should be noted in the context of the limitations of this study. First, we utilized solely publicly available TCGA datasets. We are aware that our findings and conclusions would have been stronger with a validation cohort. Unfortunately, given the low incidence of pancreatic cancer despite its high mortality, a cohort including transcriptomic and clinicopathological data was not available, despite our extensive search. Second, there was some missing information from the original reports in TIES. However, we were able to retrieve approximately 85% of LVI and PNI statuses. Further, pathological information for LVI and PNI was obtained from the original reports through TIES, and these reports were not validated or standardized . Third, http://ties.dbmi.pitt.edu/#) through the Roswell Park Comprehensive Cancer Center. Given that TCGA is a publicly available, de-identified database, the Institutional Review Board (IRB) was exempted.Clinicopathological data and gene expression data from RNA sequences were obtained from the TCGA pancreatic cancer cohort (PAAD) through cBioPortal ,53, whichttps://software.broadinstitute.org/gsea/index.jsp), as described before [GSEA was performed, comparing tumors that were LVI-positive and negative, utilizing the Hallmark gene sets  with thed before ,27,60,61p-value < 0.05 on univariate analyses.DFS was defined as the time from the date of surgery to the date of disease progression. OS was defined as the time from the date of surgery to the date of death by any cause. In order to obtain hazard ratios (HRs) and 95% confidence intervals (CIs), univariate and multivariate analyses for OS were conducted, using age, gender, tumor size, AJCC Staging T and N categories, histological grade, residual tumor status, history of adjuvant radiation treatment, PNI, and LVI. AJCC pathological stage IA and IB and stage IIA and IIB were simplified to stage I and stage II, respectively. Some of the parameters were dichotomized as follows: age below 65 and age 65 and above, tumor size below 3.5 cm and greater than or equal to 3.5 cm , AJCC T category T1 + T2 and T3 + T4, pathological AJCC stage I + II and III + IV, residual tumor status R1 + R2 and R0, and histologic grade G3 (poorly differentiated) and G1 + G2 (well-differentiated + moderately-differentiated). Multivariate analysis was performed with variables with a http://www.r-project.org/) together with Bioconductor (http://bioconductor.org/). A p-value < 0.05 (two-tailed) was considered to be statistically significant.Statistical comparisons of the clinicopathological parameters were performed by a Chi square test. Continuous values were compared by a Student’s t-test. All statistical analyses were performed using JMP 14.2  and R software (In conclusion, a positive LVI status was associated with shorter OS in PDACs, possibly due to accelerated cell proliferation and enhanced TGF-beta signaling, leading to faster tumor growth and higher lymph node metastasis potential. Transcriptomic profiling from human pancreatic cancer specimens elucidates more precise tumor biology in LVI-positive PDACs.


Work engagement is important for employee well-being and work performance. However, no intervention study has investigated the effect of an eMental Health intervention on work engagement among workers in low- and middle-income countries (LMICs).The aim of the study was to examine the effects of a newly developed smartphone-based stress management program (ABC Stress Management) on improving work engagement among hospital nurses in Vietnam, an LMIC.Full-time registered nurses (n=949) were randomly assigned to one of 2 intervention groups or a control group. The intervention groups were a 6-week, 6-lesson program offering basic cognitive behavioral therapy (CBT-based stress management skills), provided in either free-choice (program A) or fixed order (program B). Work engagement was assessed at baseline and 3-month and 7-month follow-ups in each of the 3 groups.P=.049) with a small effect size . Program A showed nonsignificant trend  toward improved engagement at 3 months. Neither program achieved effectiveness at the 7-month follow-up.The scores of work engagement in both intervention groups improved from baseline to 3-month follow-up, and then decreased at the 7-month follow-up, while the score steadily increased from baseline to 7-month follow-up in the control group. Program B showed a significant intervention effect on improving work engagement at the 3-month follow-up (The study demonstrated that a fixed order (program B) delivery of a smartphone-based stress management program was effective in improving work engagement in nurses in Vietnam. However, the effect was small and only temporary. Further improvement of this program is required to achieve a greater effect size and more sustained, longer lasting impact on work engagement.University Hospital Medical Information Network Clinical Trials Registry UMIN000033139; tinyurl.com/55gxo253RR2-10.1136/bmjopen-2018-025138 Work engagement is a popular topic in occupational mental health, given its positive impact on employee well-being and work performance ,2. IncreSmartphone ownership has been rapidly increasing in low- and middle-income countries (LMICs) , and theEngagement in their work holds an important role in nurses’ health, well-being ,16, workThe purpose of this study was to determine whether a newly developed smartphone-based stress management program improved work engagement among hospital nurses in Vietnam. We analyzed data collected in a randomized controlled trial (RCT) that included work engagement as a secondary outcome .This was a 3-armed RCT  examining improvement of depressive and anxiety symptoms as primary outcomes and, as stated, work engagement as a secondary outcome. The results of two internet-based CBT stress management programs  were compared with that of a control group at 3-month and 7-month follow-ups among hospital nurses in Vietnam . The resAll participants (n=1256) were recruited from a large public tertiary hospital at national level in Hanoi, Vietnam in 2018. We distributed written information about the study, consent form, baseline questionnaires, and a numbered envelope to return the completed questionnaires anonymously. The inclusion criteria were being employed full time as a registered nurse and having internet access via a mobile device such as a smartphone. The exclusion criteria were (1) plans to change or leave the job in the next 7 months, (2) being an assistant nurse and helper, (3) being temporary or part-time employed, (4) having taken leave for 15 or more days for a physical or mental condition in the past 3 months, and (5) undergoing treatment for a mental health problem from a mental health professional. However, exclusion criteria 4 and 5 were withdrawn before the start of the baseline survey (see Changes to the Protocol in Methods).Two smartphone-based stress management programs (program A and program B) were developed in the ABC Stress Management app. Program A was a free-choice multimodule program, in which participants could select a module to complete each week in any order. Program B was a fixed-sequential order multimodule program, in which participants were required to complete one module per week in a fixed order. The contents of program A were based on a previous online stress management program to reduce the distress of office workers in Japan . ProgramParticipants in the intervention groups were required to complete program A or B within 10 weeks after the baseline survey. Participants began the program after signing in with their ID and password. The clinical research coordinator sent weekly reminder messages to people who had not completed a module on time. An informal group chat  with researchers and hospital head nurses was used to deliver intensive technical support for participants to complete the program. Before the start of the intervention, researchers helped participants download the app and complete an introductory module that provided a general explanation of how to use the app.Participants in the control group did not receive any intervention during the 7-month intervention period. However, they were free to use any other mental health service as usual treatment. Intervention programs were provided for the control group after the 7-month follow-up.All outcomes were assessed at baseline and, 3-month (the end of the intervention period), and 7-month follow-ups with a paper-based self-administered survey questionnaire. Participants were allowed 10 weeks to complete the program (6 weeks for the modules and 4 weeks to review any modules they desired). Follow-up at 3 months was timed to assess immediate effects of the interventions. For administrative reasons, we conducted a follow-up at 7 months, instead of a usual 6-month follow-up, to evaluate longer term effects.The short form of the Utrecht Work Engagement Scale–9 item (UWES-9) was used to assess work engagement . The UWEDemographic and occupational variables were assessed using a questionnaire and included gender , age, education , marital status , and employment contract . Age was calculated based on the year of birth.The sample size in the study was calculated for the primary outcome  when the effect size was set to 0.25. A post hoc test power (1-beta) for work engagement was calculated as 0.52 at the 3-month follow-up and 0.10 at the 7-month follow-up, assuming that the alpha was less than 0.05 (2-tailed) and the number of respondents in each group who were included in the analyses was 317, using the G*Power 3.1 program (Heinrich-Heine-Universität Düsseldorf) ,40.Eligible participants were randomly assigned to one of the 3 trial arms (2 intervention groups and a control group). Stratified permuted-block randomization was conducted. The block sizes were fixed at 3. Participants were stratified according to the baseline depression subscale score of DASS-21 into 2 strata (≥10 or <10) . A stratFor the main pooled analysis, a mixed model for repeated measures conditional growth model analysis with an unstructured covariance matrix was conducted using a group (intervention and control) × time (baseline and 3-month and 7-month follow-ups) interaction as an indicator of the intervention effect. The 2 intervention effects (program A vs control and program B vs control) were simultaneously tested in the model. For sensitivity analysis, a similar mixed model for repeated measures, but using the analysis of variance model with an unstructured covariance matrix, was conducted.At the baseline survey, if the number of missing items was less than half of the number of total items, the missing values were imputed, using values calculated according to the following equation:  / number of missing items. Otherwise, if the number of missing items was more than half of the total items, the case was not imputed and treated as missing. Missing values at follow-up surveys were imputed by applying the maximum likelihood estimation. An intention-to-treat principle was applied.d among completers at baseline for each follow-up.The effect size was estimated in 2 ways. First, we estimated a regression coefficient for a group (each of the 2 intervention groups vs the control group) × time (baseline and 2 follow-ups) interaction, which was converted to an effect size by dividing by a pooled standard deviation at baseline and follow-ups. Second, we calculated Cohen P<.05. All statistical analyses were performed using SPSS Statistics 26.0, Japanese version (IBM Corp).Statistical significance was defined as Before starting the study, 2 of the exclusion criteria  were removed because these restrictions would be expected to reduce the participation rate, and because reducing the eligibility restrictions when selecting participants is desirable for the purpose of ascertaining the effect of the programs in the real setting as a pragmatic trial .The participant flowchart is shown in t=1.97, P=.049, d=0.16; 95% CI 0.001 to 0.43). On the other hand, program A showed a nonsignificant trend  toward improved work engagement at 3 months. At 7 months, neither program showed a significant effect .The average scores of work engagement and subscales at each time are shown in d=0.16, P=.049). Program A did not show a significant effect at the 3-month follow-up. Neither program achieved effectiveness at the 7-month follow-up. A smartphone-based stress management program with fixed sequential order may be effective in improving work engagement in a population of nurses in an LMIC, Vietnam.The 3-arm RCT examined the effects of a newly developed smartphone-based stress management program to improve work engagement as the secondary outcome at 3-month and 7- month follow-ups among hospital nurses in Vietnam. Program B, a 6-module CBT program with fixed sequential order, showed a significant small intervention effect on work engagement at the 3-month follow-up (Scores on the UWES-9 increased (indicating improved work engagement) from baseline to seven-month follow-up in the control group as well. A possible reason is potential contamination by information provided about the intervention programs from intervention groups to the control group . ControlProgram B significantly improved work engagement at the 3-month follow-up among nurses in the intervention groups compared with nurses in the control group. This result was consistent with a previous RCT on work engagement among information technology workers in Japan , which sIn terms of the feasibility and reach of a smartphone-based intervention, more than 80% of nurses in the target hospital owned smartphones. The content of the programs was appropriate and relevant since the case story presented was based on interviews with nurses in Vietnam about managing their stress on the job. After making an outline, the content was reviewed and confirmed by nurses. These factors may facilitate the use of program B and support its ability to improve work engagement. However, the effectiveness of an iCBT program may depend on the culture and internet or smartphone literacy in a target country. Moreover, nurses are professionals. Their job requires an advanced college or university education. Additional research is needed to expand these findings to other LMICs and occupations.Nurses who used program B were required to learn the cognitive behavioral model in an early module before continuing to later modules. Studying cognitive restructuring skills may decrease negative emotions , enhanced=0.16) for 1-beta over .80. Further study should be conducted to examine long-term effectiveness for hospital nurses.There was no significant effect of program B on work engagement at 7 months. A previous review of eHealth interventions indicated that the long-term benefits of an eHealth program are still unknown due to small effect size . In thisd=0.16, P=.07) and 7-month follow-up. One study in a Western country reported that tailored  options provided a better outcome of eHealth programs because free choice was culturally preferred [Program A shows only nonsignificant effect on work engagement at 3-month  led by researchers and hospital head nurses used to increase the participation rate may also have contributed to improvement of work engagement in the intervention groups. Sixth, there may have been social pressure or frustrations caused by frequent reminding to study the programs, reducing the effect of the program on work engagement. Seventh, the programs were designed mainly to target smartphone users, but they can be used on a PC or tablet. Nurses who did not have smartphones or internet access were excluded from access to the programs. In a future trial, in addition to the smartphone-based program, the same content in the programs should also be provided via other delivery modes such as computer, tablet, or booklet. Finally, it is not known whether a similar effect of this program would be observed outside of the nursing profession, in Vietnam or in other LMICs. Future studies should explore the generalizability of our findings to occupations other than nurses and in other LMICs.The study demonstrated that a smartphone-based stress management program with fixed order significantly improved work engagement in a working population of nurses in an LMIC, Vietnam. However, the effect of the intervention was small and temporary. Further improvement of this program is necessary to achieve a greater effect size and more sustained impact on work engagement. However, fully automated and self-guided programs with great accessibility and minimal cost can be well suited for LMICs. The generalizability of these findings to occupations other than nursing and in other LMICs should be investigated in future studies.


Given the uncertainty of the coronavirus disease 2019 (COVID-19) pandemic, implementing telerehabilitation that enables the remote delivery of rehabilitation services is needed to mitigate the spread of COVID-19. We studied the implementation and the effectiveness of the virtual Graded Repetitive Arm Supplementary Program (GRASP) delivered and evaluated via videoconferencing in individuals with stroke.The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework with mixed methods was used to evaluate the implementation of the 2 iterations of the program delivered by a nonprofit organization during the pandemic.Reach: Seventeen people were screened, 13 people were eligible, and 11 consented to participate in the study. Effectiveness: Between baseline and posttest, participants with stroke demonstrated significant improvement in upper extremity function (Arm Capacity and Movement Test) and self-perceived upper extremity (UE) function . Adoption: Factors that facilitate program uptake by the staff were well-planned implementation, appropriate screening procedure, and helpful feedback from the audits. All staff felt comfortable using videoconferencing technology to deliver the program despite some technical difficulties. Factors contributing to ongoing participation included that the participants liked the group, they perceived improvements, and the instructor was encouraging. Only one participant with stroke was not comfortable using the videoconferencing technology. Implementation: The program was implemented as intended as evaluated by a fidelity checklist. Participants’ adherence was high, as verified by the average attendance and practice time. Maintenance: The organization continued to offer the program.The virtual GRASP program was successfully implemented. Although the program was effective in improving both measured and perceived UE function in a small sample of individuals with stroke, caution should be taken in generalizing the results.Implementing telerehabilitation is crucial to optimize patient outcomes and reduce the spread of COVID-19. Our findings provide guidance on the process of delivering a UE rehabilitation program remotely via videoconferencing for stroke. Moreover, insights that arise from this study also inform the implementation of other telerehabilitation services. The findings of this study will not only inform the considerations of the successful implementation of the virtual GRASP program but also allow for insight into the delivery of other telerehabilitation programs during the COVID-19 pandemic and beyond.Two virtual GRASP programs were delivered from June to August 2020. The 2 programs were delivered over the same period of 10 weeks but on different days during the week. Promotion and participant screening began 1 month prior to the commencement of the program. To ensure the program fidelity, 2 audits were conducted by the research team member during in-class observation via videoconferencing during the second and sixth weeks and the audit feedback was then provided to the instructor. The research team, as an outreach facilitator,Supplementary Appendix 1.http://neurorehab.med.ubc.ca/grasp/). Details regarding the virtual program are summarized using the Template for Intervention Description and Replication checklisthttps://neurorehab.med.ubc.ca/grasp/grasp-manuals-and-resources/). One instructor led the weekly class, and 2 or 3 volunteers were available to assist with the classes. Before the program started, the participant manuals were mailed to the participants. The participants were responsible to source their own equipment for the program according to an equipment list provided by the SRABC/MODC. Most of the equipment was available in the home except for weights, therapy putty, and hand grippers. Information on where to purchase the equipment and alternatives  was provided to the participants. To ensure the safety of participants during online classes, the participants were asked to leave their cameras on so that the staff could visually monitor participants’ conditions during online classes. The emergency contact information, home address, and phone number of each participant were on hand in case of an emergency or medical event. If the staff were concerned about the participant’s safety, the staff would contact the person by phone and offer assistance by calling 911 or his or her emergency contact person. The instructor also reviewed the program safety guideline  with the participants during the screening process.The virtual GRASP program was adapted from the GRASP community program  age ≥ 19 years; (2) diagnosis of stroke; (3) difficulty using the affected UE; (4) some voluntary movement in the affected UE, including the ability to lift the affected arm to the chest level and hold for 5 seconds, some ability to extend the affected wrist, and some ability to grasp and release an object such as a cup handle; 5) living in the community; 6) ability to log into a videoconference to attend the weekly class; 7) ability to understand and follow instructions; and 8) willingness to practice GRASP exercises daily. Eligibility criterion 4 was assessed by asking potential participants to lift the affected arm to the chest level (approximately 60–70 degrees of shoulder flexion), extend the affected wrist (visible active wrist extension from a flexion position), and to grasp and release an object . Participants with severe pain that prevented movement in the affected arm and hand were excluded. Eligible participants could register for the program. At that point, they were approached to participate and consent to an optional research study by the research team.https://www.aphasia.ca/communityhub/).One paid instructor with experience leading the GRASP community program led the program and had received prior GRASP training through an in-person group workshop led by a physical therapist about a year prior. The instructor was a health science student. One volunteer was a registered kinesiologist, and the other 2 volunteers were health science students. The instructor and volunteers received training on aphasia provided by the organization. The aphasia training consisted of a webinar on aphasia knowledge provided by a speech-language pathologist and an online learning module on Supported Conversation for Adults with Aphasia from the Aphasia Institute (http://www.re-aim.org/).https://www.youtube.com/watch?v=CsplVu_U-mg.The implementation was examined using the RE-AIM framework, which provided a systematic and comprehensive framework to evaluate the translation of an evidence-based intervention to practice  is calculated as a Z statistic from the Wilcoxon signed-rank test divided by the square root of the sample size.P less than .05. SPSS 25.0 software  was used for statistical analyses.Descriptive analysis was used to summarize baseline demographic, stroke characteristics, individual changes in clinical assessment scores, responses to the questionnaires, and program and individual records. Effectiveness shown by the differences across 3 time points  was assessed by the Friedman tests with a within-group factor of time. Post hoc paired comparisons  were made using the Wilcoxon signed-rank test. The effect size The funders played no role in the design, conduct, or reporting of this study.Seventeen individuals were screened for eligibility and 13 were eligible. Four did not meet the inclusion criteria because of insufficient voluntary movement in the affected arm/hand. Among the 13 eligible individuals, 1 person did not register for the program because of a busy schedule. With 55,000 individuals experiencing the effects of stroke in British Columbia, Canada2(2) = 7.032, P = .030], REACH Scale , SIS-Hand , and SIS-Hand Recovery . Post hoc analysis revealed that there were significant improvements between the baseline and posttest in ArmCAM , SIS-Hand , and SIS-Hand Recovery . Significant improvements were also found between the baseline and follow-up in the REACH Scale , SIS-Hand , and SIS-Hand Recovery .Individual changes in ArmCAM, SIS-Hand, and SIS-Hand Recovery are shown in the As shown in Common reasons that facilitated ongoing participation included that the participants liked the group (N = 7), they perceived improvements (N = 7), and the instructor was encouraging (N = 7) and well trained (N = 6). When asked what the best part of the class was, 6 participants identified positive group dynamics, for example: “Learning from each instructor and each other participants. Amazing how much I learned and get new ideas from the others” and “I think the best part of the class was the constant insistence that we use the affected arm, that we found new ways of using it, and we were encouraged to share ideas and bring one or two new ideas to class every week.” Another participant reported that “Our instructor was a pleasure to deal with, and she was always encouraging us even in our smallest accomplishments.” Three participants identified fatigue, 2 participants reported pain, and 2 participants thought the exercises were too difficult, as the barriers to doing the GRASP exercises. All participants agreed that they had the necessary equipment to do the GRASP exercises. Only one participant stated the cost of the program was a barrier and financial assistance was provided by the nonprofit organization. All but one participant was comfortable using the videoconference technology  and identified that the videoconference technology did not interfere with the GRASP program.The virtual GRASP program was implemented successfully by the organization with support from the research team. The program was implemented as intended as verified by the fidelity checklist. The program consisted of daily GRASP exercise self-managed at home, plus weekly discussion of how participants used their affected UE in the previous week, review of weekly log sheets, discussion on facilitator/barriers to doing exercise, breakout sessions to view exercises and progressions, and set goals for the affected UE use in the upcoming week. Some accommodations were made for participants with aphasia, such as asking clear questions, calling on them to give them the floor to speak, being patient, and not interrupting/finishing their sentences. Adaptions made for each RE-AIM category are presented in Only 2 participants missed 1 class out of 10 classes, and all other participants (N = 7) had full attendance. The average GRASP practice time per day ranged from 58 minutes to 75.7 minutes . Two caregivers were available to attend the weekly classes and assist the participants in various ways, such as managing technology, setting up the GRASP equipment, being supportive and encouraging, and making sure that the exercises were challenging and performed correctly.https://youtu.be/lnXKSNXpc8U). Visual cue cards  were developed by the SRABC/MODC regional coordinator for future programs to help participants get familiar with videoconferencing. The program fee was subject to change for future programs to cover an increase in time to screen participants via videoconferencing.The SRABC/MODC continued to offer the program. Another 2 10-week iterations (October to December 2020 and January to March 2021) have been completed. The next program (March to June 2021) has been undergoing. A video describing the virtual program was made by the research team to facilitate the promotion and advertisement  delivered via videoconferencing in a group setting for individuals with stroke. By using the RE-AIM framework to evaluate the impact of this implementation, we demonstrated the effectiveness of the program on improving UE function and self-perceived hand function and recovery. Next steps to inform the future delivery of this virtual program were also identified. These findings are valuable to facilitate the broader implementation of this virtual program and guide the field of community-based telerehabilitation, especially during the COVID-19 pandemic, for which measures such as social distancing were imposed to limit person-to-person contacts.The findings of this study demonstrated that the virtual GRASP program had similar effects on improving self-perceived hand function as the in-person GRASP program in our previous study. As the evaluation was conducted virtually via videoconferencing, commonly used clinical assessments  requiring special equipment  or the examiner to palpate or give resistance were not used in this study. Thus, a newly developed assessment, the ArmCAM test,reach individuals who would not be able to come to weekly in-person classes such as people living in remote areas and in different provinces. Attendance was higher than the in-person GRASP community program, possibly due to less commute stress. Other advantages related to videoconferencing technology may also contribute to the successful implementation, including the use of breakout rooms to allow for individualized exercises progression in smaller groups and the screen sharing to allow for sharing exercises videos/pictures efficiently.Similar to our previous studyWhile the videoconferencing technology enabled the GRASP program to be delivered in a virtual format, it also introduced challenges associated with technical difficulties and therefore disrupted the class content agenda. As the SRABC/MODC staff had previous experience in delivering the in-person GRASP community program, factors affecting program uptake reported by staff were primarily due to its adaptions to the virtual format. The most-reported challenge by the instructor and volunteers was the nonideal and limited webcam views for them to observe participants’ UE movements, especially when using a monitor with a built-in webcam or using a phone/tablet that requires a holder to place the device at the ideal angle. Although an egg carton holder  was ableThe study has several limitations. First, this is a study from 2 iterations in 1 setting. Additional insights may arise with more iterations or with scaling up of the programs. Second, correction for multiple comparisons was not applied because it may cause us to miss out on potential differences with the small sample size and low power. Future studies with a larger sample size and multiple comparison correction are needed to confirm our findings. Furthermore, our study excluded individuals who were not able to log into a videoconference to attend the class, which also limited the generalizability. However, we demonstrated a high level of reach to individuals with stroke in remote areas and other provinces, showing the potential of scaling up this virtual GRASP program.This study demonstrated the feasibility of implementing the virtual format of the GRASP program delivered via videoconferencing by a nonprofit organization. We also demonstrated the effectiveness of this virtual program on improving UE motor function and self-perceived hand function in a small sample of individuals with stroke. By evaluating each RE-AIM component, the study provided useful insights to inform the next steps for future iterations and scaling-up and, most important, to guide the field of telerehabilitation during the COVID-19 pandemic and beyond.Supplemental_Appendix_1_pzab083Click here for additional data file.Supplemental_Appendix_2_pzab083Click here for additional data file.Supplemental_Appendix_3_pzab083Click here for additional data file.Supplemental_Appendix_4_pzab083Click here for additional data file.