Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study.

INTRODUCTION: Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care. METHODS AND ANALYSIS: In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events. ETHICS AND DISSEMINATION: We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

A reason to renovate: The association between hospital age of plant and value-based purchasing performance.

BACKGROUND/PURPOSE: Value-based purchasing (VBP) is increasing in influence in the health care industry; however, questions remain regarding the structural factors associated with improved performance. This study evaluates the association between age of hospital infrastructure and VBP outcomes. METHODOLOGY: Data on 1,911 hospitals from three sources (the American Hospital Association Annual Survey Database, the American Hospital Association DataViewer Financial Module, and the Centers for Medicare & Medicaid Services Hospital VBP Total Performance Scores data set) were evaluated. Age of health care facilities was represented by the "average age of plant" financial ratio. VBP performance was measured by an aggregate Total Performance Score composed of four equally weighted domains, including Efficiency and Cost Reduction, Clinical Care, Patient- and Caregiver-Centered Experience, and Patient Safety. We hypothesize that average age of plant is negatively correlated with each of these measures. RESULTS: Hospitals within the lowest quartile of average age of plant (0-8.13 years) were found to have a total Performance Score of 2.35 points higher than hospitals with a an average age of plant in the fourth quartile (14.63 years and above; R = 21.5%; p < .001) while controlling for hospital ownership, size, teaching status, geographic location, service mix, case mix, length of stay, community served, and labor force relative cost. Comparable results were found within the VBP domains, specifically for Clinical Care (ß = 4.09, p < .001) and Patient Experience (ß = 3.41, p < .001). Findings for the Patient Safety and Efficiency domains were not significant. A secondary and more granular examination of capitalized assets indicates organizations with higher building asset accumulated depreciation per bed in service were associated with lower total performance (ß = -.25, p < .001), Clinical Care (ß = -.31, p < .05), and Patient Experience scores (ß = -.45, p < .001). CONCLUSIONS: The results of this study provide evidence of an inverse association between a hospital's age of plant and specific elements of VBP performance. PRACTICE IMPLICATIONS: To date, no studies have investigated the relationship between hospital age of plant and value-based care. The results of our study may serve as supportive foundational evidence for health care leaders to target future capital investments to improve VBP outcomes.

Alternate Access to Care: A Cross Sectional Survey of Low Acuity Emergency Department Patients.

Introduction Patients with low-acuity (Canadian Triage and Acuity Scale level IV and V) complaints use the emergency department (ED) to access care. This has often been attributed to lack of a primary care provider. However, simply being registered with a primary care provider may not prevent low acuity ED presentation. There is some evidence that a lack of timely access to primary care may contribute to low acuity ED presentations. The Wait Time Alliance, a group of Canadian physicians and their respective professional associations, has recently set a benchmark of same day access to family doctors. It is unclear if this benchmark has been achieved in all jurisdictions.  Methods We performed linked cross sectional surveys to quantify the number of people presenting to the ED for nonurgent problems who felt unable to access primary care. Primary care practices were also surveyed to assess access using the metric of time to third next available appointment.  Results In the patient survey, 381 of 580 patients consented to participate. Of the 89 patients who met eligibility criteria, 100% completed the survey. 32 (35.9%) reported that the wait to see their primary care provider was "too long". 45 (50.5%) patients did not contact their primary care provider's office prior to ED presentation. 45 of 72 physician surveys were returned; a response rate of 62.5%. Most (77%) physicians estimated their wait time for a standard appointment to be greater than 48 hours. The mean calculated time to third next available appointment in the region was 6.6 (95% CI 4.6-8.7) days. Conclusions Approximately half of low acuity patients do not attempt to access their primary care provider prior to ED presentation. The benchmark of same day access to primary care has not been achieved in many practices in our region. Further education regarding primary care access would likely be beneficial to both patients and providers.

Barriers and facilitators to successful transition from long-term residential substance abuse treatment.

Although residential substance abuse treatment has been shown to improve substance use and other outcomes, relapse is common. This qualitative study explores factors that hinder and help individuals during the transition from long-term residential substance abuse treatment to the community. Semi-structured interviews were conducted with 32 individuals from residential substance abuse treatment. Based on the socio-ecological model, barriers and facilitators to transition were identified across five levels: individual, interpersonal, organizational, community, and policy. The major results indicate that primary areas of intervention needed to improve outcomes for these high-risk individuals include access to stable housing and employment, aftercare services and positive support networks; expanded discharge planning services and transitional assistance; and funding to address gaps in service delivery and to meet individuals' basic needs. This study contributes to the literature by identifying transition barriers and facilitators from the perspectives of individuals in residential treatment, and by using the socio-ecological model to understand the complexity of this transition at multiple levels. Findings identify potential targets for enhanced support post-discharge from residential treatment.

Education. Undergraduate research experiences: impacts and opportunities.

Most undergraduates give high ratings to research experiences. Studies report that these experiences improve participation and persistence, often by strengthening students' views of themselves as scientists. Yet, the evidence for these claims is weak. More than half the 60 studies reviewed rely on self-report surveys or interviews. Rather than introducing new images of science, research experiences may reinforce flawed images especially of research practices and conceptual understanding. The most convincing studies show benefits for mentoring and for communicating the nature of science, but the ideas that students learn are often isolated or fragmented rather than integrated and coherent. Rigorous research is needed to identify ways to design research experiences so that they promote integrated understanding. These studies need powerful and generalizable assessments that can document student progress, help distinguish effective and ineffective aspects of the experiences, and illustrate how students interpret the research experiences they encounter. To create research experiences that meet the needs of interested students and make effective use of scarce resources, we encourage systematic, iterative studies with multiple indicators of success.

Treatment and outcomes among 102 posterior inferior cerebellar artery aneurysms: a comparison of endovascular and microsurgical clip ligation.

BACKGROUND: The vicinity of brainstem and cranial nerves as well as the limited operative working space make clip ligation of posterior inferior cerebellar artery (PICA) aneurysms challenging. The small caliber of the PICA and the broad neck often associated with these aneurysms also create challenges in preserving this artery during treatment. Few data exist to compare the 2 treatment approaches for aneurysms in this location. OBJECT: To assess treatment outcomes for PICA aneurysms based on mode of management and anatomical location. METHODS: A prospectively maintained database was queried for PICA aneurysms treated from 2000 through 2012. Patients were categorized on the basis of their aneurysm's anatomical location, presentation status, treatment modality, and subsequent complications. Descriptive, univariate, and multivariate statistical analyses were performed. RESULTS: A total of 113 PICA aneurysms were identified; 11 did not undergo treatment. Of the remaining 102 aneurysms, 77% were ruptured and 64% were treated microsurgically. In the ruptured group, patients with more proximally located aneurysms such as vertebral and proximal PICA aneurysms were more likely to experience hydrocephalus and cranial nerve deficits after treatment. Endovascular therapy was less likely to cause postoperative deficit or lead to a need for percutaneous endoscopic gastrostomy. Most importantly, discharge, 6-month, and 1-year outcomes were predicted based on presenting Hunt and Hess score and patient's age, not aneurysm location or management mode. CONCLUSIONS: PICA aneurysms are challenging and require a multimodality treatment paradigm. Although microsurgery is associated with more short-term postoperative complications, presenting grade and patient's age remain the primary predictors of long-term outcome.

Emergency department use: is frequent use associated with a lack of primary care provider?

OBJECTIVE: To determine if having a primary care provider is an important factor in frequency of emergency department (ED) use. DESIGN: Analysis of a central computerized health network database. SETTING: Three EDs in southern New Brunswick. PARTICIPANTS: All ED visits during 1 calendar year to an urban regional hospital (URH), an urban urgent care centre (UCC), and a rural community hospital (RCH) were captured. MAIN OUTCOME MEASURES: Patients with and without listed primary care providers were compared in terms of number of visits to the ED. A logistic regression analysis was used to determine factors predictive of frequent attendance. RESULTS: In total, 48 505, 41 004, and 27 900 visits were made to the URH, UCC, and RCH, respectively, in 2009. The proportion of patients with listed primary care providers was 36.6% for the URH, 37.1% for the UCC, and 89.4% for the RCH. Among ED patients at all sites, frequent attenders (4 or more visits to an ED in 1 year) were significantly more likely (59.6% vs 45.1%, P < .001) to have listed primary care providers. Other factors that predicted frequent use included attendance at a rural ED, female sex, and older age. CONCLUSION: This study characterizes attendance rates for 3 EDs in southern New Brunswick. Our findings highlight interesting differences between urban and rural ED populations, and suggest that frequent use of the ED might not be related to lack of a listed primary care provider.

Incidence, epidemiology, and treatment of aneurysmal subarachnoid hemorrhage in 12 midwest communities.

Only 8 studies have investigated the incidence and epidemiology of aneurysmal subarachnoid hemorrhage (aSAH) in the United States. This is the first investigation in Indiana, which has some of the highest rates of tobacco smoking and obesity in the nation. The authors prospectively identified 441 consecutive patients with aSAH from 2005 to 2010 at 2 hospitals where the majority of cases are treated. Incidence calculations were based on US Census populations. Epidemiologic variables included demography; risk factors; Hunt and Hess scale; Fisher grade; number, location, and size of aneurysms; treatment type; and complications. Overall incidence was 21.8 per 100,000 population. Incidence was higher in women, increased with age, and did not vary by race. One third to half of patients were hypertensive and/or smoked cigarettes at the time of ictus. Variations by count were partially explained by Health Factor and Morbidity Rankings. Complications varied by treatment. These findings deviate from estimates that 6-16 per 100,000 people in the United States will develop aSAH and are double the incidence in a Minnesota population between 1945 and 1974. The results also deviate from the worldwide estimate of 9.0 aSAHs per 100,000 person-years. The predictive value of variations in Health Factor and Morbidity Rankings implicates the importance of future research on multivariate biopsychosocial causation of aSAH.

Risk of hemorrhage from de novo cerebral aneurysms.

OBJECT: A small percentage of patients will develop a completely new or de novo aneurysm after discovery of an initial aneurysm. The natural history of these lesions is unknown. The authors undertook this statistical evaluation a large cohort of patients with both ruptured and unruptured de novo aneurysms with the aim of analyzing risk factors for rupture and estimating a risk of subarachnoid hemorrhage (SAH). METHODS: A review of a prospectively maintained database of all aneurysm patients treated by the vascular neurosurgery service of Goodman Campbell Brain and Spine from 1976-2010 was performed. Of the 4718 patients, 611 (13%) had long-term follow-up imaging. The authors identified 27 patients (4.4%) with a total of 32 unruptured de novo aneurysms from routine surveillance imaging. They identified another 10 patients who presented with a new SAH from a de novo aneurysm after treatment of their original aneurysm. The total study group was thus 37 patients with a total of 42 de novo aneurysms. The authors then compared the 27 patients with incidentally discovered aneurysms with the 10 patients with SAH. A statistical analysis was performed, comparing the 2 groups with respect to patient and aneurysm characteristics and risk factors. RESULTS: Thirty-seven patients were identified as having true de novo aneurysms. This group had a female predominance and a high percentage of smokers. These 37 patients had a total of 42 de novo aneurysms. Ten of these 42 aneurysms hemorrhaged. De novo aneurysms in both the SAH and non-SAH group were anatomically small (< 10 mm). The estimated risk of hemorrhage over 5 years was 14.5%, higher than the expected SAH risk of small, unruptured aneurysms reported in the ISUIA (International Study of Unruptured Intracranial Aneurysms) trial. There was no statistically significant correlation between hemorrhage and any of the following risk factors: hypertension, diabetes, tobacco and alcohol use, polycystic kidney disease, or previous SAH. There was a statistically significant between-groups difference with respect to patient age, with the mean patient age being significantly older in the SAH aneurysm group than in the non-SAH group (p = 0.047). This is likely reflective of longer follow-up and discovery time, as the mean length of time between initial treatment and discovery of the de novo aneurysm was longer in the SAH group (p = 0.011). CONCLUSIONS: While rare, de novo aneurysms may have a risk for SAH that is comparatively higher than the risk associated with similarly sized, small, initially discovered unruptured saccular aneurysms. The authors therefore recommend long-term follow-up for all patients with aneurysms, and they consider a more aggressive treatment strategy for de novo aneurysms than for incidentally discovered initial aneurysms.

Cyclic lactam hybrid α-MSH/Agouti-related protein (AGRP) analogues with nanomolar range binding affinities at the human melanocortin receptors.

A novel hybrid melanocortin pharmacophore was designed based on the topographical similarities between the pharmacophores of Agouti related protein (AGRP) an endogenous melanocortin antagonist, and α-melanocyte-stimulating hormone (α-MSH), an endogenous melanocortin agonist. When employed in two different 23-membered macrocyclic lactam peptide templates, the designed hybrid AGRP/MSH pharmacophore yielded non-competitive ligands with nanomolar range binding affinities. The topography-based pharmacophore hybridization strategy will prove useful in development of unique non-competitive melanocortin receptor modulators.

Solid-phase peptide head-to-side chain cyclodimerization: discovery of C(2)-symmetric cyclic lactam hybrid α-melanocyte-stimulating hormone (MSH)/agouti-signaling protein (ASIP) analogues with potent activities at the human melanocortin receptors.

A novel hybrid melanocortin pharmacophore was designed based on the pharmacophores of the agouti-signaling protein (ASIP), an endogenous melanocortin antagonist, and α-melanocyte-stimulating hormone (α-MSH), an endogenous melanocortin agonist. The designed hybrid ASIP/MSH pharmacophore was explored in monomeric cyclic, and cyclodimeric templates. The monomeric cyclic disulfide series yielded peptides with hMC3R-selective non-competitive binding affinities. The direct on-resin peptide lactam cyclodimerization yielded nanomolar range (25-120 nM) hMC1R-selective full and partial agonists in the cyclodimeric lactam series which demonstrates an improvement over the previous attempts at hybridization of MSH and agouti protein sequences. The secondary structure-oriented pharmacophore hybridization strategy will prove useful in development of unique allosteric and orthosteric melanocortin receptor modulators. This report also illustrates the utility of peptide cyclodimerization for the development of novel GPCR peptide ligands.

Multiple N-methylation of MT-II backbone amide bonds leads to melanocortin receptor subtype hMC1R selectivity: pharmacological and conformational studies.

Multiple N-methylation is a novel technology to improve bioavailability of peptides and increase receptor subtype selectivity. This technique has been applied here to the superpotent but nonselective cyclic peptide MT-II. A library of all possible 31 backbone N-methylated derivatives has been synthesized and tested for binding and activation at melanocortin receptor subtypes 1, 3, 4, and 5. It turned out that selectivity is improved with every introduced N-methyl group, resulting in several N-methylated selective and potent agonists for the hMC1R. The most potent of these derivatives is N-methylated on four out of five amide bonds in the cyclic structure. Its solution structure indicates a strongly preferred backbone conformation that resembles other alpha-MSH analogs but possesses much less flexibility and in addition distinct differences in the spatial arrangement of individual amino acid side chains.

Structure-activity relationships of cyclic lactam analogues of alpha-melanocyte-stimulating hormone (alpha-MSH) targeting the human melanocortin-3 receptor.

A variety of dicarboxylic acid linkers introduced between the alpha-amino group of Pro(6) and the -amino group of Lys(10) of the cyclic lactam alpha-melanocyte-stimulating hormone (alpha-MSH)-derived Pro(6)-D-Phe(7)/D-Nal(2')(7)-Arg(8)-Trp(9)-Lys(10)-NH2 pentapeptide template lead to nanomolar range and selective hMC3R agonists and antagonists. Replacement of the Pro(6) residue and the dicarboxylic acid linker with 2,3-pyrazine-dicarboxylic acid furnished a highly selective nanomolar range hMC3R partial agonist (analogue 12, c[CO-2,3-pyrazine-CO-D-Phe-Arg-Trp-Lys]-NH2, EC50 = 27 nM, 70% max cAMP) and an hMC3R antagonist (analogue 13, c[CO-2,3-pyrazine-CO-D-Nal(2')-Arg-Trp-Lys]-NH2, IC50 = 23 nM). Modeling experiments suggest that 2,3-pyrazinedicarboxylic acid stabilizes a beta-turn-like structure with the D-Phe/D-Nal(2') residues, which explains the high potency of the corresponding peptides. Placement of a Nle residue in position 6 produced a hMC3R/hMC5R antagonist (analogue 15, c[CO-(CH 2)2-CO-Nle-D-Nal(2')-Arg-Trp-Lys]-NH2, IC50 = 12 and 17 nM, respectively), similarly to the previously described cyclic gamma-melanocyte-stimulating hormone (gamma-MSH)-derived hMC3R/hMC5R antagonists. These newly developed melanotropins will serve as critical biochemical tools for elucidating the full spectrum of functions performed by the physiologically important melanocortin-3 receptor.

Novel selective human melanocortin-3 receptor ligands: use of the 4-amino-1,2,4,5-tetrahydro-2-benzazepin-3-one (Aba) scaffold.

In search of new selective antagonists and/or agonists for the human melanocortin receptor subtypes hMC1R to hMC5R to elucidate the specific biological roles of each GPCR, we modified the structures of the superagonist MT-II (Ac-Nle-c[Asp-His-D-Phe-Arg-Trp-Lys]-NH(2)) and the hMC3R/hMC4R antagonist SHU9119 (Ac-Nle-c[Asp-His-D-Nal(2')-Arg-Trp-Lys]-NH(2)) by replacing the His-d-Phe and His-d-Nal(2') fragments in MT-II and SHU9119, respectively, with Aba-Xxx (4-amino-1,2,4,5-tetrahydro-2-benzazepin-3-one-Xxx) dipeptidomimetics (Xxx=D-Phe/pCl-D-Phe/D-Nal(2')). Employment of the Aba mimetic yielded novel selective high affinity hMC3R and hMC3R/hMC5R antagonists.

Influence of an information literacy course on students' information search behavior.

UNLABELLED: The purpose of this study was to determine the influence of an information literacy course on students' information gathering behavior. METHODS: Two student groups, consisting of 69 (Group One) and 177 (Group Two) students, were compared in their performance on a literature review assignment. Group one did not have an information literacy course, while group two was the first class to receive a newly introduced course in information literacy. Assignment references served as the dependent variables and included the following categories: total number of references, number and percentage of peer reviewed journal references, number and percentage of non-peer reviewed journal references, number and percentage of website references, number and percentage of authority opinion references, and number and percentage of textbook references. Referenced websites were further divided into the following: .com, .org, .edu, .gov. for both total number and percent utilization.Independent T-tests were performed between the information literacy course status and each of the dependent variables. RESULTS: Descriptive data (prior education, cumulative GPA, average age of student groups) was similar for both groups. Independent T-test analysis revealed a strong association (p < .05) between increasing both the number and percentage of peer reviewed references and having the information literacy course. CONCLUSIONS: The introduction of an information literacy course did influence the information gathering behavior of students. Students showed an increased reliance on peer-reviewed references.