pH1N1 - a comparative analysis of public health responses in Ontario to the influenza outbreak, public health and primary care: lessons learned and policy suggestions.

BACKGROUND: Ontario's 36 Public Health Units (PHUs) were responsible for implementing the H1N1 Pandemic Influenza Plans (PIPs) to address the first pandemic influenza virus in over 40 years. It was the first under conditions which permitted mass immunization. This is therefore the first opportunity to learn and document what worked well, and did not work well, in Ontario's response to pH1N1, and to make recommendations based on experience. METHODS: Our objectives were to: describe the PIP models, obtain perceptions on outcomes, lessons learned and to solicit policy suggestions for improvement. We conducted a 3-phase comparative analysis study comprised of semi-structured key informant interviews with local Medical Officers of Health (n=29 of 36), and Primary Care Physicians (n=20) and in Phase 3 with provincial Chief-Medical Officers of Health (n=6) and a provincial Medical Organization. Phase 2 data came from a Pan-Ontario symposium (n=44) comprised leaders representing: Public Health, Primary Care, Provincial and Federal Government. RESULTS: PIPs varied resulting in diverse experiences and lessons learned. This was in part due to different PHU characteristics that included: degree of planning, PHU and Primary Care capacity, population, geographic and relationships with Primary Care. Main lessons learned were: 1) Planning should be more comprehensive and operationalized at all levels. 2) Improve national and provincial communication strategies and eliminate contradictory messages from different sources. 3) An integrated community-wide response may be the best approach to decrease the impact of a pandemic. 4) The best Mass Immunization models can be quickly implemented and have high immunization rates. They should be flexible and allow for incremental responses that are based upon: i) pandemic severity, ii) local health system, population and geographic characteristics, iii) immunization objectives, and iv) vaccine supply. CONCLUSION: "We were very lucky that pH1N1 was not more severe." Consensus existed for more detailed planning and the inclusion of multiple health system and community stakeholders. PIPs should be flexible, allow for incremental responses and have important decisions (E.g., under which conditions Public Health, Primary Care, Pharmacists or others act as vaccine delivery agents.) made prior to a crisis.

Monitoring trends in waiting periods in Canada for elective surgery: validation of a method using administrative data.

BACKGROUND: Provincial governments require timely, economical methods to monitor surgical waiting periods. Although use of prospective procedure-specific registers would be the ideal method, a less elaborate system has been proposed that is based on physician billing data. This study assessed the validity of using the date of the last service billed prior to surgery as a proxy for the beginning of the post-referral, pre-surgical waiting period. METHOD: We examined charts for 31,824 elective surgical encounters between 1992 and 1996 at an Ontario teaching hospital. The date of the last service before surgery (the last billing date) was compared with the date of the consultant's letter indicating a decision to book surgery (i.e., to begin waiting). RESULTS: Several surgical specialties (but excluding cardiac, orthopedic and gynecologic) had a close correlation between the dates of the last pre-surgery visit and those of the actual decision to place the patient on the waiting list. Similar results were found for 12 of 15 individually studied procedures, including some orthopedic and gynecological procedures. CONCLUSION: Used judiciously, billing data is a timely, inexpensive and generally accurate method by which provincial governments could monitor trends in waiting times for appropriately selected surgical procedures.

Risk of emergency admission while awaiting elective cholecystectomy.

BACKGROUND: There is uncertainty regarding the frequency of adverse events while on a surgical waiting list. We assess the relationship between the duration of wait for cholecystectomy and the risk of emergency admission. METHODS: We analyzed time to emergency admission in a group of 761 patients who underwent cholecystectomy after being seen in clinic for biliary colic and placed on waiting lists at 2 acute care centres in Ontario, from 1997 to 2000. RESULTS: Emergency admissions due to worsening symptoms occurred in 51 patients (6.7%) waiting for elective cholecystectomy. The weekly rate of emergency admission was low during the first 19 weeks on the list, but increased almost by a factor of 3 after 20 weeks (rate ratio 2.7; 95% confidence interval 2.0-3.7). Relative to the first 4 weeks on the list, the rate was 1.6 times higher after 20 weeks, 2 times higher after 28 weeks and 7 times higher after 40 weeks. INTERPRETATION: The probability that a patient on a waiting list will be admitted for emergency cholecystectomy consistently increases with the duration of wait, particularly after 20 weeks.

Equity in Canadian health care: does socioeconomic status affect waiting times for elective surgery?

BACKGROUND: Waiting times for surgical and other procedures are an important measure of how well the health care system responds to patient needs. In a universal health care system such as Canada's, it is important to determine if waiting times vary by socioeconomic status (SES). We compared waiting times for elective surgery of patients living in low and high socioeconomic areas. METHODS: We reviewed the medical charts of all patients who underwent elective surgery at a Canadian academic health centre between 1992 and 1999. Using patient postal codes we assigned SES on the basis of 5 characteristics in the 1996 census data. We compared waiting times for surgery for people from regions in the lowest third (low SES group) with that for patients from regions in the upper third (high SES group). RESULTS: On average, patients in the high SES group waited 31.1 days and those in the low SES group waited 29.3 days. When differences in waiting times for 22 common procedures were examined between the groups, only the difference for prostatectomy was statistically significant: patients in the high SES group waited 4.4 fewer days than those in the low SES group. INTERPRETATION: We found little evidence that residing in a region in which SES was in the lowest third was associated with longer waiting times for elective surgery.

Hashimoto's thyroiditis with granulomas: A unifying immunological etiology?

Two cases of granulomatous inflammation of the thyroid gland associated with Hashimoto's thyroiditis are presented. In neither case is there an obvious cause of granuloma formation, the only accompanying abnormality being rheumatoid arthritis in one of the patients. Autoimmune thyroid disease has been reported in association with sarcoidosis as well as rheumatoid arthritis, diseases in which cellular immunity is activated. Immune mechanisms alone are capable of initiating and amplifying granulomatous inflammation. In this report, we suggest that the granulomas in both cases may have their origin in immunological malfunction, the same immunological malfunction responsible for Hashimoto's thyroiditis.