The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review.

OBJECTIVES: Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions. METHODS: An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison. RESULTS: From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating. DISCUSSION: A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

Beyond COVID-19: Five commentaries on reimagining governance for future crises and resilience.

Several Canadian and international scholars offer commentaries on the implications of the COVID-19 pandemic for governments and public service institutions, and fruitful directions for public administration research and practice. This second suite of commentaries considers the challenges confronting governments as a result of the COVID-19 pandemic and in the decades to come with an increasingly broad lens: the need to understand and rethink the architecture of the state given recent and future challenges awaiting governments; the need to rethink government-civil society relations and policies to deliver services for increasingly diverse citizens and communities; the need for new repertoires and sensibilities on the part of governments for recognizing, anticipating, and engaging on governance risks despite imperfect expert knowledge and public skepticism; how the COVID-19 crisis has caused us to reconceive international and sub-national borders where new "borders" are being drawn; and the need to anticipate a steady stream of crises similar to the COVID-19 pandemic arising from climate change and related challenges, and develop new national and international governance strategies for fostering population and community resilience.

Plusieurs universitaires canadiens et internationaux ont offert des suggestions sur les implications de la pandémie du COVID­19 pour les gouvernements et les institutions de la fonction publique, ainsi que des orientations futures pour la recherche et la pratique en administration publique. Cette deuxième série de commentaires examine les défis que devront affronter les gouvernements en raison de la pandémie de COVID­19 et dans les décennies à venir, dans une optique large. Cette série souligne le besoin de comprendre et de repenser l'architecture de l'État, de revoir les relations entre le gouvernement et la société civile pour fournir des services à des citoyens et des communautés de plus en plus divers, d'élaborer de nouvelles façons d'identifier et d'anticiper les risques, et de s'engager malgré l'imperfection des connaissances d'experts et le scepticisme du public, de repenser les frontières, tout ceci en tenant compte des crises et défis à venir, de façon à promouvoir la résilience de la population et des communautés.

Area deprivation and attachment to a general practitioner through centralized waiting lists: a cross-sectional study in Quebec, Canada.

BACKGROUND: Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists. METHODS: A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients' socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs. RESULTS: Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas. CONCLUSION: Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.

Explaining time elapsed prior to cancer diagnosis: patients' perspectives.

BACKGROUND: Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients' prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal. METHODS: This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment. RESULTS: Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients' experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization. CONCLUSIONS: This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol.

BACKGROUND: Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. METHODS: A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers. DISCUSSION: This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.

Assessing the performance of centralized waiting lists for patients without a regular family physician using clinical-administrative data.

BACKGROUND: With 4.6 million patients who do not have a regular family physician, Canada performs poorly compared to other OECD countries in terms of attachment to a family physician. To address this issue, several provinces have implemented centralized waiting lists to coordinate supply and demand for attachment to a family physician. Although significant resources are invested in these centralized waiting lists, no studies have measured their performance. In this article, we present a performance assessment of centralized waiting lists for unattached patients implemented in Quebec, Canada. METHODS: We based our approach on the Balanced Scorecard method. A committee of decision-makers, managers, healthcare professionals, and researchers selected five indicators for the performance assessment of centralized waiting lists, including both process and outcome indicators. We analyzed and compared clinical-administrative data from 86 centralized waiting lists (GACOs) located in 14 regions in Quebec, from April 1, 2013, to March 31, 2014. RESULTS: During the study period, although over 150,000 patients were attached to a family physician, new requests resulted in a 30% median increase in patients on waiting lists. An inverse correlation of average strength was found between the rates of patients attached to a family physician and the proportion of vulnerable patients attached to a family physician meaning that as more patients became attached to an FP through GACOs, the proportion of vulnerable patients became smaller (r = -0.31, p < 0.005). The results showed very large performance variations both among GACOs of different regions and among those of a same region for all performance indicators. CONCLUSIONS: Centralized waiting lists for unattached patients in Quebec seem to be achieving their twofold objective of attaching patients to a family physician and giving priority to vulnerable patients. However, the demand for attachment seems to exceed the supply and there appears to be a tension between giving priority to vulnerable patients and attaching of a large number of patients. Results also showed heterogeneity in the performance of centralized waiting lists across Quebec. Finally, our findings suggest it is critical that similar mechanisms should use available data to identify the best strategies for reducing variations and improving performance.

Evaluation of the effects of health impact assessment practice at the local level in Monteregie.

BACKGROUND: In Quebec (Canada), the Monteregie Regional Public Health Department has chosen to use health impact assessment (HIA) to support municipalities through a knowledge exchange and collaborative process in order to positively influence decision-making regarding local policies and projects. The value of HIA is becoming increasingly recognized by municipalities interested in planning and managing their cities with an eco-systemic perspective. However, the knowledge and tools which support the use of the HIA at regional and local levels are still missing. METHODS: The general objective is to evaluate the impact the collaborative HIA process used in Monteregie has had on the formulation, adoption and implementation of policies and projects favourable to health. The methodology is based on Mayne's CA design, which allows the identification of factors which contribute to a change process. It is described as one of the best approaches to reduce uncertainty regarding the observed results and the contribution of a program. All of the HIA processes realised between January 2013 and January 2016 in Monteregie will be studied following a case study strategy. Study populations include regional and local public health professionals, municipal officers and community members implicated in these HIAs. Various qualitative and quantitative methods will be used, including examination of documentation, observations on the city grounds, and individual or group interviews. A model of change will be constructed for each HIA process and will present the logical pathway which leads to the observed results, alternative explanations and hypothesises as to why these results were obtained, and contextual factors that could have influenced them. This model will allow the production of a refined contribution story for each HIA. A convergence and divergence analysis will be completed in order to identify differences or similitudes between the different HIAs studied. DISCUSSION: In addition to contributing to the production of knowledge in relation to the collaborative model of HIA, this research project will allow other regional and local public health actors and municipalities of Quebec or other decision-making and political bodies to understand the usefulness of this approach for the improvement of population health and well-being.

Hepatitis C in Intravenous Drug Users: Study of Obstacles and Facilitators to Access to Health Care and Services / Hépatite C chez les usagers de drogues par voie veineuse : exploration des barrières et des facilitants pour l'accès aux soins et services.

Objective: The study was designed to document the experiences of people affected by hepatitis C with respect to prevention, screening and treatment to more clearly understand the determinants of health trajectories and access to the health system.Methods: Based on an evaluative research, we conducted a thematic qualitative analysis of four focus group interviews with people affected by hepatitis C. Two interviews (n = 3) consisted of people at risk of contracting hepatitis C, the third interview (n = 6) concerned people diagnosed HCV positive but not treated and the fourth interview (n = 6) targeted people who had access to treatment (n = 6).Results: We identified the drivers, barriers and facilitating factors, trajectories of health and care of people affected by hepatitis C in two periods of life: from the injection to HCV screening and from HCV diagnosis to treatment. Life trajectories in relation to hepatitis C are the product of many influences: the personal life experience, the attitude of healthcare staff, the organization of the health system and contingent factors.Conclusion: Understanding the life experience of people affected by hepatitis C is essential to identify potential levers of change and new ways to organize the health system in order to more effectively reach these people.

A process-based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis.

BACKGROUND: Integrating Nurse Practitioners into primary care teams is a process that involves significant challenges. To be successful, nurse practitioner integration into primary care teams requires, among other things, a redefinition of professional boundaries, in particular those of medicine and nursing, a coherent model of inter- and intra- professional collaboration, and team-based work processes that make the best use of the subsidiarity principle. There have been numerous studies on nurse practitioner integration, and the literature provides a comprehensive list of barriers to, and facilitators of, integration. However, this literature is much less prolific in discussing the operational level implications of those barriers and facilitators and in offering practical recommendations. METHODS: In the context of a large-scale research project on the introduction of nurse practitioners in Quebec (Canada) we relied on a logic-analysis approach based, on the one hand on a realist review of the literature and, on the other hand, on qualitative case-studies in 6 primary healthcare teams in rural and urban area of Quebec. RESULTS: Five core themes that need to be taken into account when integrating nurse practitioners into primary care teams were identified. Those themes are: planning, role definition, practice model, collaboration, and team support. The present paper has two objectives: to present the methods used to develop the themes, and to discuss an integrative model of nurse practitioner integration support centered around these themes. CONCLUSION: It concludes with a discussion of how this framework contributes to existing knowledge and some ideas for future avenues of study.

Who gets a family physician through centralized waiting lists?

BACKGROUND: North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians' enrolment of orphan patients through centralized waiting lists, the Guichet d'accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians' after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled. METHODS: A longitudinal quantitative analysis spanning a five-year period (2008-2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used. RESULTS: The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level. CONCLUSION: Centralized waiting lists linked to financial incentives increased the number of family physicians' patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.

[Integrating mental health and addiction services: the encounter of two worlds]. / Intégration des services en santé mentale et en toxicomanie: processus de rencontre de deux mondes.

OBJECTIVE: The needfor integrated services to treat co-occurring disorders is now recognized. Specialised clinics have now been created for this purpose. This study analysed the integration process that occurred in a particular clinic in order to identify the strategies and means used and their overall impact. METHODS: We conducted a longitudinal case study. Data collection was based on three sources: semi-structured interviews, observations and documents. It took place over a period of 3years and covered the first 6 years of the clinic transformation process. We analysed data from a process perspective. The analysis was also validated by informants. RESULTS: Our analysis shows that the pursuit of integration is associated with important challenges at various levels: patient populations, professional practices, structural framework, inter-organizational relationships. These challenges were encountered right from the creation of the clinic. Various strategies and approaches were used to reduce the tensions raised by these challenges and had a considerable impact on the integration process. However, our analysis reveals that integration is an ongoing process that is never completely achieved. In fact, challenges are never completely resolved, but tend to be transformed, raising new tensions to which members of the organization respond with new strategies and means to ensure a continuing integration process. CONCLUSIONS: These resultsforce us to reconsider the integration of services, not as a fixed result but rather as an object of change emerging from a complex process with an unknown outcome. Four important implicationsfor practice are derived from these results.

Learning reflexively from a health promotion professional development program in Canada.

In recent decades, reflexivity has received much attention in the professional education and training literature, especially in the public health and health promotion fields. Despite general agreement on the importance of reflexivity, there appears to be no consensus on how to assess reflexivity or to conceptualize the different forms developed among professionals and participants of training programs. This paper presents an analysis of the reflexivity outcomes of the Health Promotion Laboratory, an innovative professional development program aimed at supporting practice changes among health professionals by fostering competency development and reflexivity. More specifically, this paper explores the difference between two levels of reflexivity (formative and critical) and highlights some implications of each for practice. Data were collected through qualitative interviews with participants from two intervention sites. Results showed that involvement in the Health Promotion Laboratory prompted many participants to modify their vision of their practice and professional role, indicating an impact on reflexivity. In many cases, new understandings seem to have played a formative function in enabling participants to improve their practice and their role as health promoters. The reflective process also served a critical function culminating in a social and moral understanding of the impacts on society of the professionals' practices and roles. This type of outcome is greatly desired in health promotion, given the social justice and equity concerns of this field of practice. By redefining the theoretical concept of reflexivity on two levels and discussing their impacts on practice, this study supports the usefulness of both levels of reflexivity.

How can both the intervention and its evaluation fulfill health promotion principles? An example from a professional development program.

The emergence over the past 20 years of health promotion discourse poses a specific challenge to public health professionals, who must come to terms with new roles and new intervention strategies. Professional development is, among other things, a lever for action to be emphasized in order to meet these challenges. To respond to the specific training needs of public health professionals, a team from the Direction de santé publique de Montréal (Montreal Public Health Department) in Quebec, Canada, established in 2009 the Health Promotion Laboratory, an innovative professional development project. An evaluative component, which supports the project's implementation by providing feedback, is also integrated into the project. This article seeks to demonstrate that it is possible to integrate the basic principles of health promotion into a professional development program and its evaluation. To this end, it presents an analytical reading of both the intervention and its evaluation component in light of the cardinal principles in this field. Initiatives such as the Health Promotion Laboratory and its evaluation are essential to consolidate the foundations of professional development and its assessment by concretely integrating health promotion discourse into these practices.

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis.

INTRODUCTION: Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use. METHODS: A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada). RESULTS: Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers' access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use. CONCLUSION AND DISCUSSION: This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Youth and parent perceptions on participating in specialized multidisciplinary pain rehabilitation options: A qualitative timeline effect analysis.

Background: Little is known about how the specialized treatment journey is perceived by youth with pain-related disability and their parents. Aims: Describe and compare the treatment effects and outcomes as perceived by youth and their parents enrolled in intensive interdisciplinary pain treatment (IIPT) or multimodal treatment (MMT). Methods: Eleven IIPT youth and five parents and three MMT youth and five parents were recruited. All were asked to complete a treatment journey timeline, followed by separately conducted semistructured interviews. Transcribed interviews were analyzed using reflective thematic analysis. Results: The main themes spanned the treatment trajectory. All participants described similar initial struggles (Theme 1). Positive and negative treatment effects associated with acquisitions and disruptions (Theme 2), and outcomes post-discharge related to supports and realities (Theme 3) emerged. Knowledge, skills, and support acquisition during treatment and feeling empowered and confident to self-manage postdischarge were identified as IIPT benefits. However, the change effort and life disruptions required and the difficulty transitioning to real life postprogram were acknowledged as detrimental IIPT impacts. Continuing with life as usual and maintaining supports in daily contexts (e.g., school personnel, friends) were reported MMT benefits. However, the challenges of managing pain, treatment adherence within the competing demands of daily realities, and the lack of support to integrate strategies were emphasized as detrimental MMT impacts. Conclusions: Detailed impacts of two specialized multidisciplinary pain rehabilitation interventions on the lives of youth with pain-related disability and their parents are described. The treatments benefits and previously unexplored detrimental effects are unveiled.

Contexte: On en sait peu sur les parcours de traitement spécialisés tels que perçus par les jeunes ayant une incapacité liée à la douleur et par leurs parents.Objectifs: Décrire et comparer les effets et les résultats du traitement tels qu'ils sont perçus par les jeunes inscrits à un traitement interdisciplinaire intensif de la douleur ou à un traitement multimodal, ainsi que par leurs parents.Méthodes: Onze jeunes inscrits à un traitement interdisciplinaire intensif de la douleur et cinq parents, ainsi que trois jeunes inscrits à un traitement multimodal et cinq parents, ont été recrutés. Tous ont été invités à décrire le calendrier de leur parcours de traitement, puis à participer à des entrevues semi-structurées menées séparément. Les entrevues transcrites ont été analysées à l'aide d'une analyse thématique réflexive.Résultats: Les principaux thèmes couvraient la trajectoire du traitement. Tous les participants ont décrit des difficultés initiales similaires (Thème 1). L'association des effets positifs et négatifs du traitement avec les acquis et les perturbations (Thème 2), et les issues liées au soutien et aux réalités suite à leur congé (Thème 3) ont émergé. L'acquisition de connaissances et d'habiletés, l'accès à du soutien et le sentiment d'autonomisation et de confiance en sa capacité d'autoprise en charge après le congé ont été répertoriés comme des avantages du traitement interdisciplinaire intensif de la douleur. Toutefois, les efforts de changement requis et les perturbations de la vie nécessaires, ainsi que les difficultés de la vie réelle après le programme, ont été considérés comme des répercussions négatives du traitement interdisciplinaire intensif de la douleur. La possibilité de poursuivre la vie comme d'habitude et de conserver le soutien dans des contextes de la vie quotidienne (ex. : personnel scolaire, amis) ont été rapportés comme des avantages du traitement multimodal. Toutefois, les défis liés à la prise en charge de la douleur, l'adhésion au traitement dans le cadre des exigences concurrentes des réalités quotidiennes, ainsi que le manque de soutien pour intégrer les stratégies, ont été mis en relief comme des effets néfastes du traitement multimodal.Conclusions: Les effets détaillés de deux interventions multidisciplinaires spécialisées en matière de réadaptation pour la douleur dans la vie de jeunes atteints d'une incapacité liée à la douleur et de leurs parents ont été décrits. Les avantages des traitements et leurs effets néfastes qui n'avaient pas encore été étudiés ont été dévoilés.

Designing centralized waiting lists for attachment to a primary care provider: Considerations from a logic analysis.

Access to a regular primary care provider is essential to quality care. In Canada, where 15 % of patients are unattached (i.e., without a regular provider), centralized waiting lists (CWLs) help attach patients to a primary care provider (family physician or nurse practitioner). Previous studies reveal mechanisms needed for CWLs to work, but focus mostly on CWLs for specialized health care. We aim to better understand how to design CWLs for unattached patients in primary care. In this study, a logic analysis compares empirical evidence from a qualitative case study of CWLs for unattached patients in seven Canadian provinces to programme theory derived from a realist review on CWLs. Data is analyzed using context-intervention-mechanism-outcome configurations. Results identify mechanisms involved in three components of CWL design: patient registration, patient prioritization, and patient assignment to a provider for attachment. CWL programme theory is revised to integrate mechanisms specific to primary care, where patients, rather than referring providers, are responsible for registering on the CWL, where prioritization must consider a broad range of conditions and characteristics, and where long-term acceptability of attachment is important. The study provides new insight into mechanisms that enable CWLs for unattached patients to work.

Economic Analysis of the Prevention and Control of Nosocomial Infections: Research Protocol.

Background: Nosocomial infections (NIs) are among the main preventable healthcare adverse events. Like all countries, Canada and its provinces are affected by NIs. In 2004, Ministry of Health and Social Services (MSSS) of Quebec instituted a mandatory surveillance NI program for the prevention and control (NIPC) in the hospitals of the province. One target of the MSSS 2015-2020 action plan is to assess the implementation, costs, effects, and return on investment of NIPC measures. This project goes in the same way and is one of the first major studies in Canada to evaluate the efficiency of the NIPC measures. Three objectives will be pursued: evaluate the cost of implementing clinical best practices (CBPs) for infection control; evaluate the economic burden attributable to NIs; and examine the cost-effectiveness of the NIPC by comparing the costs of CBPs against those of NIs. Methods: This project is based on an infection control intervention framework that includes four CBPs: hand hygiene; hygiene and sanitation; screening; and additional precautions. Four medical and surgical units in two hospitals (nonUniversity, University) in the province of Quebec will be studied. The project has four components. Component 1 will construct and content validate an observation grid for measuring the costs of CBPs. Component 2 will estimate CBP costs via 2-week prospective observations of health workers, conducted every 2 months over a 1-year period. Component 3 will evaluate, through a matched case-control study, the economic burden of the four most monitored NIs in Quebec (C-difficile, MRSA, VRE, and CPGNB). Archival patient data will be collected retrospectively. Component 4 will determine the optimal breakeven point for CBPs associated with NIPC. Discussion: This project will produce evidence of the economic analysis of NIPC and give health stakeholders an overview of NIPC cost-effectiveness. It will meet the objectives of the Canadian Patient Safety Institute and the MSSS action plan to analyze the efficiency of NIPC preventive measures. To our knowledge, this is the first such exercise in Quebec and Canada. It will provide governments with a decision support tool through a major empirical study that could be replicated nationally to capture the financial benefits of NIPC.

Integrating services for patients with mental and substance use disorders: What matters?

BACKGROUND: Over the past decade, practice standards have recommended that people suffering from both mental and substance use disorders receive integrated treatment. Yet, few institutions offer integrated services, and patients are too often turned away from psychiatric and addiction rehabilitation services. PURPOSE: The purpose of this study was to identify key factors in integrating services for patients with co-occurring disorders. METHODOLOGY: We conducted a process evaluation with the aim of identifying factors that enhance or impede service integration. First, we elaborated a sound conceptual framework of service integration. We then conducted in-depth case studies analysis using socioanthropological methods (interviews with managers and professionals, focus groups with patients, nonparticipant observation, and document analysis). We analyzed two contrasted forms of services integration, a joint venture and a strategic alliance, separately and then compared them. FINDINGS: The integrations achieved in the two cases were of different intensities. However, from our study, we were able to identify various levers and characteristics that affect the development of an integrated approach. Reflecting on the dynamics of these two cases, we formulated six propositions to identify what matters when integrating services for persons with mental and substance use disorders. PRACTICE IMPLICATIONS: The integration of services transcends debates on care models and must be focused on the patients' experience of care. The process should stimulate a learning experience that helps to align practices (normative integration) and to integrate teams and care. In this study, we identified a number of key conditions and levers for success.