Continuity of primary care and emergency department visits following knee and hip replacement surgery: a retrospective cohort study.

BACKGROUND: Continuity of primary care (CPC) improves patient well-being, but the association between CPC and surgical outcomes has not been well studied. The numbers of joint replacement procedures are expected to rise considerably in the coming years, so it is crucial to identify factors related to successful outcomes. The purpose of this study was to examine the association between CPC and emergency department (ED) visits after knee and hip replacement surgery. METHODS: Physician claims and hospital data from 2005 to 2020 in Nova Scotia were used in this retrospective study. To measure CPC, we used the Modified Modified Continuity Index (MMCI), which is the number of primary care providers adjusted for the total number of visits. The outcome was ED visits within 90 days of discharge. Logistic regression was used to test for associations between MMCI and the probability of an ED visit. RESULTS: There were 28 574 knee and 16 767 hip procedures in the data set; 13.9% (95% confidence interval [CI] 13.5%-14.3%) and 13.5% (95% CI 13.0%-14.0%) of the patients, respectively, had an ED visit within 90 days. For patients who underwent knee procedures, the mean MMCI was 0.868 (95% CI 0.867-0.870); 10.7% (95% CI 10.4 %-11.1 %) had perfect continuity of care. For patients who underwent hip procedures, the corresponding measures were 0.864 (95% CI 0.862-0.866) and 13.5% (95% CI 13.0%-14.0%). There was a statistically significant negative association between greater continuity of care and the probability of an ED visit after controlling for confounders. CONCLUSION: Having multiple primary care providers before surgery increased the likelihood of negative outcomes following knee or hip replacement surgery compared with having a single provider. Presurgical conversations should include primary care history to improve postsurgical outcomes.

Association between surgical wait time and hospital length of stay in primary total knee and hip arthroplasty.

AIMS: In countries with social healthcare systems, such as Canada, patients may experience long wait times and a decline in their health status prior to their operation. The aim of this study is to explore the association between long preoperative wait times (WT) and acute hospital length of stay (LoS) for primary arthroplasty of the knee and hip. METHODS: The study population was obtained from the provincial Patient Access Registry Nova Scotia (PARNS) and the Canadian national hospital Discharge Access Database (DAD). We included primary total knee and hip arthroplasties (TKA, THA) between 2011 and 2017. Patients waiting longer than the recommended 180 days Canadian national standard were compared to patients waiting equal or less than the standard WT. The primary outcome measure was acute LoS postoperatively. Secondarily, patient demographics, comorbidities, and perioperative parameters were correlated with LoS with multivariate regression. RESULTS: A total of 11,833 TKAs and 6,627 THAs were included in the study. Mean WT for TKA was 348 days (1 to 3,605) with mean LoS of 3.6 days (1 to 98). Mean WT for THA was 267 days (1 to 2,015) with mean LoS of 4.0 days (1 to 143). There was a significant increase in mean LoS for TKA waiting longer than 180 days (2.5% (SE 1.1); p = 0.028). There was no significant association for THA. Age, sex, surgical year, admittance from home, rural residence, household income, hospital facility, the need for blood transfusion, and comorbidities were all found to influence LoS. CONCLUSION: Surgical WT longer than 180 days resulted in increased acute LoS for primary TKA. Meeting a shorter WT target may be cost-saving in a social healthcare system by having shorter LoS. Cite this article: Bone Jt Open 2021;2(8):679-684.

Variable effects of obesity on access to total hip and knee arthroplasty.

Background: Obesity is an important comorbidity affecting outcomes after total joint arthroplasty. Consequently, surgeons may delay care of obese patients to first address obesity through different care pathways. The effect of obesity on patient wait times for total joint arthroplasty has not been explored. The purpose of this study was to evaluate the effect of obesity on access to total hip (THA) and knee (TKA) arthroplasty. Methods: The study data set was constructed from the Nova Scotia Health Authority's Horizon Patient Folder system and the Patient Access Registry Nova Scotia. Wait time was measured as days between the decision to treat and date of surgery. Body mass index (BMI) was calculated from a preoperative assessment, and patients were grouped into BMI categories. Multivariate log-linear regression was used to test for statistical differences, controlling for confounding factors. Results: We observed longer wait times for TKA with increasing BMI weight class. Patients with BMIs greater than 50 had 34% longer waits than reference weight patients. However, THA recipients showed no statistical difference in wait times across weight categories. Furthermore, there was variability among surgeons in the wait times experienced by patients. Conclusion: The finding of longer wait times for TKAs, but not THAs, among patients who were obese was unexpected. This shows the variable wait times for THA and TKA that patients who are obese can experience with different surgeons. It is important to understand the variability in wait times so that efforts to standardize the patient experience can be accomplished.

Contexte: L'obésité est une comorbidité importante qui a des répercussions sur les résultats d'une arthroplastie totale. Ainsi, les chirurgiens pourraient reporter les soins aux patients obèses afin de d'abord traiter l'obésité par différents parcours de soins. Les effets de l'obésité sur le temps d'attente pour une arthroplastie totale n'ont pas été étudiés. La présente étude visait donc à évaluer les effets de l'obésité sur l'accès à une arthroplastie totale de la hanche (ATH) ou du genou (ATG). Méthodes: L'ensemble de données à l'étude provient du système Horizon Patient Folder de la Régie de la santé de la Nouvelle-Écosse et du registre d'accès des patients de la Nouvelle-Écosse. Le temps d'attente a été défini comme étant le nombre de jours séparant la décision de traitement et la date de l'intervention. L'indice de masse corporelle (IMC) a été calculé selon les données recueillies lors d'une évaluation préopératoire, et les patients ont été classés par catégorie d'IMC. Une régression loglinéaire multiple a été utilisée pour mesurer les différences statistiques et tenir compte des facteurs de confusion. Résultats: Nous avons constaté que le temps d'attente pour une ATG augmente avec la catégorie d'IMC. En effet, les patients ayant un IMC de plus de 50 ont attendu 34 % plus longtemps que les patients du groupe de référence. Pourtant, il n'y avait aucune différence statistiquement significative entre les catégories d'IMC pour ce qui est du temps d'attente avant une ATH. De plus, le temps d'attente variait d'un chirurgien à l'autre. Conclusion: La conclusion selon laquelle les patients obèses attendent plus longtemps pour une ATG, mais pas pour une ATH, était inattendue. Cela met en évidence le temps d'attente variable que peuvent connaître les patients obèses selon les différents chirurgiens. Il est important de comprendre la variabilité du temps d'attente afin de normaliser l'expérience patient.

Use of Disease-modifying Antirheumatic Drugs, Biologics, and Corticosteroids in Older Patients With Rheumatoid Arthritis Over 20 Years.

OBJECTIVE: To examine changes in prescribing patterns, especially the use of corticosteroids (CS), in patients with rheumatoid arthritis (RA) over 2 decades. METHODS: This was a secondary analysis of health administrative data using a previously validated dataset and case definition for RA. Cases were matched 1:4 by age and sex to controls within a population of approximately 1 million inhabitants with access to universal health care. Longitudinal data for incident and prevalent RA cases were studied between 1997 and 2017. RESULTS: There were 8240 RA cases (all ≥ 65 yrs) with a mean (SD) age 72.2 (7.5) years and 70.6% were female. Over 20 years, annual utilization of coxibs in prevalent RA cases fell with a concomitant increase in disease-modifying antirheumatic drugs (DMARDs) and biologics. Over the same period, CS use was largely unchanged. Approximately one-third of patients had at least 1 annual prescription for CS, most frequently prednisone. The mean annual dose showed a modest reduction and the duration of utilization in each year shortened. Rheumatologists prescribed CS less frequently and in lower doses than other physician groups. For incident RA cases, there was a significant fall in annual prescribed dose of prednisone by rheumatologists over time. CONCLUSION: In older adults with RA, the utilization of DMARDs and biologics has increased over the past 20 years. However, the use of CS has persisted. Renewed efforts are required to minimize their use in the long-term pharmacological management of RA.

Increased Mortality with the Use of Cementless Fixation for Femoral Neck Fractures: Analysis of 5883 Hip Arthroplasty Cases.

BACKGROUND: The use of cemented fixation for hip arthroplasty for femoral neck fractures has been advocated to limit the postoperative and intraoperative risk of periprosthetic fractures. However, there are concerns with the potential effects of cementing on patient mortality, particularly at the time of cementation. METHODS: This study examined the mortality rates of cemented compared to cementless hip arthroplasty fixation in a group of 5883 femoral neck fracture patients from 2001 to 2017. The data were derived from large administrative databases and census data. Confounders were identified and controlled with a multivariate analysis. The data were also stratified into 2 time frames, 2001-2008 and 2009-2017, to determine if there was an effect of more recent improvements in patient care or implant technology. RESULTS: Cemented fixation had a statistically significant reduction in mortality rates at 30, 90, and 365 days after surgery. There was no difference in mortality in 0, 1, or ≤7 days after discharge or during the admission. The mortality rate decreased but was still significantly increased with cementless fixation when the subjects were grouped from 2001 to 2008 and 2009 to 2017. CONCLUSION: Based on this evidence, the cemented fixation of hip arthroplasty should be considered for patients with femoral neck fractures.

Total cost of surgical site infection in the two years following primary knee replacement surgery.

OBJECTIVE: The disease burden of surgical site infection (SSI) following total knee (TKA) replacement is considerable and is expected to grow with increased demand for the procedure. Diagnosing and treating SSI utilizes both inpatient and outpatient services, and the timing of diagnosis can affect health service requirements. The purpose of this study was to estimate the health system costs of infection and to compare them across time-to-diagnosis categories. METHODS: Administrative data from 2005-2016 were used to identify cases diagnosed with SSI up to 1 year following primary TKA. Uninfected controls were selected matched on age, sex and comorbidities. Costs and utilization were measured over the 2-year period following surgery using hospital and out-of-hospital data. Costs and utilization were compared for those diagnosed within 30, 90, 180, and 365 days. A subsample of cases and controls without comorbidities were also compared. RESULTS: We identified 238 SSI cases over the study period. On average, SSI cases cost 8 times more than noninfected controls over the 2-year follow-up period (CaD$41,938 [US$29,965] vs CaD$5,158 [US$3,685]) for a net difference of CaD$36,780 (US$26,279). The case-to-control ratio for costs was lowest for those diagnosed within 30 days compared to those diagnosed later. When only patients without comorbidities were included, costs were >7 times higher. CONCLUSION: Our results suggest that considerable costs result from SSI following TKA and that those costs vary depending on the time of diagnosis. A 2-year follow-up period provided a more complete estimate of cost and utilization.

Measuring Surgical Site Infection From Linked Administrative Data Following Hip and Knee Replacement.

BACKGROUND: Surgical site infections (SSIs) in hip and knee arthroplasty are increasing internationally. Current trends in SSI monitoring use single source administrative databases with data collection points commonly at 30 or 90 days. We hypothesize that SSI rates are being under-reported due to methodological biases. METHODS: Data from multiple administrative data sets were contrasted and compared to look at the 90-day SSI rates for hip and knee arthroplasty in a single province from 2001 to 2015. SSI rates were calculated over time by year, and the differences in infection rates between single and multiple administrative data sets were calculated as an estimate of under reporting rates of SSIs. Days until diagnosis was measured for those diagnosed with an infection within 1 year. RESULTS: Combining administrative data sets indicates that hospital-based data underestimate SSI rates by 0.44 (P < .0001) of a percentage point over all years, a clinically significant result given the overall infection rate of 2.2% over the period. Less than 50% of hip and knee arthroplasty was recorded as infected by 30 days and approximately 75% of cases were recorded as infected by 90 days. CONCLUSION: Single source administrative data sets and short follow-up periods underestimate SSI rates. Administrative data sets should be combined and a minimum follow-up period of 90 days should be used to more accurately track SSI rates in hip and knee arthroplasty.

Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non-First Nations children and youth.

BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non-First Nations children. METHODS: Data from a study population of age- and sex-matched First Nations and non-First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health). RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non-First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non-First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non-First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.0, and OR 1.7, 95% CI 1.2-2.3, respectively). INTERPRETATION: First Nations children were diagnosed with more pain than non-First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non-First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty.

BACKGROUND: Total joint replacement (TJR) is increasingly performed in older patients with more comorbidities, who are considered at higher risk for postoperative complications. We aimed to identify and calculate the odds ratio of the risk factors for infection, revision and death 3 months and 1 year after TJR as well as for postoperative blood transfusion and longer hospital stay. METHODS: We analyzed all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases in Nova Scotia between Apr. 1, 2000, and Mar. 31, 2014, as identified from the Discharge Abstract Database. We used the Charlson Comorbidity Index as a surrogate measure of comorbidities. We used hospital and physician billings data and Nova Scotia Vital Statistics data to identify the postoperative events in this cohort. RESULTS: A total of 10 123 primary THA and 17 243 primary TKA procedures were performed during the study period. The mean patient age was 66.1 (standard deviation 11.7) years and 67.1 (standard deviation 9.3) years, respectively. With THA, the risk of infection was higher in patients with heart failure and those with diabetes. For TKA, liver disease and blood transfusion were associated with a higher risk of infection. Revision rates were higher among patients with hypertension and those with paraparesis/hemiparesis for THA, and among patients with metastatic disease for TKA. Significant risk factors for death included metastatic disease, older age, heart failure, myocardial infarction, dementia, rheumatologic disease, renal disease, blood transfusion and cancer. Multiple medical comorbidities and older age were associated with higher rates of blood transfusion and longer hospital stay. CONCLUSION: We have identified the risk factors associated with higher rates of postoperative complications and longer hospital stay after TJR. The results enable individualized risk stratification during the preoperative consultation.

CONTEXTE: Les arthroplasties totales (AT) sont de plus en plus pratiquées chez les patients âgés présentant de plus nombreuses comorbidités et considérés de ce fait exposés à un risque accru de complications postopératoires. Nous avons voulu déterminer et calculer le rapport des cotes pour les facteurs de risque d'infection, de révision chirurgicale et de décès 3 mois et 1 an après l'AT, de même que de transfusions sanguines postopératoires et de prolongation du séjour hospitalier. MÉTHODES: Nous avons analysé toutes les interventions primaires pour prothèse totale de la hanche (PTH) et prothèse totale du genou (PTG) en Nouvelle-Écosse entre le 1er avril 2000 et le 31 mars 2014, répertoriées dans la base de données sur les congés des patients. Nous avons utilisé le score de comorbidité de Charlson comme marqueur de substitution des comorbidités. Nous avons utilisé les données de facturation des hôpitaux et des médecins et les données de l'état civil de la Nouvelle-Écosse pour recenser les événements postopératoires dans cette cohorte. RÉSULTATS: En tout, 10 123 PTH primaires et 17 243 PTG primaires ont été effectuées pendant la période de l'étude. L'âge moyen des patients était de 66,1 ans (écart-type 11,7) et de 67,1 ans (écart-type 9,3), respectivement. Avec la PTH, le risque d'infection a été plus élevé chez les patients atteints d'insuffisances cardiaques et les patients diabétiques, tandis qu'avec la PTG, il a été plus élevé chez les patients atteints de maladie hépatique et traités par transfusions sanguines. Les taux de révision chirurgicale ont été plus élevés chez les patients hypertendus et ceux qui souffraient de paraparésie ou d'hémiparésie dans les cas de PTH, et chez les patients atteints de maladies métastatiques dans les cas de PTG. Les facteurs de risque de décès significatifs incluaient maladie métastatique, âge avancé, insuffisance cardiaque, infarctus du myocarde, démence, maladie rhumatismale, maladie rénale, transfusions sanguines et cancer. La présence de comorbidités multiples et l'âge avancé ont été associés à des taux plus élevés de transfusions sanguines et à des séjours hospitaliers plus longs. CONCLUSION: Nous avons déterminé les facteurs de risque associés aux taux plus élevés de complications postopératoires et aux séjours hospitaliers prolongés après une AT. Les résultats permettent d'établir une stratification individualisée des risques dès la consultation préopératoire.

Examining palliative care program use and place of death in rural and urban contexts: a Canadian population-based study using linked data.

INTRODUCTION: Palliative care has been both more available and more heavily researched in urban than in rural areas. This research studies factors associated with palliative care program (PCP) enrollment and place of death across the urban/rural continuum. Importantly, rather than simply comparing urban and rural areas, this article examines how the effects of demographic, geographic, and socioeconomic factors differ across service delivery settings within the Canadian province of Nova Scotia. METHODS: This study linked PCP patient enrollment files from three districts to Nova Scotia vital statistics death certificate data. Postal codes of the decedents were mapped to 2006 Canadian dissemination area census data. The study examined 23 860 adult residents of three district health authorities, who died from 2003 to 2009 with a terminal illness, organ failure, or frailty and who were not nursing home residents. Demographic, geographic, and socioeconomic predictors of PCP enrollment and place of death were investigated using logistic regression across the entire study area, and stratified by district of residence. Univariate and multivariate (adjusted) odds ratios (OR) and their 95% confidence intervals (CI) are reported. RESULTS: Overall, 40.3% of the study subjects were enrolled in a PCP, and 73.4% died in hospital. Odds of PCP enrollment were highest for females (OR: 1.30; 95%CI: 1.22, 1.39), persons aged 50-64 years (OR: 1.50; 95%CI: 1.35, 1.67), and persons with a terminal disease such as cancer. While in overall multivariate analysis residents of census metropolitan areas and agglomerations had higher odds of enrollment (OR: 1.51; 95%CI: 1.29, 1.77), and those at greater distance from a PCP had lower odds (OR: 0.33; 95%CI: 0.27, 0.40), stratified analysis revealed a more nuanced picture. Within each district, travel time to PCP remained a significant predictor of enrollment but the magnitude of its effect differed markedly. There was no consistent relationship with urban/rural residence, social deprivation, or economic deprivation. Enrollment in a PCP was associated with lower adjusted odds of dying in hospital (OR: 0.78; 95%CI: 0.72, 0.84), and those living at greater distance from a PCP had higher odds of hospitalization (OR: 1.52; 95%CI: 1.28, 1.81), but there was no consistent relationship for urban/rural residence or across districts. CONCLUSIONS: Geographic patterns of PCP enrollment and place of death differed by district, as did the impact of economic and social deprivation. Analysis and reporting of population-based indicators of access should be grounded in an understanding of the characteristics of geographic areas and local context of health services. Although more research is needed, these findings show promise that disparities in access between urban and rural settings are not unavoidable, and positive aspects of rural and remote communities may be leveraged to improve care at end of life.

Identifying persons with diabetes who could benefit from a palliative approach to care.

OBJECTIVE: To determine the need for diabetes mellitus palliative care, we identified persons with a diagnosis of diabetes who accessed palliative care programs and those who may have benefited from a palliative approach to care. METHODS: This retrospective, descriptive research used 6 linked databases comprising 66 634 Nova Scotians from 3 health districts who died between 1995 and 2009, each with access to a palliative care program and diabetes centres. RESULTS: The percentage of persons with diabetes enrolled in palliative care increased from 3.2% in 1995 to 34.3% in 2009; 31.5% were enrolled within their last 2 weeks of life. Most did not have their diabetes recorded in palliative data. Among the 5353 persons with a diagnosis of diabetes who died between 2005 and 2009, 61.0% were in the Diabetes Care Program of Nova Scotia registry. An additional 19.6% were identified in the Cardiovascular Health Nova Scotia registry, and a further 3.7% in palliative data. Applying the criteria of Rosenwax et al to the 5353, 65.8% to 97.9% may have benefitted from a palliative approach. CONCLUSIONS: Rates of palliative enrollment for persons with diabetes are increasing. Diabetes care providers need to prepare patients and their families for changes in diabetes management that will be beneficial as end of life approaches. Collaboration among chronic disease programs, palliative care and primary care is advised to identify persons at end of life who have diabetes and to develop and implement care guidelines for this population.

Co-morbidities of persons dying of Parkinson's disease.

INTRODUCTION: Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD. METHODS: We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age-sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated. RESULTS: PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age-sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21-2.85) and 1.83 (CI 1.58-2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex. DISCUSSION: Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.

Cost-utility of the 21-gene recurrence score assay in node-negative and node-positive breast cancer.

The 21-gene recurrence score (Oncotype DX: RS) appears to augment clinico-pathologic prognostication and is predictive of adjuvant chemotherapy benefit in node-negative (N-) and node-positive (N+), endocrine-sensitive breast cancer. RS is a costly assay that is associated with good 'value for money' in N- disease, while economic evaluations in N+ disease based on most recent data have not been conducted. We examined the cost-utility (CU) of a RS-guided adjuvant strategy, compared to current practice without RS in N- and N+, endocrine-sensitive, breast cancer from a Canadian health care system perspective. A generic state-transition model was developed to compute cumulative costs and quality-adjusted life years (QALYs) over a 25-year horizon. Patient outcomes with and without chemotherapy in RS-untested cohorts and in those with low, intermediate and high RS were examined based on the reported prognostic and predictive impact of RS in N- and N+ disease. Chemotherapy utilization (current vs. RS-guided), unit costs and utilities were derived from a Nova Scotia Canadian population-based cohort, local unit costs and the literature. Costs and outcomes were discounted at 3% annually, and costs were reported in 2011 Canadian dollars ($). Probabilistic and one-way sensitivity analyses were conducted for key model parameters. Compared to a non-RS-guided strategy, RS-guided adjuvant therapy was associated with $2,585 and $864 incremental costs, 0.27 and 0.06 QALY gains, and resultant CUs of $9,591 and $14,844 per QALY gained for N- and N+ disease, respectively. CU estimates were robust to key model parameters, and were most sensitive to chemo utilization proportions. RS-guided adjuvant therapy appears to be a cost-effective strategy in both N- and N+, endocrine-sensitive breast cancer with resultant CU ratios well below commonly quoted thresholds.

Eliminating the shortage of registered nurses in Canada: an exercise in applied needs-based planning.

OBJECTIVE: To demonstrate the application of a needs-based framework for health human resources (HHR) planning to illustrate the potential effects of policies on the shortage of Registered Nurses (RNs) in Canada. METHODS: A simulation model was developed to simultaneously estimate the supply of and requirements for RNs based on data on the health needs of Canadians with current service delivery patterns and levels of productivity as a baseline scenario. The potential individual and cumulative effects of various policy scenarios on the 'gap' between these were simulated. RESULTS: A baseline scenario estimated a shortage of about 11,000 RN FTEs in 2007 for Canada, increasing to over 60,000 by 2022. However, multifaceted approaches have the potential to eliminate the estimated shortage. CONCLUSIONS: Estimating the requirements for health human resources must explicitly consider population health needs, levels of service delivery and HHR productivity while changing supply to meet requirements involves consideration of a broad range of comprehensive interventions. Investments in improved data collection and planning tools are needed to support more effective HHR planning. The estimated Canadian shortage of RNs based on current circumstances can be resolved in the short to medium tern through modest improvements in RN retention, activity and productivity.

Planning for what? Challenging the assumptions of health human resources planning.

OBJECTIVES: Health human resource planning has traditionally been based on simple models of demographic changes applied to observed levels of service utilization or provider supply. No consideration has been given to the implications of changing levels of need within populations over time. Recently, needs based resource planning models have been suggested that incorporate changes in needs for care explicitly as a determinant of health care needs. METHODS: In this paper, population indicators of morbidity, mortality and self-assessed health are analyzed to determine if health care needs have changed across birth cohorts in Canada from 1994 to 2005 among older age groups. Multivariate regression analysis was used to estimate the age pattern of health by birth year with interaction terms included to examine whether the association of age with health was conditional on the birth year. RESULTS: Results indicate that while the probability of mortality, mobility problems and pain rises with age, the rate of change is greater for those born earlier. The probability of self-assessed poor health increases with age but the rate of change with age is constant across birth years. CONCLUSIONS: Even in the short time period covered, our analysis shows that health care needs by age are changing over time in Canada.

Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology.

This study is concerned with methods to measure population-based indicators of quality end-of-life care. Using a retrospective cohort approach, we assessed the feasibility, validity and reliability of using administrative databases to measure quality indicators of end-of-life care in two Canadian provinces. The study sample consisted of all females who died of breast cancer between 1 January 1998 and 31 December 2002, in Nova Scotia or Ontario, Canada. From an initial list of 19 quality indicators selected from the literature, seven were determined to be fully measurable in both provinces. An additional seven indicators in one province and three in the other province were partially measurable. Tests comparing administrative and chart data show a high level of agreement with inter-rater reliability, confirming consistency in the chart abstraction process. Using administrative data is an efficient, population-based method to monitor quality of care which can compliment other methods, such as qualitative and purposefully collected clinical data.

Long-run consequences of parental paid work hours for child overweight status in Canada.

This paper explores the connection between the labour market and child overweight status in Canada. The labour market is a social institution which plays a critical role in determining how families live their day-to-day lives, for example, how much time and which parts of the day are available for cooking, eating and exercise. Using longitudinal data from the Statistics Canada National Longitudinal Survey of Children and Youth, we find that a history of higher hours of paid work by mothers (but not fathers) is associated with a higher probability of being 'at risk of overweight'/overweight for children aged 6-11. The policy implication we draw from this work is that additional support to better enable parents to engage in paid work without penalty to their own health or that of their children is clearly warranted.

Chronic poverty and childhood asthma in the Maritimes versus the rest of Canada.

OBJECTIVE: To examine the role of higher long-term poverty rates in the Maritimes as an explanation for higher rates of asthma among children 2-7 years of age. METHODS: Using longitudinal data from the National Longitudinal Survey of Children and Youth (NLSCY), logistic regressions examine associations between poverty duration and the probability of a child having been diagnosed with asthma, having a current asthma attack or experiencing wheezing in the past 12 months, controlling for other known determinants. RESULTS: NLSCY data indicate that 15.9% of Maritime children have been diagnosed with asthma, 8.7% have recently had an attack and 24.1% experienced wheezing, statistically higher levels than in the rest of Canada. Children in chronic poverty show rates that are over 30% higher than the Canadian averages. Although 19.9% of Maritime children have been chronically poor compared to 11.7% elsewhere, and although poverty is associated with a higher probability of asthma/wheezing, controlling for poverty status does not eliminate the regional difference in asthma rates. Including other controls with poverty status again does not fully explain the difference. CONCLUSION: While these findings do not completely explain why asthma prevalence rates are higher for Maritime children, they do indicate important pathways from poverty to childhood asthma. For example, chronically poor children are more likely to have had low birthweights and are less likely to have been breastfed, both of which are correlates of asthma. Such information can be useful for policy-makers. Pollutants and other environmental factors associated with asthma not included in the study may help further explain regional differences.