Autonomic Parameter and Stress Profile Predict Secondary Ischemic Events After Transient Ischemic Attack or Minor Stroke.

Background and Purpose- Traditional risk factors for ischemic stroke are body stressors that are related to autonomic autonomic system (ANS) dysfunction. The value of ABCD2 score (age, blood pressure, clinical features, duration of symptoms, diabetes) to predict ischemic stroke after transient ischemic attack is compromised by the inclusion of a limited number of stressors. We aimed to assess whether markers of ANS function and stress could predict the occurrence of secondary ischemic events after transient ischemic attack or minor stroke. Methods- This is a prospective cohort study in which 201 patients were recruited within 48 hours after initial transient ischemic attack or minor stroke and followed for 90 days to assess the development of secondary ischemic events. ABCD2 score, heart rate variability (HRV) parameters as markers of ANS function, and psychological stress were assessed. Logistic regression and area under the curve (AUC) were used to assess the models' predictive ability. Results- Morning high frequency (HF) HRV power and changes in HF HRV from morning to afternoon (daytime HF changes) were the most useful HRV predictors for both ischemic events (AUC=0.61 and 0.70) and ischemic stroke (AUC=0.62 and 0.72). Compared with ABCD2 score, 2 HRV-based stress models showed higher predictive ability for ischemic events (AUC=0.82 versus 0.63, 0.76 versus 0.63; P<0.05) and ischemic stroke (AUC=0.87 versus 0.64, 0.82 versus 0.64; P<0.05). Conclusions- Assessing the effects of stress on the ANS may be an innovative way to stratify the risk of ischemic events after transient ischemic attack or minor stroke. New risk stratification by assessing the dynamic features of ANS dysfunction and stress may help identify high-risk sub-populations that may benefit from added management.

Autonomic Nervous System and Stress to Predict Secondary Ischemic Events after Transient Ischemic Attack or Minor Stroke: Possible Implications of Heart Rate Variability.

Transient ischemic attack (TIA) and minor stroke have high risks of recurrence and deterioration into severe ischemic strokes. Risk stratification of TIA and minor stroke is essential for early effective treatment. Traditional tools have only moderate predictive value, likely due to their inclusion of the limited number of stroke risk factors. Our review follows Hans Selye's fundamental work on stress theory and the progressive shift of the autonomic nervous system (ANS) from adaptation to disease when stress becomes chronic. We will first show that traditional risk factors and acute triggers of ischemic stroke are chronic and acute stress factors or "stressors," respectively. Our first review shows solid evidence of the relationship between chronic stress and stroke occurrence. The stress response is tightly regulated by the ANS whose function can be assessed with heart rate variability (HRV). Our second review demonstrates that stress-related risk factors of ischemic stroke are correlated with ANS dysfunction and impaired HRV. Our conclusions support the idea that HRV parameters may represent the combined effects of all body stressors that are risk factors for ischemic stroke and, thus, may be of important predictive value for the risk of subsequent ischemic events after TIA or minor stroke.

Family physician access to specialist advice by telephone: Reduction in unnecessary specialist consultations and emergency department visits.

PROBLEM ADDRESSED: Timely access to specialist care is an important issue for patients with mild to moderate symptoms, and wait times for referrals are currently quite long. OBJECTIVE OF PROGRAM: To provide FPs with quick telephone access to other specialists for treatment advice for patients with nonserious conditions that they would otherwise refer to specialist care. PROGRAM DESCRIPTION: The RACE (Rapid Access to Consultative Expertise) program is a telephone hot-line providing FPs and nurse practitioners in the Vancouver, BC, area with timely access to specialist consultations. An evaluation of data from RACE found 60% of RACE calls prevented patients from visiting a specialist and 32% of calls prevented FP referrals to hospital emergency departments. CONCLUSION: Supported by RACE, FPs can more effectively remain the locus of patient care, calling on other specialist expertise when appropriate and providing better coordination of care for their patients. Evaluations to date suggest RACE helps reduce system costs by reducing unnecessary emergency department visits and face-to-face specialist consultations.

Joint position paper on rural surgery and operative delivery.

Our professional organizations have prepared this paper as part of an integrated, multidisciplinary plan to ensure the availability of well-trained practitioner teams to sustain safe, effective and high-quality rural surgical and operative delivery services. Without these robust local (or nearby) surgical services, sustaining rural maternity care is much more difficult. This paper describes the "network model" as a health human resources solution to meet the surgical needs, including operative delivery, of rural residents; outlines necessary policy directions for achieving this solution; and poses a series of enabling recommendations.

Nos organisations professionnelles ont préparé cet article dans le cadre d'un plan multidisciplinaire intégré visant à assurer la disponibilité d'équipes soignantes bien formées pour offrir des services obstétricaux interventionnels et chirurgicaux sécuritaires, efficaces et de grande qualité en milieu rural. Sans de tels solides services chirurgicaux locaux (ou de proximité), il est beaucoup plus difficile d'assurer les soins obstétricaux en milieu rural. Cet article décrit le « modèle en réseau ¼ comme une solution au chapitre des ressources humaines en santé pour répondre aux besoins chirurgicaux des populations rurales, y compris pour les services obstétricaux interventionnels. On y décrit aussi les orientations politiques nécessaires à l'application de cette solution et on formule une série de recommandations préparatoires.

Program evaluation of a child and youth mental health training program for family physicians in british columbia.

INTRODUCTION: This brief report presents findings from the program evaluation of a portion of an educational program developed to support family physicians in improving their mental health care competencies in children and youth in British Columbia. METHOD: The Child and Youth Mental Health (CYMH) learning module is part of a broader initiative from the Practice Support Program (PSP) of the British Columbia Medical Association and was created specifically to assist family physicians in improving their competencies in the identification, diagnosis and delivery of best evidence-based treatments for children and youth exhibiting the most common mental disorders that can be effectively treated in most primary care practices. RESULTS: The initial results from the program evaluation demonstrate a substantial improvement in family physicians' knowledge of child and youth mental disorders and their self-rated clinical confidence in identifying and treating (both pharmacologically and psychotherapeutically) the most common child and youth mental disorders. Furthermore, because the training protocol involves a team-based approach which includes specialist physicians as well as school counsellors and human services providers, collaboration between primary practice and other providers is enhanced. CONCLUSION: The initial results encourage broader roll-out and further evaluation of this program on a wider scale.

INTRODUCTION: Ce bref rapport présente les résultats de l'évaluation d'une portion d'un programme éducatif mis au point pour soutenir les médecins de famille dans le perfectionnement de leurs compétences en soins de santé mentale des enfants et des adolescents de la Colombie-Britannique. MÉTHODE: Le module d'apprentissage Santé mentale de l'enfant et de l'adolescent (SMEA) fait partie d'une initiative plus vaste du programme de soutien de la pratique (PSP) de l'association médicale de la Colombie-Britannique. Il a été créé spécifiquement pour aider les médecins de famille à perfectionner leurs compétences en matière d'identification, de diagnostic, et de prestation des meilleurs traitements fondés sur des données probantes pour les enfants et les adolescents présentant les troubles mentaux les plus communs qui peuvent être traités efficacement dans la plupart des pratiques de soins de première ligne. RÉSULTATS: Les premiers résultats de l'évaluation du programme démontrent que les médecins de famille ont substantiellement amélioré leurs connaissances des troubles mentaux pédiatriques ainsi que leur confiance clinique autoévaluée de pouvoir identifier et traiter (de manière tant pharmacologique que psychothérapeutique) les troubles mentaux pédiatriques les plus communs. En outre, parce que le protocole de formation comporte une approche en équipe qui comprend des médecins spécialistes ainsi que des conseillers scolaires et des prestataires de services humains, la collaboration entre les pratiques de soins de première ligne et les autres prestataires est améliorée. CONCLUSION: Les premiers résultats incitent à un déploiement élargi et à une autre évaluation de ce programme à plus grande échelle.

Length of stay and hospital costs among patients admitted to hospital by family physicians.

OBJECTIVE: To compare length of stay and total hospital costs among patients admitted to hospital under the care of family physicians who were their usual health care providers in the community (group A) and patients admitted to the same inpatient service under the care of family physicians who were not their usual health care providers (group B). DESIGN: Retrospective observational study. SETTING: A large urban hospital in Vancouver, BC. PARTICIPANTS: All adult admissions to the family practice inpatient service between April 1, 2006, and June 30, 2008. MAIN OUTCOME MEASURES: Ratio of length of stay to expected length of stay and total hospital costs per resource intensity weight unit. Multivariate linear regression was performed to determine the effect of admitting group (group A vs. group B) on the natural logarithm transformations of the outcomes. RESULTS: The median acute length of stay was 8.0 days (interquartile range [IQR] 4.0 to 13.0 days) for group A admissions and 8.0 days (IQR 4.0 to 15.0 days) for group B admissions. The median (IQR) total hospital costs were $6498 ($4035 to $11,313) for group A admissions and $6798 ($4040 to $12,713) for group B admissions. Aftera djustment for patient characteristics, patients admitted to hospital under the care of their own family physicians did not significantly differ in terms of acute length of stay to expected length of stay ratio (percent change 0.6%, P = .942)or total hospital costs per resource intensity weight unit (percent change -2.0%, P = .722) compared with patients admitted under the care of other family physicians. CONCLUSION: These findings suggest that having networks of family physicians involved in hospital care for patients is not less efficient than having family physicians provide care for their own patients.

The medium is the (health) measure: patient engagement using personal technologies.

With the phrase "the medium is the message", Marshall McLuhan argued that technologies are the messages themselves and not just the medium. Almost 50 years later, we understand that modern information and communication technologies expand our ability to perceive our world to an extent that would be impossible without the medium. In this article, we contend that information and communication technologies are becoming the dominant medium for patient engagement. Information and communication technologies will efficiently change patient-reported measurement into much more behaviorally sophisticated information that will create a very different interaction between patients and a new kind of health care workforce.

Reviving full-service family practice in British Columbia.

In 2003, British Columbia created a joint committee of doctors and government representatives to reverse the deterioration in full-service family practice, particularly evidenced in poor morale among family physicians. The committee introduced an array of innovative programs into the province's fee-for-service system of solo and small-group practices, focusing on operational rather than structural changes. Incentive payments for managing chronically ill patients were followed by maternity care bonuses, training to enhance clinical skills and to support practice redesign, recruitment incentives for new family doctors, and other patient care initiatives. The programs, which are open to all general practitioners, have reduced health care spending on high-needs patients, research shows. Moreover, British Columbia now has the lowest hospitalization rate in Canada for seven medical conditions. The experience dem­onstrates that coordinated, operational reform of full-service family practice can improve care and reduce costs without radical restructuring of the primary care system.

Rapid access to cardiology expertise: an innovative program to provide telephone support for family physicians.

The increasing incidence of chronic diseases in the Canadian population represents one of the biggest challenges to Canada's healthcare system and its patient population. In 2005, more than one-third of Canadians were burdened with one or more chronic diseases (Broemeling et al. 2008). Moreover, it is estimated that, between 2005 and 2015, two million Canadians will die of causes related to a chronic disease at a cost of more than $9 billion (World Health Organization 2005). An aging population and improvements in the acute care of many diseases predicts that chronic diseases will continue to rise in the foreseeable future. This is a concern as those with a chronic disease use twice the amount of healthcare resources compared to the average adult and have hospital stays that are four times longer than those with acute conditions (Broemeling et al. 2005).

Collaboration in caring for psychiatric inpatients: Family physicians team up with psychiatrists and psychiatric nurses.

PROBLEM BEING ADDRESSED: The standard organization of psychiatric inpatient care at our hospital involved consultations with various specialist physicians visiting the psychiatry wards to assess patients' medical needs and to provide appropriate interventions. We thought that this type of clinical care pathway might not be leading to the best integration and timeliness of patient care, the most efficient use of specialist resources, or the least cost to the health care system. OBJECTIVE OF PROGRAM: To initiate a protocol that would involve an FP visiting all the psychiatry wards daily (on weekdays) to conduct medical consultations. We hoped this program would improve the timeliness and integration of patient care, reduce patients' length of stay in hospital, and alter the pattern of specialist consultations. PROGRAM DESCRIPTION: The FP consulted on patients referred by psychiatrists and registered psychiatric nurses; carried out assessments; initiated treatment of commonmedical problems; referred to other specialists when necessary; and made arrangements for follow-up care as appropriate. CONCLUSION: The FP consultations improved patient care in several ways, was highly valued by staff, and modified the pattern of specialist consultations on participatingpsychiatry wards.

Evidence-based prescribing of antibiotics for children: role of socioeconomic status and physician characteristics.

BACKGROUND: Evidence-based guidelines for antibiotic use are well established, but nonadherence to these guidelines continues. This study was undertaken to determine child, household and physician factors predictive of nonadherence to evidence-based antibiotic prescribing in children. METHODS: The prescription and health care records of 20 000 Manitoba children were assessed for 2 criteria of nonadherence to evidence-based antibiotic prescribing during the period from fiscal year 1996 (April 1996 to March 1997) to fiscal year 2000: receipt of an antibiotic for a viral respiratory tract infection (VRTI) and initial use of a second-line agent for acute otitis media, pharyngitis, pneumonia, urinary tract infection or cellulitis. The likelihood of nonadherence to evidence-based prescribing, according to child demographic characteristics, physician factors (specialty and place of training) and household income, was determined from hierarchical linear modelling. Child visits were nested within physicians, and the most parsimonious model was selected at p < 0.05. RESULTS: During the study period, 45% of physician visits for VRTI resulted in an antibiotic prescription, and 20% of antibiotic prescriptions were for second-line antibiotics. Relative to general practitioners, the odds ratio for antibiotic prescription for a VRTI was 0.51 (95% confidence interval [CI] 0.42-0.62) for pediatricians and 1.58 (95% CI 1.03-2.42) for other specialists. The likelihood that an antibiotic would be prescribed for a VRTI was 0.99 for each successive 10,000 Canadian dollars increase in household income. Pediatricians and other specialists were more likely than general practitioners to prescribe second-line antibiotics for initial therapy. Both criteria for nonadherence to evidence-based prescribing were 40% less likely among physicians trained in Canada or the United States than among physicians trained elsewhere. INTERPRETATION: The links that we identified between nonadherence to evidence-based antibiotic prescribing in children and physician specialty and location of training suggest opportunities for intervention. The independent effect of household income indicates that parents also have an important role.