Toward an accountability framework for Canadian healthcare.

State-funded healthcare systems increasingly recognize accountability as an important public policy issue. This article explores significant aspects of current theory and practice in order to describe an accountability framework for the Canadian health system. Stakeholders include governments, institutions, providers and patients. Their relationships may be framed in constitutional, political, financial, managerial, clinical or ethical terms. The specific processes and instruments to operationalize accountability depend on the terms by which it is framed.

The role of age- and population-based differences in the attitudes, knowledge and infection control practices of Canadian dentists.

OBJECTIVES: To investigate age- and population-based differences in dentists' infection control practices and willingness and refusal to treat patients with HIV. METHODS: A national mailed survey of a stratified random sample of dentists in Canada (n = 6444) with three follow-up attempts. Pearson's chi-square test and multiple logistic regression were used for data analysis. Predictor variables included population, age, gender, marital status, specialty, number of patients treated per day and continuing education on HIV/AIDS. RESULTS: The adjusted response rate was 66.4%. The best predictors of willingness to treat patients with HIV were younger age (compared with dentists > or = 60 years of age: < 30 years, OR = 8.6, 30-39, OR = 3.4; 40-49, OR = 2.7; 50-59, OR = 1.6), attending continuing education on HIV/AIDS in the past 2 years (> 10 hours, OR = 1.6 compared with zero hours), practicing in small population centres < 10,000 (OR = 1.6 compared with > 500,000) and gender (male OR = 1.3). The best predictors of refusal to treat patients with HIV were older age (compared with dentists < 30 years of age: > or = 60, OR = 6.1; 50-59, OR = 4.1; 40-49, OR = 3.0; 30-39, OR = 2.6); and practicing in population centres > 500,000 (OR = 1.5 compared with < 10,000). However, the latter group also reported treating more HIV patients than respondents in smaller communities. Infection control practices varied significantly with age and population centre. Dentists in communities of < 10,000 were more compliant with HBV vaccination, but less compliant with handwashing after degloving and the use of infection control manuals. Similarly, dentists > 60 years of age were the least compliant with HBV immunization, routine use of barriers and sterilization of handpieces, but reported the highest compliance with handwashing. CONCLUSIONS: Age- and population-based differences need to be considered in planning educational interventions to improve both access to care for patients with HIV and dentists' compliance with recommended infection control procedures.

Occupational injuries and exposures among Canadian dentists: the results of a national survey.

OBJECTIVES: To measure the frequency of occupational exposures reported by dentists in Canada and to identify factors associated with occupational exposure. DESIGN: A national mailed survey of a stratified random sample of 6,444 dentists with three follow-up attempts. Weighted data were analyzed using t tests, analysis of variance, and multiple logistic regression. RESULTS: The response rate was approximately 66%. Occupational exposures, percutaneous injuries, and mucous membrane exposures in the last year were reported by 67%, 62%, and 29% of respondents, respectively. Fewer than 1% reported exposure to human immunodeficiency virus or hepatitis B virus (HBV). Respondents reported means of 1.5 mucous membrane and 3.0 percutaneous exposures per year. HBV immunization was reported by 91% of dentists, but of these 28% reported no post-immunization serology. Other reports of suboptimal compliance included use of a postexposure protocol by only 41% and HBV vaccination of all assistants or of hygienists by 74% and 77% of respondents, respectively. Factors associated with percutaneous exposure included non-use of postexposure protocol or puncture-proof containers for sharps disposal, treating > or =20 patients per day, and male gender. Risk factors for mucous membrane exposure included non-use of eye protection or masks. CONCLUSION: This study provides evidence of the protective effect of puncture-proof containers, eye protection, and masks and raises concerns related to HBV post-immunization serology and postexposure protocols. To reduce risk of infection, educational interventions are required to improve compliance with Universal Precautions, with emphasis on comprehensive HBV immunization and post-immunization serology, the use of barriers, puncture-proof containers for sharps disposal, and postexposure protocols.

Gender differences in characteristics, infection control practices, knowledge and attitudes related to HIV among Ontario dentists.

We surveyed 5,997 dentists in Ontario to investigate gender differences in the characteristics, infection control practices, knowledge and attitudes regarding the treatment of HIV-infected patients. The response rate was 70.3%. Reports indicated that female dentists are younger and more likely to work in larger urban centres (P < 0.00001), and in general practice (P < 0.0001) than their male counterparts. Multiple logistic regression analyses indicated that many significant gender differences in the univariate analyses could be explained by the confounding influence of age, practice location, and specialty; however, some differences remain significant: Women were more likely than men to report attending continuing education dealing with HIV/AIDS in the past two years (P < 0.001), and to use masks and eye protection (P < 0.00001). Men reported more economic concerns than women: they were more concerned about the financial burden of infection control costs (P < 0.00001), and losing patients from their practice if it is known that they treat patients with HIV (P < 0.05). However, there were no significant differences in willingness to provide treatment for patients with HIV. We conclude that there is little evidence to show that access to oral care for patients with HIV is affected by gender differences.

Quitting smoking: why, how, and what might help.

OBJECTIVE: To examine reasons for quitting smoking, methods used in quitting, reasons for continuing smoking and potential aids to quitting in the population of Ontario, Canada. DESIGN: Two population-based, telephone interview surveys, conducted by random-digit dialing. SUBJECTS: Adults aged 18 years of age and older in 1983 (n = 1383) and 1991 (n = 1421). MAIN OUTCOME MEASURES: Information was obtained from former smokers on why and how they quit smoking, and from continuing smokers on why they smoked and what might help them quit. RESULTS: The proportion of current smokers in the population decreased from 35.5% in 1983 to 27.2% in 1991. In both surveys, former smokers cited a variety of reasons for quitting, including personal health concerns, social and environmental factors, personal attitude factors, cost, and health education messages. Responses concerning the most important reason also revealed a range of factors; "advice of a physician" was not prominent among them. When questioned about methods used in quitting, most former smokers in both surveys responded that they "just decided to quit". Very few reported using other aids such as cessation clinics or nicotine gum. More smokers in 1991 than in 1983 reported that they continued smoking for enjoyment, to satisfy a craving or addiction, and for relaxation. With regard to what might help them quit, continuing smokers in both surveys cited a wide variety of potential aids, including information on harmful effects, more restrictions on smoking and on sales, cessation clinics, programmes on radio/TV, and higher taxes. CONCLUSIONS: These findings support a multifaceted approach to tobacco control.

Geographic differences in the attitudes, knowledge and infection control practices of Ontario dentists.

Geographic differences in the HIV related attitudes, knowledge and behaviours of 5,997 dentists in Ontario were investigated using mailed questionnaires (response rate 70%). Proportionately more respondents from larger population centres reported that they knowingly treated HIV-infected patients (p < 0.00001), they were unwilling to treat HIV-infected patients (p < 0.05), they had an exaggerated perception of the risk of HIV infection after a needlestick injury (p < 0.01), they were concerned about personal risk (p < 0.01) and staff fears (p < 0.05) related to HIV/AIDS, and that patients with HIV or AIDS should be treated in hospitals/specialized practices (p < 0.001). Multiple logistic regression analysis controlling for age, sex, and specialty, showed that respondents who practised in smaller population centres were significantly more willing to treat HIV-infected patients ( < 10,000, odds ratio = 1.6; 10,000-49,999, odds ratio = 1.3). Significantly fewer respondents in the Central West, and Central East Health Planning Region, where AIDS is most prevalent, reported that they were willing to treat HIV patients.