A comparison of household food insecurity rates in Newfoundland and Labrador in 2011-2012 and 2017-2018.

OBJECTIVES: The prevalence of household food insecurity in Newfoundland and Labrador (NL) fell sharply between 2007 and 2011, but it appears to have risen since then. Our objective was to compare the prevalence of food insecurity between 2011-2012 and 2017-2018 in relation to population socio-demographic characteristics. METHODS: Our analytic sample comprised all NL households in the Canadian Community Health Survey (CCHS) cycles 2011-2012 and 2017-2018, n = 6800. We stratified the prevalence of household food insecurity for each cycle by socio-demographic characteristics and applied multivariable logistic regression models to determine food insecurity odds in 2017-2018 compared with 2011-2012 after controlling for socio-demographic covariates. Interactions of covariates with survey cycle were tested and models stratified when warranted. RESULTS: The prevalence of food insecurity rose from 12.0% (95% CI 10.5, 13.6) in 2011-2012 to 14.7% (95% CI 13.1, 16.6) in 2017-2018. After adjusting for household socio-demographic variables, the odds of food insecurity was 1.49 (95% CI 1.27, 1.75) in 2017-2018. The prevalence of food insecurity had increased significantly among unattached individuals, renters, households with low educational attainment, and households with income above the Low Income Measure, with concomitant increases in the contribution of these groups to the total provincial prevalence of food insecurity in 2017-2018 compared with that in 2011-2012. CONCLUSION: The odds of food insecurity among NL households increased significantly from 2011-2012 to 2017-2018. Given the serious negative health implications of household food insecurity, the province should draw on the lessons from its earlier success in food insecurity reduction to reverse the current trend.

RéSUMé: OBJECTIFS: La prévalence de l'insécurité alimentaire des ménages à Terre-Neuve-et-Labrador (T.-N.-L.) a connu une forte baisse entre 2007 et 2011, mais depuis, elle semble avoir augmenté. Nous avons cherché à comparer la prévalence de l'insécurité alimentaire entre 2011-2012 et 2017-2018 en lien avec le profil sociodémographique de la population. MéTHODE: Notre échantillon d'analyse comprenait tous les ménages de T.-N.-L. inclus dans les cycles 2011-2012 et 2017-2018 de l'Enquête sur la santé dans les collectivités canadiennes (ESCC), soit n = 6 800. Nous avons stratifié la prévalence de l'insécurité alimentaire des ménages pour chaque cycle selon le profil sociodémographique et appliqué des modèles de régression logistique multivariée pour déterminer la probabilité d'insécurité alimentaire en 2017-2018 comparativement à 2011-2012 compte tenu des covariables sociodémographiques. Nous avons testé les interactions des covariables avec les cycles de l'enquête et stratifié les modèles au besoin. RéSULTATS: La prévalence de l'insécurité alimentaire a augmenté, passant de 12 % (IC de 95 % 10,5, 13,6) en 2011-2012 à 14,7 % (IC de 95 % 13,1, 16,6) en 2017-2018. Après l'apport d'ajustements pour tenir compte des variables sociodémographiques des ménages, la probabilité d'insécurité alimentaire était de 1,49 (IC de 95 % 1,27, 1,75) en 2017-2018. La prévalence de l'insécurité alimentaire avait augmenté de façon significative chez les personnes seules, les locataires, les ménages ayant un faible niveau d'instruction et les ménages ayant un revenu supérieur à la mesure de faible revenu, avec des augmentations concomitantes de l'apport de ces groupes à la prévalence provinciale totale de l'insécurité alimentaire en 2017-2018 par rapport à 2011-2012. CONCLUSION: La probabilité d'insécurité alimentaire des ménages de T.-N.-L. a augmenté de façon significative entre 2011-2012 et 2017-2018. Étant donné les graves conséquences négatives de l'insécurité alimentaire des ménages pour la santé, la province devrait tirer des leçons de son succès antérieur dans la réduction de l'insécurité alimentaire pour inverser la tendance actuelle.

Transition from pediatric to adult aftercare for survivors of pediatric cancer in Newfoundland and Labrador: a qualitative study.

BACKGROUND: Childhood cancer survivors (CCSs) face increased risks during the period when they leave pediatric care and transition into adult-focused aftercare. We examined the experiences of CCSs entering adult-focused aftercare to gain a better understanding of current transition practices and barriers to transition, and to identify opportunities for improving care. METHODS: We conducted a qualitative study using in-person and telephone semi-structured interviews. Childhood cancer survivors who recently transitioned out of pediatric care and health care providers (HCPs) who provide care for CCSs in Newfoundland and Labrador were identified using purposive sampling. Participants were interviewed between July 2017 and March 2019. Data were analyzed using both qualitative descriptive and thematic analysis. RESULTS: We conducted interviews with 5 CCSs and 9 HCPs. All CCSs interviewed reported receiving aftercare through their pediatric oncology program; only 2 reported receiving any form of aftercare in the adult setting. The lack of a structured transition process for CCSs in the province emerged as a theme in this study. Interview participants identified several barriers to transition: the added challenges for survivors in rural areas, changes in the availability of services after the transition to adult-focused aftercare, challenges associated with navigating the adult system, and a lack of education on transitioning into adult aftercare. INTERPRETATION: We found that there was little preparation for the transition of CCSs into adult care, and their aftercare was disrupted. Programs serving CCSs have opportunities to improve care by standardizing and better supporting these transitions, for example through the development of context-appropriate educational resources.

Development and implementation of a risk assessment and management program for enzootic bovine leukosis in Atlantic Canada.

Over the past 30 yr, the prevalence of bovine leukemia virus (BLV) infection has increased in North America, including Atlantic Canada, at both the herd and individual cow levels. This has occurred despite increased awareness of the disease and its deleterious effects and despite implementation of management practices aimed at reducing disease transmission. Our objectives were to identify risk factors associated with the within-herd prevalence of BLV-infected cows by using a risk assessment and management program workbook, as well as to determine the current level of BLV prevalence in the Atlantic Canada region. We hypothesized that previously established risk factors, including management practices associated with calf rearing and fly control, would affect within-herd BLV prevalence. Bulk tank milk (BTM) samples were collected in January and April of 2016 and again during the same months in 2017 and 2018 from all dairy farms shipping milk in the region. Samples were tested with ELISA for levels of anti-BLV antibodies to estimate within-herd prevalence. Regional BLV prevalence at the herd level was 88.39% of dairy herds infected in 2016 and 89.30% in 2018. All dairy farms shipping milk and who had BTM samples collected in 2017 (n = 605) were eligible to participate in the risk assessment and management program questionnaire (RAMP), which was developed and distributed to all bovine veterinarians in Atlantic Canada. One hundred and six RAMP were returned, with representation from all 4 provinces. The RAMP results were combined with the mean BTM ELISA results, and univariable logistic regression followed by multivariable logistic regression was performed to investigate the association between RAMP risk factors and the estimated within-herd BLV prevalence. Factors in the multivariable model significantly associated with the odds of a herd being classified as >25% estimated within-herd prevalence included history of diagnosis of clinical BLV and calves receiving colostrum from cows with unknown BLV status. Differences in within-herd prevalence were not associated with hypodermic needle and injection practices, rectal sleeve practices, or using bulls for natural breeding, based on these 106 dairy farms.

Sex- and age-based differences in mortality during the 1918 influenza pandemic on the island of Newfoundland.

OBJECTIVES: Our aim was to understand sex- and age-based differences in mortality during the 1918 influenza pandemic on the island of Newfoundland. The pandemic's impact on different age groups has been the focus of other research, but sex-based differences in mortality are rarely considered. Aspects of social organization, labor patterns, and social behaviors that contribute to mortality between males and females at all ages are used to explain observed mortality patterns. METHODS: Recorded pneumonia and influenza deaths on the island (n = 1871) were used to calculate cause-specific death rates and to evaluate differences in sex-based mortality. Mortality levels in 17 districts and four regions (Avalon, North, South, and West) were compared using standardized mortality ratios (SMRs). A logistic regression model was fit to determine in which regions sex-based mortality could be predicted using age and region as interactive predictors. RESULTS: Differences in sex-based mortality varied across regions; they were not significant for the aggregate population. SMRs were also variable, with no significant sex-based differences. Sex-based differences were highly variable within regions. Results from a logistic regression analysis suggest that females in the South region may have experienced a higher probability of death than other island residents. CONCLUSIONS: Mortality analysis for aggregate populations homogenizes important epidemiologic patterns. Men and women did not experience the 1918 influenza pandemic in the same way, and by analyzing data at the regional and district geographic levels, patterns emerge that can be explained by the economies and social organization of the people who lived there.

Determining Student Food Insecurity at Memorial University of Newfoundland.

PURPOSE: Our study compared the prevalence of food insecurity among 3 student groups attending Memorial University of Newfoundland (MUN): International (INT), Canadian out-of-province (OOP), and Newfoundland and Labrador (NL). Factors associated with food insecurity were also investigated. METHODS: Data were collected via an online survey distributed to an estimated 10 400 returning MUN students registered at a campus in St. John's, NL. Respondents were recruited through e-mails, posters, and social media. Ten questions from the Canadian Household Food Security Survey Module adult scale were asked to assess food security. Logistic regression was used to compare rates of food insecurity between the three population subgroups. RESULTS: Of the 971 eligible student respondents, 39.9% were food insecure (moderate or severe). After controlling for program type, parental status, living arrangement, and primary income source, OOP and INT students were 1.63 (95% CI = 1.11-2.40) and 3.04 (95% CI = 1.89-4.88) times more likely, respectively, to be food insecure than NL students. CONCLUSIONS: Approximately 40% of participating MUN students experienced food insecurity, a higher proportion than reported for the overall provincial population. Groups at high risk of food insecurity include INT students, students with children, and those relying on government funding as their primary income.

Health and health service use of very elderly Newfoundlanders.

OBJECTIVE: To develop a better understanding of the current health status and health care use of the population of very elderly Newfoundlanders to inform policy makers, decision makers, and health care providers about aspects of the health care system that might be in higher demand in the near future. DESIGN: Descriptive analysis using data from the Newfoundland and Labrador component of the Canadian Primary Care Sentinel Surveillance Network database for the 2013 calendar year. SETTING: Newfoundland. PARTICIPANTS: A total of 1204 Newfoundlanders aged 80 years and older. MAIN OUTCOME MEASURES: Encounters with family physicians, medications used, hospitalizations, emergency department (ED) visits, laboratory tests, and mortality were described and compared by sex, age, and location (rural vs urban). RESULTS: Compared with men, women were prescribed more medications (P = .01), were less likely to be hospitalized (P = .007), were more likely to visit an ED (P = .049), and died less frequently (P = .001). Compared with those aged 90 and older, those aged 80 to 89 made more visits to their family doctors (P = .001) and were prescribed more medications (P = .001). Predictably, those aged 90 and older died more frequently than their younger counterparts did (P = .001). Compared with those in rural communities, urban dwellers were prescribed more medications (P = .031), were hospitalized more often (P = .001), were more likely to visit the ED (P = .002), were more likely to have laboratory tests ordered (P = .001), died more frequently (P = .023), and visited their family physicians more frequently (P = .001). CONCLUSION: Octogenarian women living in urban areas are the subcohort using the most resources. This might be owing to movement of the elderly to urban locations as they age.

Modified Reporting of Positive Urine Cultures to Reduce Inappropriate Treatment of Asymptomatic Bacteriuria Among Nonpregnant, Noncatheterized Inpatients: A Randomized Controlled Trial.

DESIGNWe conducted a randomized, parallel, unblinded, superiority trial of a laboratory reporting intervention designed to reduce antibiotic treatment of asymptomatic bacteriuria (ASB).METHODSResults of positive urine cultures from 110 consecutive inpatients at 2 urban acute-care hospitals were randomized to standard report (control) or modified report (intervention). The standard report included bacterial count, bacterial identification, and antibiotic susceptibility information including drug dosage and cost. The modified report stated: "This POSITIVE urine culture may represent asymptomatic bacteriuria or urinary tract infection. If urinary tract infection is suspected clinically, please call the microbiology laboratory … for identification and susceptibility results." We used the following exclusion criteria: age <18 years, pregnancy, presence of an indwelling urinary catheter, samples from patients already on antibiotics, neutropenia, or admission to an intensive care unit. The primary efficacy outcome was the proportion of appropriate antibiotic therapy prescribed.RESULTSAccording to our intention-to-treat (ITT) analysis, the proportion of appropriate treatment (urinary tract infection treated plus ASB not treated) was higher in the modified arm than in the standard arm: 44 of 55 (80.0%) versus 29 of 55 (52.7%), respectively (absolute difference, -27.3%; RR, 0.42; P = .002; number needed to report for benefit, 3.7).CONCLUSIONSModified reporting resulted in a significant reduction in inappropriate antibiotic treatment without an increase in adverse events. Safety should be further assessed in a large effectiveness trial before implementationTRIAL REGISTRATION. clinicaltrials.gov#NCT02797613Infect Control Hosp Epidemiol 2018;814-819.

Suicide Rates in Aboriginal Communities in Labrador, Canada.

OBJECTIVES: To compare suicide rates in Aboriginal communities in Labrador, including Innu, Inuit, and Southern Inuit, with the general population of Newfoundland, Canada. METHODS: In partnership with Aboriginal governments, we conducted a population-based study to understand patterns of suicide mortality in Labrador. We analyzed suicide mortality data from 1993 to 2009 from the Vital Statistics Death Database. We combined this with community-based methods, including consultations with Elders, youths, mental health and community workers, primary care clinicians, and government decision-makers. RESULTS: The suicide rate was higher in Labrador than in Newfoundland. This trend persisted across all age groups; however, the disparity was greatest among those aged 10 to 19 years. Males accounted for the majority of deaths, although suicide rates were elevated among females in the Inuit communities. When comparing Aboriginal subregions, the Innu and Inuit communities had the highest age-standardized mortality rates of, respectively, 165.6 and 114.0 suicides per 100 000 person-years. CONCLUSIONS: Suicide disproportionately affects Innu and Inuit populations in Labrador. Suicide rates were high among male youths and Inuit females.

A prediction model to estimate completeness of electronic physician claims databases.

OBJECTIVES: Electronic physician claims databases are widely used for chronic disease research and surveillance, but quality of the data may vary with a number of physician characteristics, including payment method. The objectives were to develop a prediction model for the number of prevalent diabetes cases in fee-for-service (FFS) electronic physician claims databases and apply it to estimate cases among non-FFS (NFFS) physicians, for whom claims data are often incomplete. DESIGN: A retrospective observational cohort design was adopted. SETTING: Data from the Canadian province of Newfoundland and Labrador were used to construct the prediction model and data from the province of Manitoba were used to externally validate the model. PARTICIPANTS: A cohort of diagnosed diabetes cases was ascertained from physician claims, insured resident registry and hospitalisation records. A cohort of FFS physicians who were responsible for the diagnosis was ascertained from physician claims and registry data. PRIMARY AND SECONDARY OUTCOME MEASURES: A generalised linear model with a γ distribution was used to model the number of diabetes cases per FFS physician as a function of physician characteristics. The expected number of diabetes cases per NFFS physician was estimated. RESULTS: The diabetes case cohort consisted of 31,714 individuals; the mean cases per FFS physician was 75.5 (median = 49.0). Sex and years since specialty licensure were significantly associated (p < 0.05) with the number of cases per physician. Applying the prediction model to NFFS physician registry data resulted in an estimate of 18,546 cases; only 411 were observed in claims data. The model demonstrated face validity in an independent data set. CONCLUSIONS: Comparing observed and predicted disease cases is a useful and generalisable approach to assess the quality of electronic databases for population-based research and surveillance.

Disparities in tobacco use by sexual orientation among high school students.

OBJECTIVE: This study examined whether cigarette use is associated with sexual orientation among high school students. METHODS: Data were from a 2012 cross-sectional survey of 5994 students in grades 9, 10 and 12 attending public schools in Atlantic Canada. Multilevel logistic regression analysis was used to examine differences in cigarette use by sexual orientation. RESULTS: Lesbian, gay and bisexual adolescents (LGB) reported higher prevalence (22%) of daily cigarette use compared with heterosexuals (11%). Multilevel logistic regression analysis, controlling for standard covariates, found that LGB adolescents were more likely to be daily smokers than non-LGB adolescents (odds ratio 2.00, 95% confidence interval 1.50-2.68). Bisexual adolescents were at least twice more likely to be a smoker compared with heterosexual adolescents. CONCLUSIONS: Prevalence of cigarette use was significantly higher among LGB adolescent students. Our results join a growing body of evidence indicating that sexual minorities are at heightened risk of tobacco use. Smoking cessation measures that specifically target this group may be beneficial given that there is no one size fits all approach.

Does the type of provider and the place of residence matter in the utilization of prenatal ultrasonography? Evidence from Canada.

BACKGROUND: There has been a proliferation of repeat prenatal ultrasound examinations per pregnancy in many developed countries over the past 20 years, yet few studies have examined the main determinants of the utilization of prenatal ultrasonography. OBJECTIVE: The objective of this study was to examine the influence of the type of provider, place of residence and a wide range of socioeconomic and demographic factors on the frequency of prenatal ultrasounds in Canada, while controlling for maternal risk profiles. METHODS: The study utilized the data set of the Maternity Experience Survey (MES) conducted by Statistics Canada in 2006. Using an appropriate count data regression model, the study assessed the influence of a wide range of socioeconomic, demographic, maternal risk factors and types of provider on the number of prenatal ultrasounds. The regression model was further extended by interacting providers with provinces to assess the differential influence of types of provider on the number of ultrasounds both across and within provinces. RESULTS: The results suggested that, in addition to maternal risk factors, the number of ultrasounds was also influenced by the type of healthcare provider and geographic regions. Obstetricians/gynaecologists were likely to recommend more ultrasounds than family physicians, midwives and nurse practitioners. Similarly, birthing women who received their care in Ontario were likely to have more ultrasounds than women who received their prenatal care in other provinces/territories. Additional analysis involving interactions between providers and provinces suggested that the inter-provincial variations were particularly more pronounced for family physicians/general practitioners than for obstetricians/gynaecologists. Similarly, the results for intra-provincial variations suggested that compared with obstetricians/gynaecologists, family physicians/GPs ordered fewer ultrasound examinations in Prince Edward Island, British Columbia, Nova Scotia, Alberta and Newfoundland. CONCLUSION: After controlling for a number of socioeconomic and demographic factors, as well as maternal risk factors, it was found that the type of provider and the province of prenatal care were statistically significant determinants of the frequency of use of ultrasounds. Additional analysis involving interactions between providers and provinces indicated wide intra- and inter-provincial variations in the use of prenatal ultrasounds. New policy measures are needed at the provincial and federal government levels to achieve more appropriate use of prenatal ultrasonography.

Palliative and end-of-life care in Newfoundland's deaf community.

The deaf community is a distinct cultural and linguistic community (the uppercase D is a cultural identification). Compared to the general population, the deaf community, as a social group, experiences poorer health status. Deaf people seek care less frequently than the general population and have fewer interactions with the health system. Their encounters with the health system are often characterized by communication difficulties, fear, mistrust, and frustration. Qualitative research was used to explore the experiences of family caregivers who provided end-of-life care for a deaf person. Key findings indicate that the deaf community has limited understanding of their options for palliative and end-of-life care. Communication and health literacy are key barriers to accessing appropriate end-of-life care. Pain and symptom management, consideration of physical environments, and limited access to bereavement care are common issues faced by deaf people when caring for loved ones at the end of life.

Continuity of care is good for elderly people with diabetes: retrospective cohort study of mortality and hospitalization.

OBJECTIVE: To examine the relationship between continuity of family physician care and all-cause mortality and acute hospitalizations in older people with diabetes. DESIGN: Retrospective cohort study of administrative health databases. Continuity of family physician care for elderly patients newly diagnosed with diabetes was estimated by 3 continuity indexes using physician claims data. The relationship of continuity of family physician care to mortality and acute hospitalizations was investigated. SETTING: The province of Newfoundland and Labrador. PARTICIPANTS: A total of 305 family practice patients 65 years of age or older with diabetes. MAIN OUTCOME MEASURES: Death rate and hospitalization rate during a 3-year period. RESULTS: Overall, continuity of family physician care was high. In the 3 years examined, the higher-continuity group had lower rates of hospitalization (53.5% vs 68.2%) and death (8.6% vs 18.5%) than the lower-continuity group. CONCLUSION: The findings suggest an association between higher continuity of family physician care and reductions in likelihood of death and hospitalizations in older people with diabetes.

Accounting for vulnerability to illness and social disadvantage in pandemic critical care triage.

In a pandemic situation, resources in intensive care units may be stretched to the breaking point, and critical care triage may become necessary. In such a situation, I argue that a patient's combined vulnerability to illness and social disadvantage should be a justification for giving that patient some priority for critical care. In this article I present an example of a critical care triage protocol that recognizes the moral relevance of vulnerability to illness and social disadvantage, from the Canadian province of Newfoundland and Labrador.

Challenges and opportunities for using administrative data to explore changes in health status: a study of the closure of the Newfoundland cod fishery.

The closure of the cod fishery in Newfoundland and Labrador has had dramatic social and economic impacts on fishing communities in the province. Following a limited closure in 1992, a more extensive closure followed in 1994, which is still in force today, although income support provided to displaced fishery workers ended in 1999. A population-based study was conducted in 2004/2005 using 7 different sources of administrative and survey data to investigate a range of social, demographic, and health changes in fishing communities affected by the closure of the cod fishery from the period 1991 to 2001. Findings of this study extend our understanding of the impact of the fishing moratorium in Newfoundland. This article also presents both the challenges to and opportunities for using administrative and survey data to explore the impact of the fishery closure on the health and well-being of Newfoundland fishing communities. One of the most significant challenges to using administrative and survey databases was the inconsistencies in how communities were identified across the various databases. Although not without limitations, administrative data is a cost-effective means to explore the impact of socioeconomic change on a population's health status.

Prehypertension and hypertension in a primary care practice.

OBJECTIVE: To assess the prevalence of prehypertension and the prevalence and treatment of hypertension in a family practice population. DESIGN: Cross-sectional study. SETTING: An academic family practice unit. PARTICIPANTS: Practice patients aged 30 to 80 years who had visited the clinic at least once during the 2 years before the study and had at least 1 blood pressure (BP) measurement recorded on their charts during that time period. MAIN OUTCOME MEASURES: Most recent BP recorded on the chart; presence or absence of a diagnosis of hypertension recorded on the chart; number and class of prescribed antihypertensive medications. RESULTS: Of the 1388 patients who met the inclusion criteria, 389 had a diagnosis of hypertension. Of the 999 who did not have a diagnosis of hypertension, 306 (30.6%) met the criteria for prehypertension used in this study (systolic BP of 130 to 139 mm Hg or diastolic BP of 85 to 89 mm Hg). Men and older patients (60 to 80 years of age) were more likely to have prehypertension than other patients were. Of the patients with hypertension, 254 (65%) had achieved a BP level of < 140/90 mm Hg. The majority of hypertensive patients were prescribed 1 or 2 medications. Only 4.5% were using more than 2 different medications. CONCLUSION: A large proportion of a family practice's patients need close surveillance of BP because of the prevalence of prehypertension. Despite the improvement in the management of hypertension, only 65% of hypertensive patients had achieved the recommended target BP. Family physicians could be treating their hypertensive patients more aggressively with medications; only 4.4% of patients were using more than 2 different antihypertensive medications, despite 35% not being at target. Hypertension surveillance and treatment to achieve target BP levels continue to be important issues in primary care.

Regular doctor, changing doctor, no doctor: does it make a difference to rural residents?

INTRODUCTION: In Canada, a larger proportion of rural residents than urban residents do not have a regular physician. In addition to lacking physicians, many rural communities also have a high rate of physician turnover. In order to discover the effect of this we compared health status, lifestyles, preventative care, and perceptions of the health system among rural residents with a regular doctor, those who did not have a regular doctor, and those whose regular doctor changed. METHODS: We examined data from the 1995 Newfoundland Panel on Health and Medical Care and the 2001 Adult Health Survey. In each year, we compared these three groups of residents using chi2 tests and multiple logistic regression. RESULTS: In 1995, 78.1% of rural residents had a regular doctor, 8.4% had changing doctors, and 13.5% did not have a regular doctor. In 2001, 84.6% of rural residents had a regular doctor, 4.9% had changing doctors, and 10.6% did not have a regular doctor. In 1995, compared with those with regular doctors, those whose doctors changed were less likely to have a disability or physical restriction, have their blood pressure checked or be satisfied with the healthcare system; while those without a regular physician were less likely to have poor health status, preventative care or be satisfied with the healthcare system. In 2001, there were no differences between those with a regular doctor and those whose doctor changed. Compared with those with a regular doctor, those without a regular doctor were less likely to have poor health status. CONCLUSION: The proportion of rural residents who had a regular doctor increased between 1995 and 2001. Disparities between those who had a regular doctor and those with a frequently changing doctor diminished.

Having a regular doctor: rural, semi-urban and urban differences in Newfoundland.

INTRODUCTION: Recent studies suggest that 23% of adult Newfoundlanders do not have a regular doctor. Using data from the 1995 Newfoundland Panel on Health and Medical Care study, we examined the urban, semi-urban and rural differences in the characteristics of adult (age 20 and over) Newfoundlanders who did and did not have a regular doctor. METHODS: We used chi2 tests and logistic regression to analyze data from 11,789 respondents from randomly selected households in Newfoundland. The dependent variable was "Have a regular doctor" (Yes / No). The independent variable was "Place of residence" (Urban / Semi-urban / Rural) and covariates included socio-demographic and health-related variables. RESULTS: Fifteen percent (1771) of Newfoundlanders did not have a regular doctor. Of these, the largest proportion of respondents without a regular doctor lived in rural communities (74.4%); were male (62.6%); were 20-29 years old (28.7%); married (68.8%); of high socio-economic status (44.7%); working full-time (35.3%); had excellent or good health (83.0%); had no chronic illness (40.3%), disability (93.3%) or impairments to activities of daily living (98.0%); and were in excellent or good emotional health (90.7%). Compared to their urban counterparts, residents of semi-urban communities were as likely (odds ratio 1.03; 95% confidence interval [CI] 0.84-1.26) not to have a regular doctor and residents of rural communities were 4.03 (95% CI 3.50-4.65) times more likely than their urban counterparts not to have a regular doctor. CONCLUSION: In 1995, fewer adult Newfoundlanders than previously estimated did not have a regular doctor. Rural residents were more likely not to have a regular doctor than residents of either urban or semi-urban communities.

Need for coronary artery bypass grafting in Newfoundland and Labrador: the impact of increased demand.

BACKGROUND: In the past decade, growth of coronary revascularization in Canada has been substantial. It was hypothesized that as coronary angiography (CA) rates increased, referral for necessary coronary artery bypass grafting (CABG) would also increase, and include patients with multivessel disease and class I to III angina who required elective surgery. Furthermore, it was proposed that the number of CABG surgeries needed would increase at a similar rate to that of CA. METHODS: An incident cohort of patients who received CA in 1998/1999 was identified, and the group referred for CABG was followed. Clinical characteristics, appropriateness and necessity scores using specific criteria, and waiting times were evaluated and compared with a similar cohort from 1994/1995. Utilization data for coronary revascularization procedures from 1994 to 2002 were reviewed. RESULTS: Between 1994/1995 and 1998/1999, the number of CAs per year increased by 37%. The inappropriateness rate for CA was 4% in 1998/1999. The proportion of patients diagnosed with critical coronary artery disease increased from 68% in 1994/1995 to 74% in 1998/1999. The number referred for CABG increased by 48%, and the number for percutaneous transluminal coronary angioplasty (PTCA) increased by 137%. The increase in the number referred for CABG was attributable to the increase in the number of patients with less severe symptoms who required delayed elective CABG. The necessity rate for CABG in the referred group was 94% in 1994/1995 and 95% in 1998/1999. A further 91 patients were identified who needed CABG but did not receive it, 86% of whom had PTCA. From 1999 to 2002, the annual growth rate in those referred for CABG was higher than the growth rate for CA. CONCLUSIONS: With the growth in CA, the rate of discovery of high risk coronary anatomy actually increased. Growth in CABG volume was attributable to growth in the need for elective surgery in patients with class I to III angina. The rate of CABG increased disproportionately to the rate of CA, despite higher rates of PTCA with stenting. It is likely that the demand for CABG will continue to rise steadily, as expansion of angiography occurs, and may be higher than expected from the growth in CA.