The educational gap in tar and nicotine content in purchases of cigarettes: An observational study using large-scale representative survey data from Japan.

The intensity of tobacco use is commonly measured by the number of cigarettes, which is inaccurate because it masks the heterogeneity and substances contained in tobacco. Unlike existing studies, this study adopted the tar and nicotine content of purchased cigarettes as proxies for smoking intensity and elicited socioeconomic disparities from the participants regarding tobacco use. Using a nationally representative consumer panel survey of Japan from 2010 to 2014, we found that socioeconomic disparities in smoking are more pronounced when tar and nicotine content in cigarettes is considered. University graduates purchased 26% fewer cigarettes, and 40% less tar or nicotine than their secondary school-educated counterparts. Low education groups purchased more tar-rich cigarettes, which cost less than low-tar cigarettes. The public health recommendations for reducing socioeconomic health inequalities might be understated because they are drawn from evidence based on the number of cigarettes smoked.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community.

BACKGROUND: Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport. METHODS: We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls. RESULTS: Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days). CONCLUSIONS: RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

Comparing Class-Based and Home-Based Exercise for Older Adults With Chronic Health Conditions: 12-Month Follow-Up of a Randomized Clinical Trial.

OBJECTIVE: To assess the maintenance of physical activity (PA) and health gains among participants in a class-based (CB) or home-based (HB) PA intervention over a 12-month study period. METHODS: A total of 172 adults aged 50 years and older were randomly allocated to either a CB or an HB intervention, each involving an intensive 3-month phase with a 9-month follow-up period. Measures at baseline, 3, 6, and 12 months included self-reported PA and health, body mass index, waist circumference (WC), blood pressure, cardiovascular endurance (6-min walk test), physical function, and functional fitness (senior fitness test). Outcomes were analyzed using generalized estimating equations. RESULTS: Maximum improvement was typically observed at 3 or 6 months followed by a modest diminution, with no differences between groups. For body mass index, waist circumference, 6-min walk test, and senior fitness test, there was progressive improvement through the study period. Greater improvement was seen in the CB group compared with the HB group on three items on the senior fitness test (lower body strength and endurance [29% vs. 21%, p < .01], lower body flexibility [2.8 cm vs. 0.4 cm, p < .05], and dynamic agility [14% vs. 7%, p < .05]). CONCLUSION: The interventions were largely comparable; thus, availability, preferences, and cost may better guide program choice.

The Saskatchewan/New Brunswick Healthy Start-Départ Santé intervention: implementation cost estimates of a physical activity and healthy eating intervention in early learning centers.

BACKGROUND: Participation in daily physical activity and consuming a balanced diet high in fruits and vegetables and low in processed foods are behaviours associated with positive health outcomes during all stages of life. Previous literature suggests that the earlier these behaviours are established the greater the health benefits. As such, early learning settings have been shown to provide an effective avenue for exploring and influencing the physical activity and healthy eating behaviours of children before school entry. However, in addition to improving individual level health of children, such interventions may also result in a number of social benefits for the society. In fact, research among adult populations has shown that sufficient participation in physical activity can significantly lower hospital stays and physician visits, in turn leading to positive economic outcomes. To our knowledge there is very limited literature about economic evaluations of interventions implemented in early learning centers to increase physical activity and healthy eating behaviours among children. The primary purpose of this paper is to identify inputs and costs needed to implement a physical activity and healthy eating intervention (Healthy Start-Départ Santé (HS-DS)) in early learning centres throughout Saskatchewan and New Brunswick over the course of three years. In doing so, implementation cost is estimated to complete the first phase of a social return on investment analysis of this intervention. METHODS: In order to carry out this evaluation the first step was to identify the inputs and costs needed to implement the intervention, along with the corresponding outputs. With stakeholder interviews and using existing database, we estimated the implementation cost by measuring, valuing and monetizing each individual input. RESULTS: Our results show that the total annual cost of implementing HS-DS was $378,753 in the first year, this total cost decreased slightly in the second year ($356,861) and again in the third year ($312,179). On average, the total annual cost is about $350,000 which implies an annual cost of $285 per child. Among all inputs, time-cost accounted for the larger share of total resources need to implement the intervention. Overall, administration and support services accounted for the largest portion of the total implementation cost each year: 74% (year 1), 79% (year 2), and 75% (year 3). CONCLUSIONS: The results from this study shed lights for future implementation of similar interventions in this context. It also helps to assess the cost effectiveness of future interventions.

An economic analysis of a system wide Lean approach: cost estimations for the implementation of Lean in the Saskatchewan healthcare system for 2012-2014.

BACKGROUND: The costs of investing in health care reform initiatives to improve quality and safety have been underreported and are often underestimated. This paper reports direct and indirect cost estimates for the initial phase of the province-wide implementation of Lean activities in Saskatchewan, Canada. METHODS: In order to obtain detailed information about each type of Lean event, as well as the total number of corresponding Lean events, we used the Provincial Kaizen Promotion Office (PKPO) Kaizen database. While the indirect cost of Lean implementation has been estimated using the corresponding wage rate for the event participants, the direct cost has been estimated using the fees paid to the consultant and other relevant expenses. RESULTS: The total cost for implementation of Lean over two years (2012-2014), including consultants and new hires, ranged from $44 million CAD to $49.6 million CAD, depending upon the assumptions used. Consultant costs accounted for close to 50% of the total. The estimated cost of Lean events alone ranged from $16 million CAD to $19.5 million CAD, with Rapid Process Improvement Workshops requiring the highest input of resources. CONCLUSIONS: Recognizing the substantial financial and human investments required to undertake reforms designed to improve quality and contain cost, policy makers must carefully consider whether and how these efforts result in the desired transformations. Evaluation of the outcomes of these investments must be part of the accountability framework, even prior to implementation.

The effects of patient education programs on medication use among asthma and COPD patients: a propensity score matching with a difference-in-difference regression approach.

BACKGROUND: Adherence to medication is one of the critical determinants of successful management of chronic diseases including asthma and chronic obstructive pulmonary disease (COPD). Given that poor adherence with self-management medication is very common among asthma and COPD patients, interventions that improve the use of chronic disease management medications for this patient group have potential to generate positive health outcomes. In an effort to improve asthma and COPD care, the Lung Association of Saskatchewan has implemented an intervention by providing access to effective and high quality asthma and COPD education for both patients and health care professionals along with increasing access to spirometry. By evaluating the impacts of this intervention, our purpose in this paper is to examine the effectiveness of spirometry use, and asthma and COPD education in primary care setting on medication use among asthma and COPD patients. METHODS: At the time of the intervention, the Lung Association of Saskatchewan has not assigned a control group. Therefore we used a propensity score matching to create a control group using administrative health databases spanning 6 years prior to the intervention. Using Saskatchewan administrative health databases, the impacts of the intervention on use of asthma and COPD medications were estimated for one to four years after the intervention using a difference in difference regression approach. RESULTS: The paper shows that overall medication use for the intervention group is higher than that of the control group. On average, intervention group uses more asthma and COPD drugs. Within the asthma and COPD drugs, this intervention creates a persistent effect over time in the form of higher utilization of chronic management drugs equivalent to $157 and $195 in a given year during four years after the intervention. CONCLUSIONS: The study suggests that effective patient education and increasing access to spirometry increases the utilization of chronic disease management drugs among asthma and COPD patients. This type of interventions with patient education focus has potential to save healthcare dollars by providing better disease management among this patient group.

"The largest Lean transformation in the world": the implementation and evaluation of lean in Saskatchewan healthcare.

The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.

Effectiveness of an interprofessional assessment and management approach for people with chronic low back disorders delivered via virtual care: A randomized controlled trial pilot intervention.

Objective: Virtual care for chronic conditions has seen uptake due to COVID-19. Evaluation of virtual models is important to ensure evidence-based practice. There is a paucity of research in the use of virtual care for management of chronic back disorders. The objective of this study was to evaluate effectiveness of a team-based virtual care model for back disorder assessment where a physical therapist uses virtual care to join a nurse practitioner and patient in a rural Saskatchewan, Canada community. Methods: Sixty-four rural adults with chronic back disorders were randomly allocated to receive either: (1) team-based virtual care (n = 24); (2) care from an urban physical therapist travelling to community (n = 20); or (3) care from a rural nurse practitioner (n = 20). The team-based care group involved a nurse practitioner located with a rural patient, and a physical therapist joining using virtual care. The physical therapist alone and the nurse practitioner alone groups received in-person assessments. Groups with a physical therapist involved had follow-up treatments by in-person physical therapy. Outcomes over six months included pain, disability, back beliefs, satisfaction, quality-adjusted health status and management-related costs. Results: There were no significant differences for pain, disability, back beliefs and satisfaction between groups. The average cost per patient for implementing in-person physical therapist assessment ($135) was higher compared with the team over virtual care ($118) and NP care ($59). Conclusion: Primary outcomes were not different by group. Physical therapist alone was more costly than other groups. Future research should include more participants, longer follow-up time and refined cost parameters. Trial Registration: ClinicalTrials.gov NCT02225535; https://clinicaltrials.gov/ct2/show/NCT02225535 (Archived by WebCite at http://www.webcitation.org/6lqLTCNF7).

"Navigating chaos": Urban, Rural, and Remote Patient Experiences in Accessing Healthcare with Indigenous and Non-Indigenous Perspectives of Living with Chronic Low Back Pain.

Background: Healthcare access for chronic low back pain is complex and should consider not only the health system, but patient care seeking experiences as well. People who live in rural and remote communities and/or identify as being Indigenous may often encounter additional barriers to accessing care for chronic low back pain; thus, these contexts must be considered to fully understand barriers and facilitators. Aims: The aim of this study was to understand care-seeking experiences of people living with chronic back pain in Saskatchewan and determine unique experiences facing urban, rural, remote, and/or Indigenous peoples. Methods: Thirty-three participants with chronic low back pain completed a preliminary survey followed by individual semistructured interviews. Participants were categorized as urban, rural, or remote including Indigenous status. A qualitative interpretive research approach with inductive thematic analysis was employed. Results: Three overarching themes were identified with the following subthemes: (1) healthcare access challenges: challenges to accessing care, challenges within the health system, and challenges leading to self-directed management/coping strategies; (2) healthcare access facilitators: funded care, participant education and knowledge, patient-provider communication, and care closer to home; and (3) participant recommendations for improved care provision: coordination of care, integrative and holistic care, and patient-centered care and support. Rural and remote participants highlighted travel as a main barrier. Indigenous participant experiences emphasized communication with healthcare providers and past experiences influencing desire to access care. Conclusion: Participants identified a range of challenges and facilitators as well as recommendations for improving access to care for chronic low back pain, with unique barriers for rural, remote, and Indigenous participants.

Contexte: L'accès aux soins de santé pour la lombalgie chronique est complexe et devrait tenir compte non seulement du système de santé, mais aussi des expériences de recherche de soins des patients. Les personnes vivant dans des communautés rurales et éloignées et/ou qui s'identifient comme autochtones font souvent face à des obstacles supplémentaires pour accéder aux soins pour la lombalgie chronique; il faut donc tenir compte de ces contextes pour bien comprendre les obstacles et les facilitateurs.Objectifs: L'objectif de cette étude était de comprendre les expériences de recherche de soins des personnes vivant avec une lombalgie chronique en Saskatchewan et de déterminer les expériences uniques d'accès aux soins auxquelles sont confrontées les personnes vivant en milieu urbain, rural, éloigné et/ou ayant un statut d'autochtone.Méthodes: Trente-trois participants souffrant de lombalgie chronique ont répondu à un questionnaire préliminaire suivi d'entretiens individuels semi-structurés. Les participants ont été catégorisés comme vivant en milieu urbain, rural, éloigné, incluant ceux ayant un statut d'autochtone. Une approche de recherche qualitative interprétative avec une analyse thématique inductive a été utilisée.Résultats: Trois thèmes principaux ont été répertoriés avec les sous-thèmes suivants : (1) difficultés d'accès aux soins de santé : difficultés pour accéder aux soins, difficultés au sein du système de santé et difficultés conduisant à des stratégies de gestion et d'adaptation autonomes; (2) facilitateurs de l'accès aux soins de santé : financement des soins, éducation et connaissances des participants, communication entre le patient et le prestataire de soins et proximité des soins par rapport au domicile et (3) recommandations des participants pour l'amélioration de la prestation des soins : la coordination des soins, les soins intégrés et holistiques, les soins et le soutien centrés sur le patient. Les participants des régions rurales et éloignées ont souligné que les déplacements constituaient un obstacle majeur. Les expériences des participants autochtones ont mis l'accent sur la communication avec les prestataires de soins de santé et les expériences passées qui influencent le désir d'accéder aux soins.Conclusion: Les participants ont répertorié un ensemble de difficultés, de facilitateurs et de recommandations pour améliorer l'accès aux soins pour les lombalgies chroniques, qui présente des obstacles uniques pour les participants vivant en milieu rural et éloigné et les participants autochtones.

Healthcare Access Challenges and Facilitators for Back Pain Across the Rural-Urban Continuum in Saskatchewan, Canada: Cross-Sectional Results From a Provincial-Wide Telephone Survey.

Background: Chronic back pain is a common musculoskeletal disorder, disproportionately affecting rural and Indigenous people. Saskatchewan has a relatively high proportion of rural and Indigenous residents; therefore, understanding barriers and facilitators to accessing healthcare are needed to improve healthcare service delivery. Methods: A provincial-wide telephone survey explored experiences and perceived healthcare access barriers and facilitators among 384 Saskatchewan residents who experienced chronic low back pain. Chi-squared tests were performed to determine if people who lived in urban versus rural areas differed in the proportion who had accessed services from various healthcare practitioners. T-test and Mann-Whitney U analyses were conducted to determine differences between urban and rural, and Indigenous and non-Indigenous respondents. Results: Of 384 residents surveyed, 234 (60.9%) reported living in a rural location; 21 (5.5%) identified as Indigenous. Wait times (47%), cost (40%), travel (39%), and not knowing how to seek help (37%) were the most common barriers for Saskatchewan residents seeking care, with travel being the only barrier that was significantly different between rural and urban respondents (P ⩽ .001). Not knowing where to go to access care or what would help their low back pain (P = .03), lack of cultural sensitivity (P = .007), and comfort discussing problems with health care professionals (P = .26) were greater barriers for Indigenous than non-Indigenous participants. Top facilitators (>50% of respondents) included publicly funded healthcare, locally accessible healthcare services, and having supportive healthcare providers who facilitate referral to appropriate care, with urban respondents considering the latter 2 as greater facilitators than rural respondents. Telehealth or virtual care (P = .013) and having healthcare options nearby in their community (P = .045) were greater facilitators among Indigenous participants compared to non-Indigenous respondents. Conclusions: Rural, urban, Indigenous, and non-Indigenous people report overlapping and unique barriers and facilitators to accessing care for chronic low back pain. Understanding perceived access experiences will assist in developing more effective care models for specific communities or regions.

Experiences of Health Care Access Challenges for Back Pain Care Across the Rural-Urban Continuum in Canada: Protocol for Cross-sectional Research.

BACKGROUND: Back pain is common and costly, with negative impacts on both individuals and the health care system. Rural, remote, and Indigenous populations are at greater risk of experiencing back pain compared to urban and non-Indigenous populations. Potential barriers to health care access among Canadians with chronic back pain (CBP) have been identified; however, no study has used lived experiences of people with CBP to drive the selection, analysis, and interpretation of variables most meaningful to patients. OBJECTIVE: The aims of this study are to (1) engage with rural, remote, and urban Indigenous and non-Indigenous patients, health care providers, and health system decision makers to explore lived experiences among people with CBP in Saskatchewan, Canada; (2) cocreate meaningful indicators of CBP care access and effectiveness; and (3) identify program and policy recommendations to overcome access barriers to CBP care. METHODS: In phase 1, one-on-one interviews with 30 people with current or past CBP and 10 health care providers residing or practicing in rural, remote, or urban Saskatchewan communities will be conducted. We will recruit Indigenous (n=10) and non-Indigenous (n=20) rural, remote, and urban people. In phase 2, findings from the interviews will inform development of a population-based telephone survey focused on access to health care barriers and facilitators among rural, remote, and urban people; this survey will be administered to 383 residents with CBP across Saskatchewan. In phase 3, phase 1 and 2 findings will be presented to provincial and national policy makers; health system decision makers; health care providers; rural, remote, and urban people with CBP and their communities; and other knowledge users at an interactive end-of-project knowledge translation event. A World Café method will facilitate interactive dialogue designed to catalyze future patient-oriented research and pathways to improve access to CBP care. Patient engagement will be conducted, wherein people with lived experience of CBP, including Indigenous and non-Indigenous people from rural, remote, and urban communities (ie, patient partners), are equal members of the research team. Patient partners are engaged throughout the research process, providing unique knowledge to ensure more comprehensive collection of data while shaping culturally appropriate messages and methods of sharing findings to knowledge users. RESULTS: Participant recruitment began in January 2021. Phase 1 interviews occurred between January 2021 and September 2022. Phase 2 phone survey was administered in May 2022. Final results are anticipated in late 2022. CONCLUSIONS: This study will privilege patient experiences to better understand current health care use and potential access challenges and facilitators among rural, remote, and urban people with CBP in Saskatchewan. We aim to inform the development of comprehensive measures that will be sensitive to geographical location and relevant to culturally diverse people with CBP, ultimately leading to enhanced access to more patient-centered care for CBP. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42484.

A short walk a day shortens the hospital stay: physical activity and the demand for hospital services for older adults.

OBJECTIVES: To estimate the impact of increased physical activity on utilization of hospital services among older adults in Canada. METHODS: The paper uses the Canadian Community Health Survey Cycle 2.1, and count data regression models. The study sample includes 18,196 adults aged 65 and above. Specification tests are used in order to identify the appropriate count data model, and sensitivity analyses are conducted to check the robustness of the results. RESULTS: The paper shows that physical activity is negatively associated with the probability of staying in the hospital as well as the numbers of hospital stay among users. However, the potential gain decreases as current activity level increases. The results also imply that an additional 20-minute daily walk by inactive older Canadians would decrease total hospital stays by about 2% of the total annual inpatient days. This is equivalent to 1.2% of total hospital bed capacity in a given year. CONCLUSIONS: Health promotion efforts to increase the level of activity among older adults may create significant savings for the health care system. The total potential gain from additional physical activity is substantial, especially for those who are inactive. However, these gains can be materialized if people stay active enough to derive positive health benefits of physical activity. These results, therefore, should be evaluated in the light of findings from related literature on health and physical activity.

Physical inactivity and its impact on healthcare utilization.

Physically inactive people are expected to use more healthcare services than active people. This inactivity imposes costs on the collectively funded health insurance programs. In this paper, excess utilization of healthcare services due to physical inactivity is examined using count data models and the Canadian Community Health Survey. The aim of the paper is to estimate utilization of healthcare services associated with inactivity and to estimate its impact on the Canadian healthcare system. The results suggest that physical inactivity increases hospital stays, and use of physician and nurse services. On average, an inactive person spends 38% more days in hospital than an active person. S/he also uses 5.5% more family physician visits, 13% more specialist services, and 12% more nurse visits than an active individual. The subsequent social cost of inactivity for the healthcare system is substantial.

What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review.

Industrial improvement approaches such as Lean management are increasingly being adopted in health care. Synthesis is necessary to ensure these approaches are evidence based and requires operationalization of concepts to ensure all relevant studies are included. This article outlines the process utilized to develop an operational definition of Lean in health care. The literature search, screening, data extraction, and data synthesis processes followed the recommendations outlined by the Cochrane Collaboration. Development of the operational definition utilized the methods prescribed by Kinsman et al. and Wieland et al. This involved extracting characteristics of Lean, synthesizing similar components to establish an operational definition, applying this definition, and updating the definition to address shortcomings. We identified two defining characteristics of Lean health-care management: (1) Lean philosophy, consisting of Lean principles and continuous improvement, and (2) Lean activities, which include Lean assessment activities and Lean improvement activities. The resulting operational definition requires that an organization or subunit of an organization had integrated Lean philosophy into the organization's mandate, guidelines, or policies and utilized at least one Lean assessment activity or Lean improvement activity. This operational definition of Lean management in health care will act as an objective screening criterion for our systematic review. To our knowledge, this is the first evidence-based operational definition of Lean management in health care.

The effect of body weight on employment among Canadian women: evidence from Canadian data.

OBJECTIVES: This paper examines the impact of obesity on labour market participation among Canadian women by using various Canadian population health surveys. METHODS: We estimate the impact of obesity on labour market participation using probit and bivariate probit regression models. To correct for a potential endogenous relationship between obesity and labour market participation, we also use instrumental variables in the bivariate probit regression context. RESULTS: The results suggest that the probability of employment has negative association with the body weight of women. This effect is statistically significant and has substantial impact on employment. The results show that obesity decreases employment probability by about 25 percentage points for women. CONCLUSION: In addition to well-known negative health consequences, obesity also has additional negative effect on employment. This negative impact on employment is comparable to the impacts of mental health or illicit drug use on employment. Public health policies aimed at reducing obesity would generate additional benefits to society. Our results also provide additional evidence for lawmakers to amend the labour laws in Canada in order to acknowledge and prohibit hiring practices that discriminate against individuals with high body weight.

Advancing Interprofessional Primary Health Care Services in Rural Settings for People with Chronic Low Back Disorders: Protocol of a Community-Based Randomized Controlled Trial.

BACKGROUND: Chronic low back disorders (CLBDs) are a substantial burden on individuals and societies, and impact up to 20% of Canadians. Rural and remote residents are approximately 30% more likely to have CLBDs. Reduced access to appropriate team-based health services, including physical therapy, is a key factor that may magnify the impact of CLBD on pain, physical function, overall quality of life, health-related system costs, and individual costs. OBJECTIVE: The purpose of this project is to evaluate the validity, comparative effectiveness, costs, barriers, and facilitators of an interprofessional management approach for people with CLBDs, delivered via telehealth. METHODS: This project will examine 3 different health care delivery options: (1) in-person nurse practitioner (NP); (2) in-person physical therapist (PT); and (3) a team approach utilizing an NP (in-person) and a PT joining via telehealth. Validity of the telehealth team care model will be explored by comparing the diagnostic categorization and management recommendations arising from participants with CLBD who undergo a team telehealth, in-person NP, and in-person PT assessment. Comparative effectiveness and costs will be examined using a community-based randomized controlled trial in a rural Saskatchewan community with limited PT services. The 3 arms of the trial are: (1) usual care delivered by a local rural NP; (2) a local NP and an urban-based PT joining via telehealth; and (3) face-to-face services by a PT traveling to the community. Patient-reported outcomes of pain, physical function, quality of life, satisfaction, and CLBD care-related costs will be evaluated up to 6 months after the intervention. Patient and provider experiences with the team telehealth approach will be explored through qualitative interviews. RESULTS: The study was funded in July 2013 and the University of Saskatchewan Biomedical Research Ethics Board approved the study in November 2013. Participant recruitment began in September 2014 and data collection was completed in December 2015. Analysis is in progress and results are anticipated in 2017. CONCLUSIONS: CLBD is a widespread public health problem, particularly in rural and remote areas, which requires new innovative approaches to deliver appropriate health care. The results of this project will inform the development of evidence-informed approaches and community-based implementation strategies to improve access to PT services in primary health care settings in other rural and remote underserved areas. Findings might also provide a framework for cost-effective and patient-centered models of service delivery for the management of other chronic conditions. CLINICALTRIAL: ClinicalTrials.gov NCT02225535; https://clinicaltrials.gov/ct2/show/NCT02225535 (Archived by WebCite at http://www.webcitation.org/6lqLTCNF7).

Is Self-Reported Physical Activity Participation Associated with Lower Health Services Utilization among Older Adults? Cross-Sectional Evidence from the Canadian Community Health Survey.

Purpose. To examine relationships between leisure time physical activity (LTPA) and health services utilization (H) in a nationally representative sample of community-dwelling older adults. Methods. Cross-sectional data from 56,652 Canadian Community Health Survey respondents aged ≥ 50 years (48% M; 52% F; mean age 63.5 ± 10.2 years) were stratified into three age groups and analysed using multivariate generalized linear modeling techniques. Participants were classified according to PA level based on self-reported daily energy expenditure. Nonleisure PA (NLPA) was categorized into four levels ranging from mostly sitting to mostly lifting objects. Results. Active 50-65-year-old individuals were 27% less likely to report any GP consultations (ORadj = 0.73; P < 0.001) and had 8% fewer GP consultations annually (IRRadj = 0.92; P < 0.01) than their inactive peers. Active persons aged 65-79 years were 18% less likely than inactive respondents to have been hospitalized overnight in the previous year (ORadj = 0.82, P < 0.05). Higher levels of NLPA were significantly associated with lower levels of HSU, across all age groups. Conclusion. Nonleisure PA appeared to be a stronger predictor of all types of HSU, particularly in the two oldest age groups. Considering strategies that focus on reducing time spent in sedentary activities may have a positive impact on reducing the demand for health services.

Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol).

BACKGROUND: Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer's needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited. METHODS: This is a protocol for a systematic review, following the Cochrane Effective Practice and Organisation of Care (EPOC) methodology. The review aims to document, catalogue and synthesize the existing literature on the effects of lean implementation in health care settings especially the potential effects on professional practice and health care outcomes. We have developed a Medline keyword search strategy, and this focused strategy will be translated into other databases. All search strategies will be provided in the review. The method proposed by the Cochrane EPOC group regarding randomized study designs, non-randomised controlled trials controlled before and after studies and interrupted time series will be followed. In addition, we will also include cohort, case-control studies, and relevant non-comparative publications such as case reports. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the reported types of implementation in the primary studies. We will present the results of studies in a tabular form. DISCUSSION: Overall, the systematic review aims to identify, assess and synthesize the evidence to underpin the implementation of lean activities in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and implementation methodologies reported in health care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014008853.

Exercise, physical activity and healthcare utilization: A review of literature for older adults.

The impacts of exercise and physical activity on healthcare utilization of older adults have been studied using either (1) clinical trials or retrospective cohort studies focusing on older people who participated in various exercise intervention programs, or (2) survey data. This review focuses on both streams of studies, which cover the topic for adults aged 65 and older. The paper reviews the literature on physical activity and its implications for healthcare system, and discusses potential directions for future research by highlighting the limitations of the existing studies. Although there are significant variations in samples and methods used, both streams of reviewed literature provide evidence that physical activity leads to lower utilization of healthcare services. Given differences in methods and samples in these studies, estimated effect of physical activity on healthcare utilization shows significant variation from one study to another. These results, therefore, cannot be generalized to justify population wide exercise intervention programs for older adults. Additional studies are needed to provide more robust estimates for the effects of exercise, and to examine the feasibility of population wide policies that aim to encourage participation of older adults in physical activity.