Factors predictive of the perceived osteoporosis-fracture link in fragility fracture patients.

OBJECTIVE: Given the asymptomatic nature of osteoporosis, a fragility fracture provides an opportunity to make the issue of osteoporosis relevant to patients. Patients who link their fragility fracture with osteoporosis are more likely to initiate osteoporosis treatment, yet to date, we know little about who is likely to make this link. This study examined whether demographic, health, and osteoporosis belief factors predicted a perceived link between a fragility fracture and osteoporosis. STUDY DESIGN: This longitudinal cohort study analyzed baseline and follow up data collected as part of a provincial osteoporosis screening initiative targeting fragility fracture patients. Logistic regression analysis was used to examine the relationship between hypothesized predictors and the outcome. MAIN OUTCOME MEASURE: Patient perception of the osteoporosis-fracture link at follow up. RESULTS: At baseline, 93% (1615/1735) of patients did not believe their fracture could have been caused by osteoporosis. Of these, only 8.2% changed this perception at follow up. Adjusted analyses showed that baseline characteristics associated with making the osteoporosis-fracture link at follow up were: a previous fracture (odds ratio (OR) 1.7, confidence interval (CI) 1.2-2.6), perception of osteoporosis pharmacotherapy benefits OR 1.2 (CI 1.0-1.5), diagnosis of rheumatoid arthritis OR 2.6 (CI 1.4-4.9) and the perception of bones as "thin" OR 8.2 (CI 5.1-13.1). CONCLUSION: These results shed more light on patient-level barriers to osteoporosis management following an osteoporosis educational programme. They may be used to identify patients less likely to make the link between their fracture and osteoporosis and to inform interventions for this patient group.

Increasing access to chronic disease self-management programs in rural and remote communities using telehealth.

OBJECTIVE: This study examined whether a telehealth chronic disease self-management program (CDSMP) would lead to improvements in self-efficacy, health behaviors, and health status for chronically ill adults living in Northern Ontario, Canada. Two telehealth models were used: (1) single site, groups formed by participants at one telehealth site; and (2) multi-site, participants linked from multiple sites to form one telehealth group, as a strategy to increase access to the intervention for individuals living in rural and remote communities. SUBJECTS AND METHODS: Two hundred thirteen participants diagnosed with heart disease, stroke, lung disease, or arthritis attended the CDSMP at a preexisting Ontario Telemedicine Network studio from September 2007 to June 2008. The program includes six weekly, peer-facilitated sessions designed to help participants develop important self-management skills to improve their health and quality of life. Baseline and 4-month follow-up surveys were administered to assess self-efficacy beliefs, health behaviors, and health status information. Results were compared between single- and multi-site delivery models. RESULTS: Statistically significant improvements from baseline to 4-month follow-up were found for self-efficacy (6.6±1.8 to 7.0±1.8; p<0.001), exercise behavior, cognitive symptom management, communication with physicians, role function, psychological well-being, energy, health distress, and self-rated health. There were no statistically significant differences in outcomes between single- and multi-site groups. CONCLUSIONS: Improvements in self-efficacy, health status, and health behaviors were equally effective in single- and multi-site groups. Access to self-management programs could be greatly increased with telehealth using single- and multi-site groups in rural and remote communities.

Pursuing enterprise risk management: a local road map for Canadian healthcare leaders.

An in-depth analysis of organizational risk management in healthcare, and in particular the concepts of Enterprise Risk Management (ERM), has identified a 5-part model that can be used by Canadian healthcare leaders as an evidence-supported approach to successful organizational risk management. The Model for Organizational Risk Management, termed "the Model," has been developed as a basis for linking the components of an ERM Framework into a Canadian health organization to overcome the barriers that commonly disrupt strategic risk management. The Model addresses how an ERM Framework can fit within an existing health organization by building off and enhancing existing processes and resources to ensure familiarity, acceptance, and sustainability of the risk management program. By approaching the Model in a stepwise fashion (based on individual organizational context), healthcare leaders are provided with a road map from which to advance their own organizational risk management program.

Predictors of home care expenditures and death at home for cancer patients in an integrated comprehensive palliative home care pilot program.

PURPOSE: Empirical understanding of predictors for home care service use and death at home is important for healthcare planning. Few studies have examined these predictors in the context of the publicly funded Canadian home care system. This study examined predictors for home care use and home death in the context of a "gold standard" comprehensive palliative home care program pilot in Ontario where patients had equal access to home care services. METHODS: Secondary clinical and administrative data sources were linked using a unique identifier to examine multivariate factors (predisposing, enabling, need) on total home care expenditures and home death for a cohort of cancer patients enrolled in the HPCNet pilot. RESULTS: SUBJECTS WITH GASTROINTESTINAL SYMPTOMS (OR: 1.64; p=0.03) and those with higher income had increased odds of dying at home (OR: 1.14; p<0.001), whereas age, number of GP visits, gastrointestinal symptoms (i.e., nausea, vomiting, bowel obstruction) and eating problems (i.e., anorexia/cachexia) predicted home care expenditures. CONCLUSIONS: Predictors of home death found in earlier studies appeared less important in this comprehensive palliative home care pilot. An income effect for home death observed in this study requires examination in future controlled studies. RELEVANCE: Access to palliative home care that is adequately resourced and organized to address the multiple domains of issues that patients/families experience at the end of life has the potential to enable home death and shift care appropriately from limited acute care resources.

Expanding the lens of HIV services provision in Canada: results of a national survey of HIV health professionals.

Those living with HIV may experience a range of disabilities, including body impairments, activity limitations, and social participation restrictions. The aim of this study was to examine HIV services provision in Canada by exploring practices, referrals, and service delivery challenges from the perspective of HIV health professionals (including nurses, physicians, social workers, pharmacists, psychologists, and dieticians), and to explore differences in referrals and perceived service delivery challenges by professional group, jurisdiction, community size, and practice in a Northern region. We conducted a nationwide mail survey with the population of selected HIV health professionals in Canada using the Dillman tailored design survey method. Of the 731 deliverable mailings, we received 462 (63%) responses, with 36% of eligible respondents completing the survey (n=214). The large majority (90%) of HIV professionals were located in metropolitan or urban communities and worked predominantly in hospital in-patient (42%), out-patient (50%), and HIV specialty clinic (46%) settings in one of the three provinces (Ontario, Quebec, and British Columbia) with the highest HIV prevalence. HIV health professionals referred primarily, and at relatively high levels, to AIDS service organizations (79%) and social workers (84%) to address participation restrictions and social issues; a lower percentage referred to rehabilitation professionals and other service providers to address impairments, activity limitations, or participation restrictions. Of respondents, 74% perceived barriers to care specific to HIV. Our results suggest that there is little difference in referral patterns by profession, jurisdiction, community size, or northern region of practice. There is a need for increased information and education of HIV health professionals that may refer to rehabilitation and other health services. In addition, new approaches are needed to coordinate multisectoral care and enhance the access and delivery of HIV rehabilitation health services to better meet the disablement needs of people living with HIV in Canada.

Enhancing continuity of information: essential components of consultation reports.

OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHODS: We completed a systematic literature review to identify important components of consultation reports. We then engaged an 8-member panel in a 2-round modified Delphi consensus process, which led to the identification of components deemed essential to good continuity of information. MAIN FINDINGS: After 2 rounds, expert panelists reached consensus on 15 components, referred to here as minimum essential elements, of consultation reports generated by medical specialists in response to referring primary care providers' consultation requests. CONCLUSION: The expert panelists considered inclusion of the minimum essential elements in consultation reports essential to achieving good continuity of information. We assembled these elements in a suggested format for a consultation report. The format can be easily modified by practitioners caring for patients with other chronic diseases.

Do clinical practice guidelines influence length of stay in ontario acute care hospitals?

Following a systematic review of literature describing the relationship between the use of clinical practice guidelines (CPGs) and length of stay (LOS), we conducted a secondary analysis of the same relationship using data from Ontario acute care hospitals over two years. Unlike the original systematic review, this analysis did not find a strong relationship between CPG usage and LOS: the relationship between CPG usage and LOS was statistically significant only in the disease states of pneumonia and prostatectomy. Possible reasons for this outcome are explored, as are limitations, policy implications and suggestions for future research.

Enhancing continuity of information: essential components of a referral document.

OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHOD: We completed a systematic literature review to develop a list of items or data elements related to patient information transfer in chronic care. We engaged an 8-member expert panel in a 2-round modified Delphi process to assess the importance of the 74 data elements identified in the literature review and to identify any additional important elements. MAIN FINDINGS: The expert panelists reached consensus on 24 components of information, referred to here as minimum essential elements of a referral document, needed for consultations on adult asthma patients. CONCLUSION: The 24 minimum essential elements of information that should be transferred during referral of asthma patients from primary care providers to experts in asthma care were generated by primary care physicians and thought essential for achieving continuity in information transfer. We assembled these elements into a suggested format for a referral document. The format can be easily modified by practitioners caring for patients with other chronic diseases.

Assessing continuity of care in a community diabetes program: initial questionnaire development and validation.

OBJECTIVE: To develop and validate a questionnaire based on agency theory to measure continuity of care in a community-based diabetes control program in Shanghai, China. STUDY DESIGN AND SETTING: Continuity of care was conceptualized in relation to two domains: information transfer and goal alignment. The questionnaire combined scales adopted from two validated questionnaires: the Primary Care Assessment Survey and the Summary of Diabetes Self-care Activities Measure. Patient interviews were conducted with 156 diabetes patients in the intervention group and 182 in the control group in two community health settings in Shanghai, China. The questionnaire was validated in terms of Likert-scaling assumptions, data completeness, score distribution, construct validity, and sensitivity. RESULTS: All scales consistently showed strong measurement properties in item reliability and validity. Requirements of data completeness and distribution were achieved in all scales. Principal components analysis of six scales provided a satisfactory explanation of the hypothesized scale-domain construction. CONCLUSIONS: The validation results suggested that the scales in our continuity of care questionnaire are consistent with the concept of continuity of care based on agency theory.

Evaluation of a diabetes management program in China demonstrated association of improved continuity of care with clinical outcomes.

OBJECTIVE: The aim of the study was to evaluate a community-based diabetes management program in Shanghai, China and to examine the association between continuity of care and clinical outcomes. STUDY DESIGN AND SETTING: The diabetes management program was implemented in downtown Shanghai. One hundred fifty-six patients participated in the intervention group and 182 patients were in the control group. Participants were elders without severe diabetic complications. Patient weight, body mass index, blood pressures, and fasting blood glucose were collected from outpatient records at baseline and the end of the study in both groups. Fructosamine level was measured to monitor glycemic control for patients in the intervention group. Continuity of care was measured based on our broad definition. RESULTS: Improved patient health outcomes were observed in the diabetes management program: patients in the intervention group significantly reduced their weight, systolic blood pressure, and fasting blood glucose compared with those in the control group (P<0.05). In hierarchical regression models, continuity of care scales had a significant association with weight loss and fasting blood glucose reduction. CONCLUSION: This study suggested that continuity based on broad terms can act as an important management tool to improve the quality of primary care in similar urban settings.

Rehabilitation professionals and human immunodeficiency virus care: results of a national Canadian survey.

OBJECTIVE: To describe rehabilitation professionals' practices, knowledge and training, professional views, and service delivery issues for people living with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (PHAs) in Canada. DESIGN: Nationwide cross-sectional postal survey. SETTING: Canada. PARTICIPANTS: Random sample (N=2105) of occupational therapists, physical therapists, speech-language pathologists, and physiatrists who had practiced in the past year. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Survey items on current practices, HIV knowledge and training, professional views on rehabilitation and HIV, and HIV rehabilitation service delivery issues. RESULTS: Seventy-four percent (1492/2006) of the traceable sample responded, 53% (n=1058) of whom yielded completed surveys. Sixty-one percent of survey respondents never knowingly had served an HIV-positive patient. Of this group, 27% indicated these were patients they would like to work with, 27% indicated they were unwilling, and 46% were unsure. The 39% who knowingly had served PHAs had served an average of 4 PHAs in the last year, and less than 25% of their HIV patients' rehabilitation issues were HIV-related. CONCLUSIONS: Despite the role rehabilitation professionals have to play in the care of PHAs, only a minority serves PHAs. Results of this survey show a potential gap between the documented rehabilitative needs of PHAs and services provided by the rehabilitation professional community.

An interdisciplinary approach to capacity building in applied research.

The Canadian Health Services Research Foundation (CHSRF) has contributed to applied health and nursing services research in Canada by establishing the Regional Training Centres (RTCs). The interdisciplinary education and experience in applied health and nursing services research that the RTCs offer has produced graduates who are highly sought after by both academic and key health services decision-making agencies. Students educated in these multidisciplinary environments learn that different perspectives and methodological approaches enrich their capacity to define and complete research. This paper describes how the RTCs have helped build capacity in health services research through an interdisciplinary approach that considers the substantive, conceptual and methodological domains.

Perceptions of the process of care among caregivers and care recipients in dementia care networks.

The Dementia Care Networks Study investigated 4 community-based, not-for-profit dementia care networks in Ontario, Canada. Investigators examined whether sociodemographic and health characteristics, type of support network, and amount of service use among care recipients and caregivers (n = 267 dyads) were associated with experiences with care processes. The process-of-care constructs were: family physicians' awareness of services; experiences with health care workers, and assessment and placement activities. The findings highlighted that family physicians' understanding of dementia and their ability to work with the dyad to become aware of and accept services, was an important component in the dyad's satisfaction. If caregivers received home support and the care recipients received emotional support from their social support network, they were more likely to be satisfied with their experiences with health care workers. In summary, increased awareness and provision of services were associated with more positive perceptions of network effectiveness.

Evaluating the effectiveness of community-based dementia care networks: the Dementia Care Networks' Study.

PURPOSE: The Dementia Care Networks' Study examined the effectiveness of four community-based, not-for-profit dementia networks. The study involved assessing the relationship between the types of administrative and service-delivery exchanges that occurred among the networked agencies and the network members' perception of the effectiveness of these exchanges. DESIGN AND METHODS: With the use of a case-study method, the evolution, structure, and processes of each network were documented. Social network analysis using a standardized questionnaire completed by member agencies identified patterns of administrative and clinical exchanges among networked agencies. RESULTS: Differences were found between the four networks in terms of their perceptions of service-delivery effectiveness; perceptions of administrative effectiveness did not factor significantly. Exchanges between groups of agencies (cliques) within each of the four networks were found to be more critical than those between individual agencies within each network. IMPLICATIONS: Integration-measured by the types of exchanges within as opposed to across networks-differentiated the four networks studied. This research contributes to our understanding of the use of multiple measures to evaluate the inner workings of service delivery and their impact on elder health and elder health care.

Rehabilitation in HIV/AIDS: development of an expanded conceptual framework.

In industrialized countries where HIV infection is becoming a chronic, episodic condition, rehabilitation services have the potential to play an expanded role for people living with HIV/AIDS (PLHAs). However, little is known about rehabilitation in the context of HIV. This paper documents the development of an enhanced, multidisciplinary conceptual framework of rehabilitation in the context of HIV, using the perceptions of PLHAs and rehabilitation professionals. Rehabilitation, broadly defined, is a dynamic process that includes all prevention and/or treatment activities and/or services that address body impairments, activity limitations and participation restrictions for an individual. The framework was developed through broad consultation and interviews with thirteen key informants. Themes that emerged from analysis of interviews related to concepts of rehabilitation in the context of HIV, rehabilitation professionals' roles in the context of HIV, and barriers to access and delivery of rehabilitation services. While there was some variation, key informants generally viewed rehabilitation as a goal-oriented and client-centered process with the potential to impact a range of life domains. Themes were presented to members of a national advisory committee (including PLHAs and health care providers), who produced the foundation of the HIV rehabilitation framework. The framework uses the perspective of the person living with HIV/AIDS, and includes individual life domains that may be affected by HIV, drawing and expanding upon the World Health Organization's (WHO's) International Classification of Functioning, Disability and Health.

Identifying performance indicators for family practice: assessing levels of consensus.

OBJECTIVE: To identify performance indicators for family practice that focus on organizational structures and clinical processes of care, to review evidence linking indicators to patient outcomes, to have providers select indicators they consider important for performance assessment, and to obtain provider views on challenges to developing a performance assessment system. DESIGN: Review of published and unpublished literature and contact with international experts resulted in a list of 131 structure and process indicators and associated evidence. This information was used in a two-round modified Delphi consensus process, which was followed by interviews with each of the 12 consensus panel members. SETTING: Ontario family practices. PARTICIPANTS: Eleven family physicians and one nurse practitioner from Ontario. MAIN OUTCOME MEASURES: Survey package with 131 indicators and associated evidence was mailed to panel members who rated each of the indicators on a Likert scale from 1 (not at all important for performance assessment) to 9 (essential for performance assessment). Interviews were conducted with panel members to discuss indicator feasibility and data sources. Consensus score and median importance score for each indicator were main outcome measures; interviews identified barriers to performance assessment. RESULTS: Fifty-one indicators achieved high consensus, 19 moderate consensus, and 38 low consensus. Clinical indicators that reached a high level of consensus were generally supported by grade A or B recommendations and level I to III evidence. Clinical indicators that achieved moderate consensus often had fair support in the literature. Low consensus was mainly associated with fair or equivocal evidence. During follow-up interviews, consensus panel members voiced frustration with inconsistencies in the evidence and practice guidelines upon which indicators are often based, and with poor transfer of patient information between health care providers. Lack of detail in patient care documentation and inconsistent documentation were mentioned frequently as threats to data quality. CONCLUSION: Despite challenges to performance measurement noted by the panel, study results support the continued development, refinement, and testing of primary care performance indicators.

Recruitment strategies. Pharmacists' participation in an evaluation project to dispense emergency contraception.

The objective of this article was to describe the effectiveness of a multifocus recruitment strategy to a pilot project allowing direct provision of emergency contraception (EC) in a community pharmacy through collaborative agreements between pharmacists and physicians. The project recruited pharmacies through direct appeals to pharmacists, pharmacy managers and/or owners, and corporate pharmacy chains. The evaluation project was successful in recruiting sufficient numbers of pharmacies to warrant proceeding with the project. The most successful component of the recruitment strategy was reference to the opportunities that participation offered to expand the pharmacist's role in patient-focused care. The importance of peer influence was also noted in terms of encouraging pharmacy involvement.

Pharmacy provision of emergency contraception: the Ontario emergency contraception pilot project.

OBJECTIVES: To develop and evaluate a program to provide emergency contraception (EC) directly in pharmacies that would recruit and train pharmacists and physician partners, and inform women about the availability of EC in pharmacies. METHODS: Pharmacists and physicians working in the Scarborough, Rexdale, and North York regions of Toronto were recruited to receive a training program on EC. The pharmacists in each pharmacy were linked with a designated physician who retrospectively authorized prescriptions provided under the protocol. Client eligibility for EC was determined using a self-administered questionnaire that was reviewed by the pharmacist. A poster and radio campaign advertised the service, and a telephone hotline informed users of their nearest participating pharmacy. Data on the client's age, reasons for requesting EC, time elapsed from intercourse until presentation, and requests for follow-up referral were analyzed using descriptive methodology. User satisfaction was determined through a mail-back questionnaire. RESULTS: A total of 146 pharmacists practising in 40 pharmacies were linked with 34 physicians. In the 1 year of the project, 6931 prescriptions for EC were provided. Fifty-four percent of the women accessed EC within 24 hours of intercourse. The majority of women were very satisfied with the service, and 21.1% indicated that had they not obtained EC in this way, they would not have obtained it elsewhere. More information about birth control was desired by 10.2% of the women. CONCLUSION: Direct pharmacist provision of EC is an effective pregnancy-prevention strategy that is well accepted by the women who access it.

Career satisfaction and surgical practice patterns among female ophthalmologists.

PURPOSE: To identify gender differences in career satisfaction and practice patterns among Ontario ophthalmologists. METHODS: Survey mailed to all Ontario female ophthalmologists (n = 65) and a random sample of male ophthalmologists (n = 72). RESULTS: Men reported performing more operations per month (p = 0.039) and more operations in the last typical year (p = 0.003). More men than women were doing laser refractive surgery (p = 0.004). There were no gender differences in the proportion performing eye surgery or in the hours worked per week or weeks worked per year. Women reported being primarily responsible for their children for significantly more hours per week than men (p = 0.0003). There were no gender differences in any of the parameters of career satisfaction evaluated: number of hours worked, number of hours in the operating room (OR), balance with personal life, flexibility of work schedules, ability to structure work, relationship with colleagues and relationship with OR staff. INTERPRETATION: Despite spending significantly more hours as the primary supervisor of their children, female ophthalmologists were maintaining the same work week as their male colleagues and reported equal career satisfaction. Further investigation is needed to explore the differences between male and female ophthalmologists in the reported number of operations performed.

Emergency contraception: models to increase accessibility.

Much of the recent focus on emergency contraception (EC) has been on the need to increase the availability of EC without a prescription. Barriers to the wider accessibility of EC include the need to use the medication within a 72-hour window, cost, and knowledge about its availability. Concerns about the non-prescription accessibility of EC include missing the opportunity to see a physician, possible reduced use of barrier contraceptives and the resulting increase in sexually transmitted infections, and overuse of EC and underuse of regular contraception. As the wider availability of EC is a reality, and pressure to further increase its access is growing, it is timely that issues surrounding accessibility of EC be discussed. This paper explores the issues around making EC more accessible and the various models of obtaining EC, namely, prescription medication, pharmacist-physician collaboration, pharmacist-dispensed medication, schedule II (behind the counter) medication, or on-the-shelf medication. The ideal model will be the one that provides improved accessibility for adolescents, other low-income women, and indeed for all women. Increased accessibility of EC should also lead to cost savings for the health-care system because of fewer unwanted pregnancies.