Prioritizing and Implementing Primary Care Performance Measures for Ontario.

In the fall of 2014, Health Quality Ontario released A Primary Care Performance Measurement Framework for Ontario. Recognizing the large number of recommended measures and the limited availability of data related to those measures, the Steering Committee for the Primary Care Performance Measurement (PCPM) initiative established a prioritization process to select two subsets of high-value performance measures - one at the system level and one at the practice level. This article describes the prioritization process and its results and outlines the initiatives that have been undertaken to date to implement the PCPM framework and to advance primary care performance measurement and reporting in Ontario. Establishing a framework for primary care measurement and prioritizing system- and practice-level measures are essential steps toward system improvement. Our experience suggests that the process of implementing a performance measurement system is inevitably non-linear and incremental.

Association of physician payment model and team-based care with timely access in primary care: a population-based cross-sectional study.

BACKGROUND: It is unclear how patient-reported access to primary care differs by physician payment model and participation in team-based care. We examined the association between timely and after-hours access to primary care and physician payment model and participation in team-based care, and sought to assess how access varied by patient characteristics. METHODS: We conducted a cross-sectional analysis of adult (age ≥ 16 yr) Ontarians who responded to the Ontario Health Care Experience Survey between January 2013 and September 2015, reported having a primary care provider and agreed to have their responses linked to health administrative data. Access measures included the proportion of respondents who reported same-day or next-day access when sick, satisfaction with time to appointment when sick, telephone access and knowledge of an after-hours clinic. We tested the association between practice model and measures of access using logistic regression after stratifying for rurality. RESULTS: A total of 33 665 respondents met our inclusion criteria. In big cities, respondents in team and nonteam capitation models were less likely to report same-day or next-day access when sick than respondents in enhanced fee-for-service models (team capitation 43%, adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.79-0.98; nonteam capitation 39%, adjusted OR 0.78, 95% CI 0.70-0.87; enhanced fee-for-service 46% [reference]). Respondents in team and nonteam capitation models were more likely than those in enhanced fee-for-service models to report that their provider had an after-hours clinic (team capitation 59%, adjusted OR 2.59, 95% CI 2.39-2.81; nonteam capitation 51%, adjusted OR 1.90, 95% CI 1.76-2.04; enhanced fee-for service 34% [reference]). Patterns were similar for respondents in small towns. There was minimal to no difference by model for satisfaction with time to appointment or telephone access. INTERPRETATION: In our setting, there was an association between some types of access to primary care and physician payment model and team-based care, but the direction was not consistent. Different measures of timely access are needed to understand health care system performance.

Right heart function interacts with left ventricular remodeling after CRT: A pressure volume loop study.

BACKGROUND: Right ventricular (RV) dysfunction is recognized as a cardinal prognostic marker in systolic heart failure patients. Conflicting data exist on the interaction of RV function and left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT). This prospective monocentric trial was set up to assess the predictive value of baseline RV function and corresponding RV-pulmonary artery (PA) coupling on LV reverse remodeling after CRT. METHODS: 110 patients with a CRT indication were prospectively enrolled. RV function and RV-PA interaction were analyzed at baseline using echocardiographic and invasive pressure-volume loop catheter approach. The primary endpoint was reverse LV remodeling (CRT-responder) defined as a reduction in LV end-systolic volume of ≥15% at 6 months. RESULTS: Responders had higher RV-PA coupling ratios (single-beat end-systolic elastance/PA elastance: Ees/Ea) at baseline, which corresponded to smaller RVs with better ejection fraction and lower afterload. After multivariate adjustment, the baseline Ees/Ea remained an independent predictor for LV response (OR 14.0 [1.5-130.8], p = 0.021). Normal coupling (Ees/Ea ≥ 1) was associated with higher responder rates (RR) (86%). Progressive uncoupling was associated with lower LV-RR (Ees/Ea ≤ 1-0.5: 57%, and Ees/Ea < 0.5: 32%, p < 0.001), corresponded with higher degrees of LV impairment and severity of mitral regurgitation, and was independently associated with an adverse outcome. CONCLUSIONS: A higher baseline RV-PA coupling, reflecting a lower degree of LV-induced pulmonary hypertension and secondary RV-dysfunction, is associated with an improved LV-reverse remodeling and is independently associated with better prognosis. The value of RV-PA ratio as potential guide for CRT patient selection warrants further investigation. Clinical Trial Registration - URL: http://www.drks.de. Unique Identifier: DRKS00011133.

Animal Models of Depression and Drug Delivery with Food as an Effective Dosing Method: Evidences from Studies with Celecoxib and Dicholine Succinate.

Multiple models of human neuropsychiatric pathologies have been generated during the last decades which frequently use chronic dosing. Unfortunately, some drug administration methods may result in undesirable effects creating analysis confounds hampering model validity and preclinical assay outcomes. Here, automated analysis of floating behaviour, a sign of a depressive-like state, revealed that mice, subjected to a three-week intraperitoneal injection regimen, had increased floating. In order to probe an alternative dosing design that would preclude this effect, we studied the efficacy of a low dose of the antidepressant imipramine (7 mg/kg/day) delivered via food pellets. Antidepressant action for this treatment was found while no other behavioural effects were observed. We further investigated the potential efficacy of chronic dosing via food pellets by testing the antidepressant activity of new drug candidates, celecoxib (30 mg/kg/day) and dicholine succinate (50 mg/kg/day), against standard antidepressants, imipramine (7 mg/kg/day) and citalopram (15 mg/kg/day), utilizing the forced swim and tail suspension tests. Antidepressant effects of these compounds were found in both assays. Thus, chronic dosing via food pellets is efficacious in small rodents, even with a low drug dose design, and can prevail against potential confounds in translational research within depression models applicable to adverse chronic invasive pharmacotherapies.

Tlr4 upregulation in the brain accompanies depression- and anxiety-like behaviors induced by a high-cholesterol diet.

An association between metabolic abnormalities, hypercholesterolemia and affective disorders is now well recognized. Less well understood are the molecular mechanisms, both in brain and in the periphery, that underpin this phenomenon. In addition to hepatic lipid accumulation and inflammation, C57BL/6J mice fed a high-cholesterol diet (0.2%) to induce non-alcoholic fatty liver disease (NAFLD), exhibited behavioral despair, anxiogenic changes, and hyperlocomotion under bright light. These abnormalities were accompanied by increased expression of transcript and protein for Toll-like receptor 4, a pathogen-associated molecular pattern (PAMP) receptor, in the prefrontal cortex and the liver. The behavioral changes and Tlr4 expression were reversed ten days after discontinuation of the high-cholesterol diet. Remarkably, the dietary fat content and body mass of experimental mice were unchanged, suggesting a specific role for cholesterol in the molecular and behavioral changes. Expression of Sert and Cox1 were unaltered. Together, our study has demonstrated for the first time that high consumption of cholesterol results in depression- and anxiety-like changes in C57BL/6J mice and that these changes are unexpectedly associated with the increased expression of TLR4, which suggests that TLR4 may have a distinct role in the CNS unrelated to pathogen recognition.

Visual capabilities and cortical maps in BALB/c mice.

By combining behavioural analyses with intrinsic signal optical imaging, we analysed visual performance and visual cortical activity in the albino mouse strain BALB/c, which is increasingly being used as an animal model of neuropsychological disorders. Visual acuity, as measured by a virtual-reality optomotor system, was 0.12 cycles per degree (cyc/deg) in BALB/c mice and 0.39 cyc/deg in pigmented C57BL/6 mice. Surprisingly, BALB/c mice showed reflexive head movements against the direction of the rotating stimulus. Contrast sensitivity was significantly lower in BALB/c mice (45% contrast at 0.064 cyc/deg) than in C57BL/6 mice (6% contrast). In the visual water task, visual acuity was 0.3 cyc/deg in BALB/c mice and 0.59 cyc/deg in C57BL/6 mice. Thus, the visual performance of BALB/c mice was significantly impaired in both behavioural tests - visual acuity was ∼ 0.3 cyc/deg lower than in C57BL/6 mice, and contrast sensitivity was reduced by a factor of ∼ 8. In BALB/c mice, visual cortical maps induced by stimulation of the contralateral eye were normal in both activation strength and retinotopic map quality. In contrast, maps induced by ipsilateral eye stimulation differed significantly between the strains - activity in a region representing 15° to 19° elevation in the visual field was significantly weaker in BALB/c mice than in C57BL/6 mice. Taken together, our observations show that BALB/c mice, like the albino animals of other species, have a significantly lower visual performance than C57BL/6 mice and a modified cortical representation of the ipsilateral eye that may impair stereopsis. Thus, our results caution against disregarding vision as a confounding factor in behavioural tests of neuropsychological disorders.

Anhedonic-like traits and lack of affective deficits in 18-month-old C57BL/6 mice: Implications for modeling elderly depression.

The prevalence of depression increases with aging. We hypothesized that like humans, old animals exhibit anhedonic-like behavior, along with signs of behavioral despair. In rodents, anhedonia, a reduced sensitivity to reward, which is listed as a core feature of major depression in the DSM-IVR, can be measured by a decrease in intake of and preference for sweet solutions. Here, sucrose intake, forced swimming, immobility in the modified tail suspension test, novelty exploration, grooming, anxiety and locomotor activity were compared in naïve 3- and 18-month-old male C57BL/6 mice. The absolute amounts and the ratio of consumed 1% sucrose solution to water intake was significantly smaller in 18-month-old mice than in 3-month-old mice. The consumption of 5%-sucrose solution requiring high levels of drinking effort, novelty exploration in two setups and grooming behavior in the splash test were reduced in older animals. Analysis of other behaviors suggested that the above-mentioned signs of anhedonic-like traits were unlikely to be attributable to the potential effect of aging on metabolic needs for water, taste perception, motor capabilities or the induction of essential anxiety and neophobia. A 4-week treatment with the antidepressant imipramine (7mg/kg/day) or dimebon, a compound with suggested neuroprotective proneurogenic properties (1mg/kg/day) restored sucrose intake and preference in 18-month-old mice. Meanwhile, young and old mice showed no differences in the parameters of behavioral despair evaluated in the forced swim and modified tail suspension tests. Thus, the behavioral profile of aged mice parallels that of humans with elderly depression, in whom the symptoms of hedonic deficits typically outweigh affective disturbances. The assessment of anhedonic-like traits with the sucrose preference test in 18-month-old mice will be useful in preclinical studies of elderly depression.

Sociodemographic factors associated with cervical cancer screening and follow-up of abnormal results.

OBJECTIVE: To determine the sociodemographic factors associated with cervical cancer screening and follow-up of abnormal results. DESIGN: Population cohort study. SETTING: Ontario. PARTICIPANTS: Women between the ages of 18 and 70 years who were eligible for Papanicolaou testing. MAIN OUTCOME MEASURES: Rates of cervical cancer screening and follow-up of abnormal and inadequate Pap test results, and associated sociodemographic factors such as age, neighbourhood income level, and health region. Multivariate logistic regression was used to identify independent factors associated with screening and follow-up. RESULTS: Of the 3.7 million women eligible for screening, 69% had had Pap tests in the past 3 years. These rates varied by age, income, and region (P < .001). Women residing in the lowest-income neighbourhoods were half as likely to be screened (odds ratio 0.56, 95% CI 0.55 to 0.56). Only 44% of those whose Pap test results revealed atypical squamous cells of uncertain significance or low-grade squamous intraepithelial lesions had repeat Pap tests or colposcopy within 6 months, and this varied by age, income, and region (P < .001). Among women with unsatisfactory Pap test results, only 35% were retested within 4 months, and this varied by age (P < .001). CONCLUSION: Despite universal health coverage, cervical cancer screening rates are suboptimal among low-income women at greatest risk. Follow-up among women with inadequate or abnormal test results is often poor. Novel models of cervical cancer screening are needed to address these inadequacies.

Identifying population-level indicators to measure the quality of cancer care for women.

OBJECTIVE: Although there is interest in measuring the quality of cancer care, there has been limited effort to evaluate quality for specific subpopulations such as women or to examine differences in performance among women associated with sociodemographic characteristics. The objective of this study was to identify a comprehensive set of quality indicators for evaluation of the quality of cancer care received by women using administrative data. DESIGN: A conceptual measurement framework developed by the study investigators was used to guide literature review to identify existing quality indicators. The list of potential indicators from the literature was first reviewed by the study investigators with respect to importance and feasibility to determine a set of indicators to present to an expert panel who used a modified Delphi process to select indicators for inclusion using predetermined explicit criteria. SETTING: The Project for an Ontario Women's Health Evidence-Based Report Card. PARTICIPANTS: A multidisciplinary expert panel consisting of clinicians, researchers and administrators with expertise in cancer, quality of care and/or health services research. MAIN OUTCOME MEASURE: Set of quality indicators evaluable from administrative data. RESULTS: The initial literature search identified 427 indicators, of which 46 were rated as important and feasible by the study investigators. Following two rounds of ratings and an in-person meeting, the expert panel recommended 31 indicators for inclusion in the final set spanning the following areas: general indicators (three indicators), cancer screening (six), colorectal cancer (four), lung cancer (three), breast cancer (five), gynecologic cancers (five), and end-of-life care (five). CONCLUSIONS: A comprehensive set of 31 indicators was identified to evaluate the quality of cancer care received by women that also allows assessment of gender and socioeconomic disparities in cancer care.