'It doesn't happen any other way': relationship-building and reflexivity for equity-focused intersectoral practice (EquIP).

Intersectoral processes that bring together public institutions, civil society organizations and affected community members are essential to tackling complex health equity challenges. While conventional wisdom points to the importance of human relationships in fostering collaboration, there is a lack of practical guidance on how to do intersectoral work in ways that support authentic relationship-building and mitigate power differentials among people with diverse experiences and roles. This article presents the results of RentSafe EquIP, a community-based participatory research initiative conducted in Owen Sound, Canada, in the midst of a housing crisis. The research explored the potential utility of equity-focused intersectoral practice (EquIP), a novel approach that invests in human relationships and knowledge co-creation among professionals and affected members of the community. The three-phase EquIP methodology centred the grounded expertise of community members with lived/living experience of housing inadequacy to catalyze reflexive thinking by people in professional roles about the institutional gaps and barriers that prevent effective intersectoral response to housing-related inequities. The research demonstrated that EquIP can support agency professionals and community members to (i) engage in (re)problematization to redefine the problem statement to better include upstream drivers of inequity, (ii) support reflexivity among those in professional roles to identify institutional practices, policies and norms that perpetuate stigma and impede effective intersectoral response and (iii) spark individual and collective agency and commitment towards a more equity-focused intersectoral system. We conclude that the EquIP methodology is a promising approach for communities seeking to address persistent health equity and social justice challenges.

Exploration of the spatial patterns and determinants of asthma prevalence and health services use in Ontario using a Bayesian approach.

The purpose of this study was to examine the spatial variability of asthma outcomes in Ontario, Canada and broad environmental factors that contribute to this variability. Age-/sex-standardized asthma prevalence and health services use rates (2003-2013) were obtained from a provincial cohort of asthma patients. Employing an ecological-level study design, descriptive and Bayesian spatial regression analyses were used to examine patterns of asthma outcomes and their relationship to physical environment, socioeconomic environment and healthcare factors. Significant spatial variation in asthma outcomes was found between southern urban/suburban areas and northern/rural areas. Rurality was found to have a substantial effect on all asthma outcomes, except hospitalizations. For example, the most rural areas were associated with lower asthma prevalence and physician visits [RR = 0.708, 95% credible interval (CI): 0.636-0.795 and RR = 0.630, 95% CI: 0.504-0.758, respectively], and with higher ED visits (RR = 1.818, 95% CI: 1.194-2.858), when compared to urban areas. Strong associations were also found between material deprivation and ED visits (RR = 1.559, 95% CI: 1.358-1.737) and hospitalizations (RR = 1.259, 95% CI: 1.143-1.374). Associations between asthma outcomes and environmental variables such as air pollution and temperature were also found. Findings can be expected to inform the development of improved public health strategies, which take into account local environmental, socioeconomic and healthcare characteristics.

A spatial analysis of COPD prevalence, incidence, mortality and health service use in Ontario.

BACKGROUND: Risk factors for chronic obstructive pulmonary disease (COPD) include smoking, occupational exposure and air pollution, which vary geographically, but relatively little is known about how COPD varies spatially. DATA AND METHODS: This population-based ecological analysis examines physician-diagnosed COPD prevalence, incidence, mortality, and health care services use in Ontario over a 10-year period. Data were mapped and analyzed at the sub-Local Health Integration Network level (n = 141). Comparative morbidity figures were calculated and analyzed for local clusters of high and low rates of COPD health and health service use outcomes. RESULTS: A total of 722,494 individuals were identified as having COPD over the study period. Clusters of high rates in health outcomes and in most indicators of health service use emerged in northern parts of Ontario and in industrial and more rural agricultural areas. Clusters of low rates were centered on major urban and suburban areas. An exception was COPD-specific physician visits, which were lower in northern areas suggesting greater reliance on acute care. INTERPRETATION: This study highlights the need for research focused on explaining the spatial patterns identified here.

Asthma and chronic obstructive pulmonary disease (COPD) prevalence and health services use in Ontario Métis: a population-based cohort study.

INTRODUCTION: Chronic respiratory diseases cause a significant health and economic burden around the world. In Canada, Aboriginal populations are at increased risk of asthma and chronic obstructive pulmonary disease (COPD). There is little known, however, about these diseases in the Canadian Métis population, who have mixed Aboriginal and European ancestry. A population-based study was conducted to quantify asthma and COPD prevalence and health services use in the Métis population of Ontario, Canada's largest province. METHODS: The Métis Nation of Ontario Citizenship Registry was linked to provincial health administrative databases to measure and compare burden of asthma and COPD between the Métis and non-Métis populations of Ontario between 2009 and 2012. Asthma and COPD prevalence, health services use (general physician and specialist visits, emergency department visits, hospitalizations), and mortality were measured. RESULTS: Prevalences of asthma and COPD were 30% and 70% higher, respectively, in the Métis compared to the general Ontario population (p<0.001). General physician and specialist visits were significantly lower in Métis with asthma, while general physician visits for COPD were significantly higher. Emergency department visits and hospitalizations were generally higher for Métis compared to non-Métis with either disease. All-cause mortality in Métis with COPD was 1.3 times higher compared to non-Métis with COPD (p = 0.01). CONCLUSION: There is a high burden of asthma and COPD in Ontario Métis, with significant prevalence and acute health services use related to these diseases. Lower rates of physician visits suggest barriers in access to primary care services.

A spatial analysis of asthma prevalence in Ontario.

OBJECTIVE: The objective of this paper is to examine spatial patterns of asthma prevalence in the province of Ontario by age and sex between 2002 and 2006. METHODS: We conducted a population-based, ecological-level study using the Ontario Asthma Surveillance Information System Database (OASIS), a validated registry of all Ontario residents with asthma. Data were mapped and analyzed at the sub-Local Health Integration Network (subLHIN) level (n=141). Comparative morbidity figures (CMFs) were calculated and analyzed for local clusters of high and low values ("hot spots" and "cold spots"). RESULTS: There were 1,601,353 individuals identified as having asthma over the study period, representing an overall prevalence rate of 12.93%. Results demonstrate distinct spatial patterns of asthma prevalence across the province which are age- and sex-specific. There was little overlap between asthma hot spots by age group, suggesting that different spatial processes are at play. Patterns of cold spots are consistently seen in the urban and suburban subLHINs in and around Toronto and Hamilton as well as in several of the highly rural northern subLHINs. CONCLUSIONS: Findings illustrate the need for more geographically focused public health and health care planning and resource allocation, and highlight the need for research aimed at understanding the factors that may explain the spatial patterns identified here.

Evidence-based performance indicators of primary care for asthma: a modified RAND Appropriateness Method.

PURPOSE: To develop evidence-based performance indicators that measure the quality of primary care for asthma. DATA SOURCES: Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and CINAHL for peer-reviewed articles published in 1998-2008 and five national/global asthma management guidelines. STUDY SELECTION: Articles with a focus on current asthma performance indicators recognized or used in community and primary care settings. Data extraction Modified RAND Appropriateness METHOD: was used. The work described herein was conducted in Canada in 2008. Five clinician experts conducted the systematic literature review. Asthma-specific performance indicators were developed and the strength of supporting evidence summarized. A survey was created and mailed to 17 expert panellists of various disciplines, asking them to rate each indicator using a 9-point Likert scale. Percentage distribution of the Likert scores were generated and given to the panellists before a face-to-face meeting, which was held to assess consensus. At the meeting, they ranked all indicators based on their reliability, validity, availability and feasibility. RESULTS: Literature search yielded 1228 articles, of which 135 were used to generate 45 performance indicators in five domains: access to care, clinical effectiveness, patient centeredness, system integration and coordination and patient safety. The top five ranked indicators were: Asthma Education from Certified Asthma Educator, Pulmonary Function Monitoring, Asthma Control Monitoring, Controller Medication Use and Asthma Control. CONCLUSION: The top 15 ranked indicators are recommended for implementation in primary care to measure asthma care delivery, respiratory health outcomes and establish benchmarks for optimal health service delivery over time and across populations.

If you build it, they still may not come: outcomes and process of implementing a community-based integrated knowledge translation mapping innovation.

BACKGROUND: Maps and mapping tools through geographic information systems (GIS) are highly valuable for turning data into useful information that can help inform decision-making and knowledge translation (KT) activities. However, there are several challenges involved in incorporating GIS applications into the decision-making process. We highlight the challenges and opportunities encountered in implementing a mapping innovation as a KT strategy within the non-profit (public) health sector, reflecting on the processes and outcomes related to our KT innovations. METHODS: A case study design, whereby the case is defined as the data analyst and manager dyad (a two-person team) in selected Ontario Early Year Centres (OEYCs), was used. Working with these paired individuals, we provided a series of interventions followed by one-on-one visits to ensure that our interventions were individually tailored to personal and local decision-making needs. Data analysis was conducted through a variety of qualitative assessments, including field notes, interview data, and maps created by participants. Data collection and data analysis have been guided by the Ottawa Model of Research Use (OMRU) conceptual framework. RESULTS: Despite our efforts to remove all barriers associated with our KT innovation (maps), our results demonstrate that both individual level and systemic barriers pose significant challenges for participants. While we cannot claim a causal association between our project and increased mapping by participants, participants did report a moderate increase in the use of maps in their organization. Specifically, maps were being used in decision-making forums as a way to allocate resources, confirm tacit knowledge about community needs, make financially-sensitive decisions more transparent, evaluate programs, and work with community partners. CONCLUSIONS: This project highlights the role that maps can play and the importance of communicating the importance of maps as a decision support tool. Further, it represents an integrated knowledge project in the community setting, calling to question the applicability of traditional KT approaches when community values, minimal resources, and partners play a large role in decision making. The study also takes a unique perspective--where research producers and users work as dyad-pairs in the same organization--that has been under-explored to date in KT studies.

The relationship between socio-economic and geographic factors and asthma among Canada's Aboriginal populations.

OBJECTIVES: To examine the prevalence, exacerbations and management of asthma among Canada's Aboriginal populations, and its relationship to socio-economic and geographic factors. STUDY DESIGN: Secondary analysis of a national cross-sectional questionnaire survey. METHODS: Data were collected in 2000 and 2001 through a survey of Aboriginal children and adults residing on- and off-reserve as part of the 2001 Aboriginal People's Survey (APS). The asthma related outcome variables - physician-diagnosed asthma, attack in past year and regular use of inhalants - were examined in relation to socio-economic and geographic factors such as income, education, housing and location of residence. Statistical analyses were based on weighted univariate and multivariate logistic regressions. RESULTS: The results show variations in asthma diagnosis, attacks and inhalant use across geographic location, socio-economic and demographic characteristics. Geographic location was found to be significantly associated with asthma for both adults and children, with those living in the northern territories, on-reserve or rural locations being the least likely to be diagnosed. Geographic location and Aboriginal identity were also found to be significantly associated with asthma medication use. CONCLUSIONS: While these findings may suggest a "healthier" population in more remote locations, they alternatively point to a general pattern of under-diagnosis, potentially due to poor health care access, as is typical in more remote locations.

Spatio-temporal analysis of pneumonia and influenza hospitalizations in Ontario, Canada.

Pneumonia and influenza represent a significant public health and health care system burden that is expected to increase with the aging of developed nations' populations. The burden of these illnesses is far from uniform however, with recent studies showing that they are both highly spatially and temporally variable. We have combined spatial and time-series analysis techniques to examine pneumonia and influenza hospitalizations in the province of Ontario, Canada, to determine how temporal patterns vary over space, and how spatial patterns of hospitalizations vary over time. Knowledge of these patterns can provide clues to disease aetiology and inform the effective management of health care system resources. Spatial analysis revealed significant clusters of high hospitalization rates in northern and rural counties (Moran's I = 0.186; P <0.05), while county level time series analysis demonstrated significant upward trends in rates in almost a quarter of the counties (P <0.05), and significant seasonality in all but one county (Fisher-Kappa and Barlett Kolmogorov Smirnov tests significant at the level P <0.01). Areas of weak seasonality were typically seen in rural areas with high rates of hospitalizations. The highest levels of spatial clustering of pneumonia and influenza hospitalizations were found to occur in months when rates were lowest. The findings provide evidence of spatio-temporal interaction over the study period, with marked spatial variability in temporal patterns, and temporal variability in spatial patterns. Results point to the need for the effective allocation of services and resources based on regional and seasonal demands, and more regionally focused prevention strategies. This research represents an important step towards understanding the dynamic nature of these illnesses, and sets the stage for the application of spatio-temporal modelling techniques to explain them.

Using participatory design to develop (public) health decision support systems through GIS.

BACKGROUND: Organizations that collect substantial data for decision-making purposes are often characterized as being 'data rich' but 'information poor'. Maps and mapping tools can be very useful for research transfer in converting locally collected data into information. Challenges involved in incorporating GIS applications into the decision-making process within the non-profit (public) health sector include a lack of financial resources for software acquisition and training for non-specialists to use such tools. This on-going project has two primary phases. This paper critically reflects on Phase 1: the participatory design (PD) process of developing a collaborative web-based GIS tool. METHODS: A case study design is being used whereby the case is defined as the data analyst and manager dyad (a two person team) in selected Ontario Early Year Centres (OEYCs). Multiple cases are used to support the reliability of findings. With nine producer/user pair participants, the goal in Phase 1 was to identify barriers to map production, and through the participatory design process, develop a web-based GIS tool suited for data analysts and their managers. This study has been guided by the Ottawa Model of Research Use (OMRU) conceptual framework. RESULTS: Due to wide variations in OEYC structures, only some data analysts used mapping software and there was no consistency or standardization in the software being used. Consequently, very little sharing of maps and data occurred among data analysts. Using PD, this project developed a web-based mapping tool (EYEMAP) that was easy to use, protected proprietary data, and permit limited and controlled sharing between participants. By providing data analysts with training on its use, the project also ensured that data analysts would not break cartographic conventions (e.g. using a chloropleth map for count data). Interoperability was built into the web-based solution; that is, EYEMAP can read many different standard mapping file formats (e.g. ESRI, MapInfo, CSV). DISCUSSION: Based on the evaluation of Phase 1, the PD process has served both as a facilitator and a barrier. In terms of successes, the PD process identified two key components that are important to users: increased data/map sharing functionality and interoperability. Some of the challenges affected developers and users; both individually and as a collective. From a development perspective, this project experienced difficulties in obtaining personnel skilled in web application development and GIS. For users, some data sharing barriers are beyond what a technological tool can address (e.g. third party data). Lastly, the PD process occurs in real time; both a strength and a limitation. Programmatic changes at the provincial level and staff turnover at the organizational level made it difficult to maintain buy-in as participants changed over time. The impacts of these successes and challenges will be evaluated more concretely at the end of Phase 2. CONCLUSION: PD approaches, by their very nature, encourage buy-in to the development process, better addresses user-needs, and creates a sense of user-investment and ownership.

Typology of after-hours care instructions for patients: telephone survey and multivariate analysis.

OBJECTIVE: To develop a typology of after-hours care (AHC) instructions and to examine physician and practice characteristics associated with each type of instruction. DESIGN: Cross-sectional telephone survey. Physicians' offices were called during evenings and weekends to listen to their messages regarding AHC. All messages were categorized. Thematic analysis of a subset of messages was conducted to develop a typology of AHC instructions. Logistic regression analysis was used to identify associations between physician and practice characteristics and the instructions left for patients. SETTING: Family practices in the greater Toronto area. PARTICIPANTS: Stratified random sample of family physicians providing office-based primary care. MAIN OUTCOME MEASURES: Form of response (eg, answering machine), content of message, and physician and practice characteristics. RESULTS: Of 514 after-hours messages from family physicians' offices, 421 were obtained from answering machines, 58 were obtained from answering services, 23 had no answer, 2 gave pager numbers, and 10 had other responses. Message content ranged from no AHC instructions to detailed advice; 54% of messages provided a single instruction, and the rest provided a combination of instructions. Content analysis identified 815 discrete instructions or types of response that were classified into 7 categories: 302 instructed patients to go to an emergency department; 122 provided direct contact with a physician; 115 told patients to go to a clinic; 94 left no directions; 76 suggested calling a housecall service; 45 suggested calling Telehealth; and 61 suggested other things. About 22% of messages only advised attending an emergency department, and 18% gave no advice at all. Physicians who were female, had Canadian certification in family medicine, held hospital privileges, or had attended a Canadian medical school were more likely to be directly available to their patients. CONCLUSION: Important issues identified included the recommendation to use an emergency department as the sole source of AHC, practices providing no specific AHC instructions to their patients, and physicians' lack of acceptance of Telehealth. To improve AHC, new initiatives should build upon the existing system, changes should be integrated, and there should be a range of AHC options for patients and physicians.

Fourteen-year study of hospital admissions for diverticular disease in Ontario.

BACKGROUND: Diverticular disease is one of the most common gastrointestinal conditions affecting the Canadian population, yet very little is known about its epidemiology. OBJECTIVE: The aim of the present study was to measure the rate of hospital admission for diverticular disease by age and sex over a 14-year period in the population of Ontario. PATIENTS AND METHODS: The present study was a retrospective, population-based cohort study of all hospital admissions for diverticular disease from 1988 to 2002. RESULTS: There were 133,875 hospital admissions during the period. Admission rates increased with age, and women were admitted at higher rates than men across all age groups. CONCLUSION: Diverticular disease is an important cause of gastrointestinal morbidity. As the population ages, a rise in the incidence of diverticular disease can be anticipated. Future studies to explain sex difference in admissions are required.

A spatial analysis of the determinants of pneumonia and influenza hospitalizations in Ontario (1992-2001).

Previous research on the determinants of pneumonia and influenza has focused primarily on the role of individual level biological and behavioural risk factors resulting in partial explanations and largely curative approaches to reducing the disease burden. This study examines the geographic patterns of pneumonia and influenza hospitalizations and the role that broad ecologic-level factors may have in determining them. We conducted a county level, retrospective, ecologic study of pneumonia and influenza hospitalizations in the province of Ontario, Canada, between 1992 and 2001 (N=241,803), controlling for spatial dependence in the data. Non-spatial and spatial regression models were estimated using a range of environmental, social, economic, behavioural, and health care predictors. Results revealed low education to be positively associated with hospitalization rates over all age groups and both genders. The Aboriginal population variable was also positively associated in most models except for the 65+-year age group. Behavioural factors (daily smoking and heavy drinking), environmental factors (passive smoking, poor housing, temperature), and health care factors (influenza vaccination) were all significantly associated in different age and gender-specific models. The use of spatial error regression models allowed for unbiased estimation of regression parameters and their significance levels. These findings demonstrate the importance of broad age and gender-specific population-level factors in determining pneumonia and influenza hospitalizations, and illustrate the need for place and population-specific policies that take these factors into consideration.

Seasonality of service provision in hip and knee surgery: a possible contributor to waiting times? A time series analysis.

BACKGROUND: The question of how best to reduce waiting times for health care, particularly surgical procedures such as hip and knee replacements is among the most pressing concern of the Canadian health care system. The objective of this study was to test the hypothesis that significant seasonal variation exists in the performance of hip and knee replacement surgery in the province of Ontario. METHODS: We performed a retrospective, cross-sectional time series analysis examining all hip and knee replacement surgeries in people over the age of 65 in the province of Ontario, Canada between 1992 and 2002. The main outcome measure was monthly hospitalization rates per 100,000 population for all hip and knee replacements. RESULTS: There was a marked increase in the rate of hip and knee replacement surgery over the 10-year period as well as an increasing seasonal variation in surgeries. Highly significant (Fisher Kappa = 16.05, p < 0.01; Bartlett-Kolmogorov-Smirnov Test = 0.31, p < 0.01) and strong (R2Autoreg = 0.85) seasonality was identified in the data. CONCLUSION: Holidays and utilization caps appear to exert a significant influence on the rate of service provision. It is expected that waiting times for hip and knee replacement could be reduced by reducing seasonal fluctuations in service provision and benchmarking services to peak delivery. The results highlight the importance of system behaviour in seasonal fluctuation of service delivery.

Time series analysis of age related cataract hospitalizations and phacoemulsification.

BACKGROUND: Cataract surgery remains a commonly performed elective surgical procedure in the aging and the elderly. The purpose of this study was to utilize time series methodology to determine the temporal and seasonal variations and the strength of the seasonality in age-related (senile) cataract hospitalizations and phacoemulsification surgeries. METHODS: A retrospective, cross-sectional time series analysis was used to assess the presence and strength of seasonal and temporal patterns of age-related cataract hospitalizations and phacoemulsification surgeries from April 1, 1991 to March 31, 2002. Hospital admission rates for senile cataract (n = 70,281) and phacoemulsification (n = 556,431) were examined to determine monthly rates of hospitalization per 100,000 population. Time series methodology was then applied to the monthly aggregates. RESULTS: During the study period, age-related cataract hospitalizations in Ontario have declined from approximately 40 per 100,000 to only one per 100,000. Meanwhile, the use of phacoemulsification procedures has risen dramatically. The study found evidence of biannual peaks in both procedures during the spring and autumn months, and summer and winter troughs. Statistical analysis revealed significant overall seasonal patterns for both age-related cataract hospitalizations and phacoemulsifications (p < 0.01). CONCLUSION: This study illustrates the decline in age-related cataract hospitalizations in Ontario resulting from the shift to outpatient phacoemulsification surgery, and demonstrates the presence of biannual peaks (a characteristic indicative of seasonality), in hospitalization and phacoemulsification during the spring and autumn throughout the study period.

Temporal analysis of acute myocardial infarction in Ontario, Canada.

BACKGROUND: Acute myocardial infarction (AMI) is a substantial cause of morbidity and mortality in Canada. Evidence suggests that the incidence and mortality of AMI increase in the winter. Determining the strength and nature of seasonality patterns in relation to age and sex may be helpful in health care planning. OBJECTIVES: To examine the seasonal patterns of AMI hospital admissions by age and sex, to assess the strength of the seasonal patterns and to examine the overall trends in admissions. METHODS: A retrospective population-based study was conducted to assess temporal patterns in 14 years of hospital admissions for AMI (from April 1, 1988, to March 31, 2002) in Ontario. Seasonality was assessed using the autoregression coefficient (R2Autoreg), and Fisher's Kappa and Bartlett's Kolmogorov-Smirnov tests. RESULTS: There were 271,321 people in the cohort, of whom 63% (n = 171,546) were male and 37% (n = 99,775) were female. There was an increase in AMI admissions since 1988 that reached a plateau in 1992, which was attributable mostly to the increased rate in the oldest age groups (70 years and older), where admission rates more than doubled. An association between seasonality and AMI admissions was found in most age and sex groups, with men consistently exhibiting a stronger seasonality pattern. The greatest difference in the cohort, 2.5 per 100,000 per month (134 admissions), occurred between December and September (13.64 per 100,000 in September versus 16.14 per 100,000 in December). CONCLUSIONS: AMI admissions show seasonality patterns, which are more pronounced in men. Although statistically significant, the seasonal differences are small in terms of absolute numbers, and are likely irrelevant in health care planning.

Croup hospitalizations in Ontario: a 14-year time-series analysis.

OBJECTIVE: Croup is the most common form of airway obstruction in children. Known to be primarily viral, the seasonality of croup has been examined largely through its association with the human parainfluenza viruses. This study examined the seasonal pattern of croup hospitalizations in relation to age and gender for the province of Ontario during a 14-year period. METHODS: A retrospective, population-based study design was used to examine seasonal and temporal patterns of croup hospitalizations from April 1, 1988, to March 31, 2002. All residents of Ontario who were aged 0 to 4 years and eligible for universal health coverage during the study period were included for analysis. Time-series analyses then were conducted on monthly aggregations of hospitalizations. RESULTS: This study found strong evidence of croup hospitalization seasonality, with a biennial midautumn peak and annual summer trough, evident throughout the 14-year study period (Fisher's kappa = 51.11; Bartlett Kolmogorov Smirnov = 0.552). The pattern was observed in all children aged 0 to 4, although boys were hospitalized 2 times more often than girls of the same age. Rates of croup hospitalization were lower for children aged 1 to 4 years than for children aged 0 to <1. A marked decrease in croup hospitalizations was observed after the winter of 1993/1994 and continued to decrease in a step-wise manner for the remainder of the study period. CONCLUSIONS: This study delineates a clear biennial pattern of seasonal croup hospitalizations, varying by age and gender, with a large decrease in hospitalizations after the winter of 1993/1994. It is expected that these findings will have important implications for the treatment and management of childhood croup.

After-hours care in Canada: analysis of the 2001 National Family Physician Workforce Survey.

OBJECTIVE: To determine family physicians' availability to their general practice patients after hours and to explore the characteristics and determinants of after-hours services. DESIGN: Secondary analysis of the 2001 National Family Physician Workforce Survey. SETTING: Canada. PARTICIPANTS: Canadian family physicians and general practitioners currently in practice (n = 10,553). MAIN OUTCOME MEASURES: Provision of after-hours care, defined as providing care to all practice patients outside of normal office hours. RESULTS: Sixty-two percent of Canadian family physicians reported providing after-hours service. The lowest rates were found in Quebec (34%) and the highest in Alberta and Saskatchewan (88%). Respondents practising in academic and community clinics, offering selective medical services (emergency care, palliative care, housecalls, after-hours care), or living outside of Ontario or Quebec were more likely to provide after-hours care. Women physicians, those practising in walk-in clinics, or physicians primarily paid by fee-for-service were less likely to do so. Urban versus rural location, organization of practice (solo or group), age of physician, country of graduation, and physician satisfaction were not found to significantly affect the likelihood of providing after-hours services. CONCLUSION: Knowledge of these factors can be used to inform policy development for after-hours service arrangements, which is particularly relevant today, given provincial governments' interests in exploring alternative payment plans and primary care reform options.

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution.

BACKGROUND: The outbreak of SARS in 2003 had a dramatic effect on the health care system in Toronto. The main objective of this study was to investigate the psychosocial effects associated with working in a hospital environment during this outbreak. METHODS: Questionnaires were distributed to all willing employees of Sunnybrook and Women's College Health Sciences Centre between Apr. 10 and 22, 2003. The survey included questions regarding concern about SARS, precautionary measures, personal well-being and sociodemographic characteristics; a subsample also received the 12-item version of the General Health Questionnaire (GHQ-12). RESULTS: Of the 4283 questionnaires distributed, 2001 (47%) were returned, representing 27% of the total hospital employee population of 7474. The proportions of respondents who were allied health care professionals, nurses and doctors and who worked in areas other than patient care were representative of the hospital staff population as a whole. Of the 2001 questionnaires, 510 contained the GHQ-12. Two-thirds of the respondents reported SARS-related concern for their own or their family's health. A total of 148 respondents (29%) scored above the threshold point on the GHQ-12, indicating probable emotional distress; the rate among nurses was 45%. Masks were reported to be the most bothersome infection control precaution. Logistic regression analysis identified 4 factors as being significantly associated with increased levels of concern for personal or family health: perception of a greater risk of death from SARS (adjusted odds ratio [OR] 5.0, 95% confidence interval [CI] 2.6-9.6), living with children (adjusted OR 1.8, 95% CI 1.5-2.3), personal or family lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI 2.5-4.3) and being treated differently by people because of working in a hospital (adjusted OR 1.6, 95% CI 1.2-2.1). Four factors were identified as being significantly associated with the presence of emotional distress: being a nurse (adjusted OR 2.8, 95% CI 1.5-5.5), part-time employment status (adjusted OR 2.6, 95% CI 1.2-5.4), lifestyle affected by SARS outbreak (adjusted OR 2.2, 95% CI 1.4-3.5) and ability to do one's job affected by the precautionary measures (adjusted OR 2.9, 95% CI 1.9-4.6). INTERPRETATION: Our findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff. These effects differed with respect to occupation and risk perception. The effect on families and lifestyle was also substantial. These findings highlight the need for interventions to address psychosocial distress and concern and to provide support for employees during such crises.

Is there a clinically significant seasonal component to hospital admissions for atrial fibrillation?

BACKGROUND: Atrial fibrillation is a common cardiac dysrhythmia, particularly in the elderly. Recent studies have indicated a statistically significant seasonal component to atrial fibrillation hospitalizations. METHODS: We conducted a retrospective population cohort study using time series analysis to evaluate seasonal patterns of atrial fibrillation hospitalizations for the province of Ontario for the years 1988 to 2001. Five different series methods were used to analyze the data, including spectral analysis, X11, R-Squared, autocorrelation function and monthly aggregation. RESULTS: This study found evidence of weak seasonality, most apparent at aggregate levels including both ages and sexes. There was dramatic increase in hospitalizations for atrial fibrillation over the years studied and an age dependent increase in rates per 100,000. Overall, the magnitude of seasonal difference between peak and trough months is in the order of 1.4 admissions per 100,000 population. The peaks for hospitalizations were predominantly in April, and the troughs in August. CONCLUSIONS: Our study confirms statistical evidence of seasonality for atrial fibrillation hospitalizations. This effect is small in absolute terms and likely not significant for policy or etiological research purposes.