Neighbourhood immigration, health care utilization and outcomes in patients with diabetes living in the Montreal metropolitan area (Canada): a population health perspective.

BACKGROUND: Understanding health care utilization by neighbourhood is essential for optimal allocation of resources, but links between neighbourhood immigration and health have rarely been explored. Our objective was to understand how immigrant composition of neighbourhoods relates to health outcomes and health care utilization of individuals living with diabetes. METHODS: This is a secondary analysis of administrative data using a retrospective cohort of 111,556 patients living with diabetes without previous cardiovascular diseases (CVD) and living in the metropolitan region of Montreal (Canada). A score for immigration was calculated at the neighbourhood level using a principal component analysis with six neighbourhood-level variables (% of people with maternal language other than French or English, % of people who do not speak French or English, % of immigrants with different times since immigration (<5 years, 5-10 years, 10-15 years, 15-25 years)). Dependent variables were all-cause death, all-cause hospitalization, CVD event (death or hospitalization), frequent use of emergency departments, frequent use of general practitioner care, frequent use of specialist care, and purchase of at least one antidiabetic drug. For each of these variables, adjusted odds ratios were estimated using a multilevel logistic regression. RESULTS: Compared to patients with diabetes living in neighbourhoods with low immigration scores, those living in neighbourhoods with high immigration scores were less likely to die, to suffer a CVD event, to frequently visit general practitioners, but more likely to visit emergency departments or a specialist and to use an antidiabetic drug. These differences remained after controlling for patient-level variables such as age, sex, and comorbidities, as well as for neighbourhood attributes like material and social deprivation or living in the urban core. CONCLUSIONS: In this study, patients with diabetes living in neighbourhoods with high immigration scores had different health outcomes and health care utilizations compared to those living in neighbourhoods with low immigration scores. Although we cannot disentangle the individual versus the area-based effect of immigration, these results may have an important impact for health care planning.

Modeling climate effects on hip fracture rate by the multivariate GARCH model in Montreal region, Canada.

Changes in extreme meteorological variables and the demographic shift towards an older population have made it important to investigate the association of climate variables and hip fracture by advanced methods in order to determine the climate variables that most affect hip fracture incidence. The nonlinear autoregressive moving average with exogenous variable-generalized autoregressive conditional heteroscedasticity (ARMAX-GARCH) and multivariate GARCH (MGARCH) time series approaches were applied to investigate the nonlinear association between hip fracture rate in female and male patients aged 40-74 and 75+ years and climate variables in the period of 1993-2004, in Montreal, Canada. The models describe 50-56% of daily variation in hip fracture rate and identify snow depth, air temperature, day length and air pressure as the influencing variables on the time-varying mean and variance of the hip fracture rate. The conditional covariance between climate variables and hip fracture rate is increasing exponentially, showing that the effect of climate variables on hip fracture rate is most acute when rates are high and climate conditions are at their worst. In Montreal, climate variables, particularly snow depth and air temperature, appear to be important predictors of hip fracture incidence. The association of climate variables and hip fracture does not seem to change linearly with time, but increases exponentially under harsh climate conditions. The results of this study can be used to provide an adaptive climate-related public health program and ti guide allocation of services for avoiding hip fracture risk.

Modeling seasonal variation of hip fracture in Montreal, Canada.

The investigation of the association of the climate variables with hip fracture incidences is important in social health issues. This study examined and modeled the seasonal variation of monthly population based hip fracture rate (HFr) time series. The seasonal ARIMA time series modeling approach is used to model monthly HFr incidences time series of female and male patients of the ages 40-74 and 75+ of Montreal, Québec province, Canada, in the period of 1993-2004. The correlation coefficients between meteorological variables such as temperature, snow depth, rainfall depth and day length and HFr are significant. The nonparametric Mann-Kendall test for trend assessment and the nonparametric Levene's test and Wilcoxon's test for checking the difference of HFr before and after change point are also used. The seasonality in HFr indicated sharp difference between winter and summer time. The trend assessment showed decreasing trends in HFr of female and male groups. The nonparametric test also indicated a significant change of the mean HFr. A seasonal ARIMA model was applied for HFr time series without trend and a time trend ARIMA model (TT-ARIMA) was developed and fitted to HFr time series with a significant trend. The multi criteria evaluation showed the adequacy of SARIMA and TT-ARIMA models for modeling seasonal hip fracture time series with and without significant trend. In the time series analysis of HFr of the Montreal region, the effects of the seasonal variation of climate variables on hip fracture are clear. The Seasonal ARIMA model is useful for modeling HFr time series without trend. However, for time series with significant trend, the TT-ARIMA model should be applied for modeling HFr time series.

Nature and nurture in the family physician's choice of practice location.

INTRODUCTION: An understanding of the contextual, professional, and personal factors that affect choice of practice location for physicians is needed to support successful strategies in addressing geographic maldistribution of physicians. This study compared two categories of predictors of family practice location in non-metropolitan areas among undergraduate medical students: individual characteristics (nature), and the rural program component of their training program (nurture). The study aimed to identify factors that predict the location of practice 2 years post-residency training and determine the predictive value of combining nature and nurture variables using administrative data from two undergraduate medical education programs. METHODS: Databases were developed from available administrative sources for a retrospective analysis of two undergraduate medical education programs in Canada: Université de Sherbrooke (UdeS) and University of British Columbia (UBC). Both schools have a strong mandate to evaluate the impact of their programs on physician distribution. The dependent variable was location of practice 2 years after completing postgraduate training in family medicine. Independent variables included individual and program characteristics. Separate analyses were conducted for each program using multiple logistic regression. RESULTS: The nature and nurture variables considered in the models explained only 21% to 27% of the variance in the eventual location of practice of family physician graduates. For UdeS, having an address in a rural/small-town environment at application to medical school (OR=2.61, 95% CI: 1.24-6.06) and for UBC, location of high school in a rural/small town (OR=4.03, 95% CI: 1.05-15.41), both increased the chances of practicing in a non-metropolitan area. For UdeS the nurture variable (ie length of clerkship in a non-metropolitan area) was the most significant predictor (OR=1.14, 95% CI: 1.067-1.22). For both medical schools, adding a single nurture variable to the model using only nature variables significantly increased the amount of variation accounted for in predicting location of practice in non-metropolitan areas. CONCLUSIONS: Aspects of graduates' rural background increase the chances of practicing in a non-metropolitan area. A third-year clerkship experience in a rural area may increase the chances of non-metropolitan practice. Although the total variation predicted by both nature and nurture variables in this study was small, adding a nurture variable significantly improves the prediction of individuals who will practice in a non-metropolitan area. The fact that total variation predicted was small is likely to be due to the limitations of the administrative databases used. Different strategies are being implemented in each university to improve the quality of existing administrative databases, as well as to collect relevant data about intent-to-practice, training characteristics, and the attitudes, beliefs and backgrounds of students.

Attractiveness of family medicine for medical students: influence of research and debt.

OBJECTIVE: To examine the association between students' personal characteristics, backgrounds, and medical schools and their intention to enter a family medicine (FM) specialty. DESIGN: Descriptive study using data from the 2007 National Physician Survey. SETTING: Canada. PARTICIPANTS: Clinical (n=1109) and preclinical (n=829) medical student respondents to the 2007 National Physician Survey. MAIN OUTCOME MEASURES: The main variable was hoping to enter an FM specialty, and 40 independent variables were included in regression and classification-tree models. RESULTS: Fewer than 1 medical student in 3 (30.2% at the preclinical level and 31.4% at the clinical level) hoped to enter into an FM career. Those who did were more likely to be female, were slightly older, were more frequently married or living with partners, were typically born in Canada, and were more likely to have previous exposure to non-urban environments. The most important predictor for both populations was the debt related to medical studies, which acted in the opposite direction of whether or not students were interested in research. Students interested in research were attracted by specialties with high earning potential, while those not interested in research looked for short residency programs, such as FM, so they could begin to pay off debt sooner. Therefore, the interest in research appears to be inversely related to the choice of FM. CONCLUSION: Less than one-third of medical students were looking for residencies in FM in Canada. This is far below the goals of 45% set at the national level and 50% set by some provinces like Quebec. Debt and interest in research have strong influences on the choice of residency by medical students.

Rural-urban disparities in the management and health issues of chronic diseases in Quebec (Canada) in the early 2000s.

INTRODUCTION: The 'Commission on the Future of Health Care in Canada' recognized that people living in rural and remote areas of Canada are at a disadvantage in health status, access to care and health professionals, and it considers the fight against these problems as a national priority. Although some attention has been paid to the prevalence of chronic diseases, very few studies have studied specifically the management and health issues in populations with chronic diseases in relation to rurality. The objective of this study was to describe systematic gaps across rural and urban populations in incidence, mortality, morbidity, material and human resources utilization, and drug management for three important chronic diseases: atherosclerosis, osteoporosis and diabetes. METHODS: Three retrospective population-based cohort studies were used. Three study populations were selected: an atherosclerotic population including patients newly hospitalized for a myocardial infarction (MI), an osteoporotic population including the at risk population who have suffered from a fragility fracture (FF) and, finally, a diabetic population that includes only incident cases of diabetes patients. For each of the three chronic diseases, variables were selected and classified in six categories: incidence, mortality, morbidity, material resources utilization, physician consultation and drug treatment. The Statistical Area Classification (SAC) was used as the rurality definition and contains six categories including two urban areas--Census Metropolitan Areas (CMA), or metropolitan areas, and Census Agglomeration (CA), or small towns--and four rural areas: Strong, Moderate, Weak and No Metropolitan influenced zones (MIZ), depending on the proportion of the workforce that commutes to urban areas. Each disease-related variable was described using age- and sex-adjusted rates. For comparing rates between rurality classes, the adjusted relative risks were calculated using the CMA as the reference group. The X2 was used to test for the equality of risks. RESULTS: A common pattern was identified from this study: for all three studied diseases, the material resources utilization rates and the specialist (other than internist) consultation rates were almost always statistically lower in small towns and rural areas when compared with metropolitan areas. Mortality rates and drug utilization rates were very similar among regions, except for hormone replacement therapy in women where utilization rates were higher in small towns and rural areas compared with metropolitan areas. Among observations that were not common to all three chronic diseases, the first is that MI incidence was greater in small towns and in Weak MIZ compared with metropolitan areas, fragility fractures seem to be marginally more frequent in small towns but less frequent in rural areas compared with metropolitan areas, while an increased incidence rate of diabetes is observed in remote region and a smaller risk in moderate MIZ compared with metropolitan areas. For both atherosclerosis and diabetes, morbidity rates were always statistically higher in small towns and in rural areas. This was not the case for patients with osteoporotic fractures where similar morbidity rates across regions were observed, except in strong MI which show the lowest morbidity rate. CONCLUSIONS: There was substantially lower utilization of specialized services in non-metropolitan areas for all three diseases (myocardial infarction, osteoporosis, and diabetes). However, this did not translate into consistent differences in mortality and morbidity outcomes. This suggests that the impact of differential care utilization is specific to each disease, with indications that some important services may be under-utilized in rural areas, while others may be over-utilized in urban areas without improvement in outcomes.

Disparities between rural and urban areas for osteoporosis management in the province of Quebec following the Canadian 2002 guidelines publication.

RATIONALE, AIMS AND OBJECTIVES: Clinical guidelines have been seen as a tool for improving management of osteoporosis in order to prevent fragility fractures. However, the impact of guidelines on clinical management of osteoporosis has not been measured. We examined medical investigation and treatment before and after the 2002 Canadian guidelines publication and examined if practice changes were different between rural and urban areas. METHODS: We conducted a retrospective population-based observational study using secondary data analysis. Two studied populations were selected; one before, the other after the publication of Canadian practice guidelines. The studied populations consisted of all individuals 65 years or older from Quebec (Canada) for whom a physician claimed a consultation or have been hospitalized for fragility fracture between the two predefined periods. RESULTS: There was no significant difference in the rate of bone mineral density testing for women before and after guidelines publication. For men a statistically significant increase was observed but remained very low. A significant increase in bisphosphonates prescribing, but no increased in the reporting of a diagnosis of osteoporosis were observed. A significant reduction of hormonal replacement therapy was seen during the year following guidelines publication. The strongest significant increases were mostly seen in urban regions compared to rural areas. CONCLUSIONS: Very small changes were observed for diagnostic recognition by physicians, diagnostic testing and some recommended drugs prescribing following guidelines publication. This suggests low guidelines impact on medical practice for osteoporosis in patients suffering fragility fractures.

Canadian family physicians' intentions to migrate: associated factors.

OBJECTIVE: To ascertain the short-term intentions of Canadian clinically active family physicians (CAFPs) to change their practice locations. DESIGN: Secondary analysis of the 2004 National Physician Survey (NPS) data. SETTING: Canada. PARTICIPANTS: All Canadian CAFPs who responded to the 2004 NPS survey. MAIN OUTCOME MEASURES: Physicians' self-reported intentions to move their practice locations to other provinces or other countries. Variables included age, sex, marital status, having children, professional satisfaction, practice region (British Columbia, Alberta, the Prairies [Saskatchewan and Manitoba], Ontario, Quebec, or the Atlantic Provinces) and work setting (urban, small town, rural, etc). Logistic and regression tree analyses were used to find predictors of intention to move out of province. RESULTS: The 2004 NPS was completed by 21 296 physicians, 11 041 of whom were family physicians. Of these, 8537 satisfied our study inclusion criteria. A total of 3.6% of those CAFPs planned to relocate their practices to other provinces and 3.0% planned to relocate to other countries within the next 2 years (from the time of the survey). Practising in the Prairies and, to a lesser extent, in the Atlantic Provinces were the most powerful predictors of planned interprovincial migration. Dissatisfaction with professional life was the most powerful predictor of planning migration abroad as well as being a predictor of planned interprovincial migration. Other common and statistically significant predictors of interprovincial migration and migration abroad were age, sex, and marital status. CONCLUSION: Patients in the Prairie and Atlantic regions are at greater risk of having their family physicians migrate to other provinces than those in British Columbia, Ontario, and Quebec are. As interprovincial migration profiles differ according to region of practice, they could be used by provincial health human resource planners to understand and predict the movement of health care workers out of their respective provinces.

Long term regional migration patterns of physicians over the course of their active practice careers.

INTRODUCTION: The geographic distribution of physicians in the United States of America has been often described as unbalanced or maldistributed. There is much in the literature on the regional distribution of physicians but far less is written about their pattern of movement. This study aimed to examine the geographic transition of physicians at two points in time (1981 and 2003), in and out the four US census regions (Northeast, Midwest, South, and West). METHODS: We identified 83 383 non-federal clinically active primary care physicians (CAPCP) who were clinically active both in 1981 and in 2003 as registered in the American Medical Association Physician Masterfiles. The main variable was the migration status observed between 1981 and 2003, and they were categorized into three groups: (1) non-migrants (same county of practice); (2) internal migrants (different counties of practice, same region); or (3) external migrants (different regions of practice). Covariables were gender and age for the CAPCP, and the percentage of non-whites in the population, the mean per capita income of the population, the ratio of primary care physicians and the ratio of hospital beds per 1000 inhabitants, as well as the rural/urban status for the county of practice in 1981 (large metropolitan area, small metropolitan area, or non-adjacent). RESULTS: Overall, 13.2 % of CAPCP moved from one region to another between 1981 and 2003. Women and young CAPCPs were more prone to migrate during their career. Proportionally, a greater outflow of the 1981 workforce is observed for the Northeast and Midwest regions with 16% and 18%, respectively, compared with 10% for both the West and South regions. When taking into account the total flow (in and out) for each region, the West and the South 'benefited' from CAPCPs' migration, with respectively a 1.10 and 1.07 increase in 2003 when compared with 1981; while the Midwest and the Northeast regions ended with a 0.90 and 0.92 decrease in 2003. Both logistic regression and regression-tree analyses show that a physician's age is the most important covariate for all regions, with CAPCPs in their 30s being the most prone to migrate outside the region, whereas gender is a significant factor only in older CAPCPs in the Midwest and South region. The percentage of non-white population in the county of origin is also a significant covariate for all regions. CONCLUSIONS: This study looked at the net movement of clinically active primary care physicians across census regions between 1981 and 2003, and underscores the importance of performing specific regional analysis in large countries where socio-demographical and geographical heterogeneities can be observed. Overall, 13.2% CAPCP moved from one region to another over the 22 year period: the South and West regions benefited while the Midwest region was disadvantaged by the migration flow. Age is the major determinant of migrant CAPCP. Logistic and regression tree models also show that percentage of non-white population of the county of origin is a major determinant of migration.