A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Mobile Health Apps, Family Caregivers, and Care Planning: Scoping Review.

BACKGROUND: People living with multiple chronic conditions (MCCs) face substantial challenges in planning and coordinating increasingly complex care. Family caregivers provide important assistance for people with MCCs but lack sufficient support. Caregiver apps have the potential to help by enhancing care coordination and planning among the health care team, including patients, caregivers, and clinicians. OBJECTIVE: We aim to conduct a scoping review to assess the evidence on the development and use of caregiver apps that support care planning and coordination, as well as to identify key factors (ie, needs, barriers, and facilitators) related to their use and desired caregiver app functionalities. METHODS: Papers intersecting 2 major domains, mobile health (mHealth) apps and caregivers, that were in English and published from 2015 to 2021 were included in the initial search from 6 databases and gray literature and ancestry searches. As per JBI (Joanna Briggs Institute) Scoping Review guidelines and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews), 2 authors independently screened full texts with disagreements resolved by a third author. Working in pairs, the authors extracted data using a pilot-tested JBI extraction table and compared results for consensus. RESULTS: We identified 34 papers representing 25 individual studies, including 18 (53%) pilot and feasibility studies, 13 (38%) qualitative studies, and 2 experimental or quasi-experimental studies. None of the identified studies assessed an intervention of a caregiver app for care planning and coordination for people with MCCs. We identified important caregiver needs in terms of information, support, and care coordination related to both caregiving and self-care. We compiled desired functionalities and features enabling apps to meet the care planning and care coordination needs of caregivers, in particular, the integration of caregiver roles into the electronic health record. CONCLUSIONS: Caregiver needs identified through this study can inform developers and researchers in the design and implementation of mHealth apps that integrate with the electronic health record to link caregivers, patients, and clinicians to support coordinated care for people with MCCs. In addition, this study highlights the need for more rigorous research on the use of mHealth apps to support caregivers in care planning and coordination.

Primary Care's Challenges and Responses in the Face of the COVID-19 Pandemic: Insights From AHRQ's Learning Community.

The COVID-19 pandemic dramatically disrupted health care systems and delivery in the United States. Despite emotional, psychological, logistical, and financial stress, primary care clinicians responded to the challenges that COVID-19 presented and continued to provide essential health services to their communities. As the lead federal agency for primary care research, the Agency for Healthcare Research and Quality (AHRQ) identified a need to engage and support primary care in responding to COVID-19. AHRQ initiated a learning community from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. The learning community provided a forum for participants to share learning and peer support, better understand the stressors and challenges confronting practices, ascertain needs, and identify promising solutions in response to the pandemic. We identified challenges, responses, and innovations that emerged through learning community engagement, information sharing, and dialog. We categorized these across 5 domains that reflect core areas integral to primary care delivery: patient-centeredness, clinician and practice, systems and infrastructure, and community and public health; health equity was crosscutting across all domains. The engagement of the community to identify real-time response and innovation in the context of a global pandemic has provided valuable insights to inform future research and policy, improve primary care delivery, and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.

Gender-Based Differences in Outcomes Among Resuscitated Patients With Out-of-Hospital Cardiac Arrest.

BACKGROUND: Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival. METHODS: Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants. RESULTS: Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort. CONCLUSIONS: Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.

Realizing the Dream: The Future of Primary Care Research.

Primary care research is central to the successful transformation of care delivery, providing the crucial evidence to overcome the longstanding and widespread threats and challenges to the realization of primary care's full potential. The Agency for Healthcare Research and Quality (AHRQ), as the federal agency specifically charged with conducting and supporting primary care research, plays a pivotal role in supporting the research and generating the evidence needed to advance primary care. Drawing upon decades of AHRQ-supported research studies, extensive stakeholder consultation, and a Primary Care Research Summit held in fall 2020, we discuss the primary care research central to successful primary care transformation and for realizing the vision of a high-performing US health system to effectively serve all Americans and their communities while advancing health equity.Realizing the potential of primary care will require wise investments in primary care research. Newly generated evidence needs to be rapidly incorporated into the design of the delivery system, clinical care, and community interventions. Investments in evidence-informed primary care redesign can catalyze progress to achieving the quintuple aim-improved health outcomes, increased value, better patient and clinician experience, and health equity. Primary care research can provide the evidence to help stem the twin epidemics of clinician burnout and lack of trust in the health system. Actualizing this vision will require a concerted and coordinated effort by policy makers, researchers, clinicians, and community members and a commitment to ensuring people and communities have ready access to primary care.Appeared as Annals "Online First" article.

Assessing Progress Toward the Vision of a Comprehensive, Shared Electronic Care Plan: Scoping Review.

BACKGROUND: Care plans are central to effective care delivery for people with multiple chronic conditions. But existing care plans-which typically are difficult to share across care settings and care team members-poorly serve people with multiple chronic conditions, who often receive care from numerous clinicians in multiple care settings. Comprehensive, shared electronic care (e-care) plans are dynamic electronic tools that facilitate care coordination and address the totality of health and social needs across care contexts. They have emerged as a potential way to improve care for individuals with multiple chronic conditions. OBJECTIVE: To review the landscape of e-care plans and care plan-related initiatives that could allow the creation of a comprehensive, shared e-care plan and inform a joint initiative by the National Institutes of Health and the Agency for Healthcare Research and Quality to develop e-care planning tools for people with multiple chronic conditions. METHODS: We conducted a scoping review, searching literature from 2015 to June 2020 using Scopus, Clinical Key, and PubMed; we also searched the gray literature. To identify initiatives potentially missing from this search, we interviewed expert informants. Relevant data were then identified and extracted in a structured format for data synthesis and analysis using an expanded typology of care plans adapted to our study context. The extracted data included (1) the perspective of the initiatives; (2) their scope, (3) network, and (4) context; (5) their use of open syntax standards; and (6) their use of open semantic standards. RESULTS: We identified 7 projects for e-care plans and 3 projects for health care data standards. Each project provided critical infrastructure that could be leveraged to promote the vision of a comprehensive, shared e-care plan. All the e-care plan projects supported both broad goals and specific behaviors; 1 project supported a network of professionals across clinical, community, and home-based networks; 4 projects included social determinants of health. Most projects specified an open syntax standard, but only 3 specified open semantic standards. CONCLUSIONS: A comprehensive, shared, interoperable e-care plan has the potential to greatly improve the coordination of care for individuals with multiple chronic conditions across multiple care settings. The need for such a plan is heightened in the wake of the ongoing COVID-19 pandemic. While none of the existing care plan projects meet all the criteria for an optimal e-care plan, they all provide critical infrastructure that can be leveraged as we advance toward the vision of a comprehensive, shared e-care plan. However, critical gaps must be addressed in order to achieve this vision.

Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source.

BACKGROUND: Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE: The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN: Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS: Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS: The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

Developing AHRQ's Feasibility Assessment Criteria for Wide-Scale Implementation of Patient-Centered Outcomes Research Findings.

BACKGROUND: The Agency for Healthcare Research and Quality's (AHRQ) Patient-Centered Outcomes Research (PCOR) Dissemination and Implementation (D&I) Initiative identifies and prioritizes PCOR findings that could improve health care if widely implemented. To inform PCOR implementation investments, AHRQ sought to assess feasibility of widely implementing impactful PCOR findings with good strength of evidence in clinical practice. OBJECTIVE: To develop criteria to assess the feasibility of widely implementing nominated PCOR findings. METHODS: We reviewed literature and interviewed thirteen D&I experts to identify factors affecting feasibility of implementing PCOR findings. We grouped similar factors into themes. Fourteen technical expert panel (TEP) members discussed the face-validity and relative merits of the themes and additional factors, applied themes to fictional case studies, and prioritized themes for assessing feasibility. We developed criteria and guiding questions with a 3-point Likert scale. Seven D&I experts pilot-tested the criteria using sample nominations of PCOR findings. Experts represented diverse views of implementation from federal and state government agencies, research institutions, and quality improvement and advocacy organizations. KEY RESULTS: We developed a set of three essential criteria for AHRQ to assess feasibility of widely implementing PCOR findings to be widely implementable: (1) acceptability to the implementers; (2) generalizability, adaptability, and ease of implementing with fidelity; and (3) alignment with external policies and incentives. Two supplemental criteria, (1) the presence of a plan or toolkit supporting implementation, or (2) evidence supporting implementation outside the research setting, can enhance reviewers' confidence in the intervention's feasibility. Each criterion includes "guiding questions" to parse out specific components that could be more readily assessed. CONCLUSIONS: The criteria and guiding questions are a valuable tool for informing AHRQ's investment decisions regarding implementing PCOR findings. Although developed for AHRQ's needs, the criteria may help other funders and health care organizations determine the feasibility of implementing evidence-based practices.

Ethnic differences in prediabetes incidence among immigrants to Canada: a population-based cohort study.

BACKGROUND: Prediabetes appears to be increasing worldwide. This study examined the incidence of prediabetes among immigrants to Canada of different ethnic origins and the age at which ethnic differences emerged. METHODS: We assembled a cohort of Ontario adults (≥ 20 years) with normoglycemia based on glucose testing performed between 2002 and 2011 through a single commercial laboratory database (N = 1,772,180). Immigration data were used to assign ethnicity based on country of origin, mother tongue, and surname. Individuals were followed until December 2013 for the development of prediabetes, defined using either the World Health Organization/Diabetes Canada (WHO/DC) or American Diabetes Association (ADA) thresholds. Multivariate competing risk regression models were derived to examine the effect of ethnicity and immigration status on prediabetes incidence. RESULTS: After a median follow-up of 8.0 years, 337,608 individuals developed prediabetes. Using definitions based on WHO/DC, the adjusted cumulative incidence of prediabetes was 40% (HR 1.40, CI 1.38-1.41) higher for immigrants relative to long-term Canadian residents (21.2% vs 16.0%, p < 0.001) and nearly twofold higher among South Asian than Western European immigrants (23.6%; HR 1.95, CI1.87-2.03 vs 13.1%; referent). Cumulative incidence rates based on ADA thresholds were considerably higher (47.1% and 32.3% among South Asians and Western Europeans, respectively). Ethnic differences emerged at young ages. South Asians aged 20-34 years had a similar prediabetes incidence as Europeans who were 15 years older (35-49 years), regardless of which prediabetes definition was used (WHO/DC 14.4% vs 15.7%; ADA 38.0% vs 33.0%). CONCLUSION: Prediabetes incidence was substantially higher among non-European immigrants to Canada, highlighting the need for early prevention strategies in these populations.

Prioritizing Evidence-based Interventions for Dissemination and Implementation Investments: AHRQ's Model and Experience.

BACKGROUND: The Agency for Healthcare Research and Quality (AHRQ) is mandated to implement patient-centered outcomes research (PCOR) to promote safer, higher quality care. With this goal, we developed a process to identify which evidence-based PCOR interventions merit investment in implementation. We present our process and experience to date. MATERIALS AND METHODS: AHRQ developed and applied a systematic, transparent, and stakeholder-driven process to identify, evaluate, and prioritize PCOR interventions for broad dissemination and implementation. AHRQ encouraged public nominations, and assessed them against criteria for quality of evidence, potential impact, and feasibility of successful implementation. Nominations with sufficient evidence, impact, and feasibility were considered for funding. RESULTS: Between June 2016 and June 2018, AHRQ received 35 nominations from researchers, nonprofit corporations, and federal agencies. Topics covered diverse settings, populations, and clinical areas. Twenty-eight unique PCOR interventions met minimum criteria; 16 of those had moderate to high evidence/impact and were assessed for feasibility. Fourteen topics either duplicated other efforts or lacked evidence on implementation feasibility. Two topics were prioritized for funding (cardiac rehabilitation after myocardial infarction and screening/treatment for unhealthy alcohol use). CONCLUSIONS: AHRQ developed replicable criteria, and a transparent and stakeholder-driven framework that attracted a diverse array of nominations. We identified 2 evidence-based practice interventions to improve care with sufficient evidence, impact, and feasibility to justify an AHRQ investment to scale up practice. Other funders, health systems or institutions could use or modify this process to guide prioritization for implementation.

The Care and Learn Model: a Practice and Research Model for Improving Healthcare Quality and Outcomes.

The Agency for Healthcare Research and Quality conducted internal work to formulate a model that could be used to analyze the Agency's research portfolio, identify gaps, develop and prioritize its research agenda, and evaluate its performance. Existing models described the structure and components of the healthcare system. Instead, we produced a model of two functions: caring and learning. Central to this model is the commitment to and participation of people-patients, communities, and health professionals-and the organization of systems to respond to people's problems using evidence. As a product of caring, the system produces evidence that is then used to adapt and continuously improve this response, closely integrating caring and learning. The Agency and the health services research and improvement communities can use this Care and Learn Model to frame an evidence-based understanding of vexing clinical, healthcare delivery, and population health problems and to identify targets for investment, innovation, and investigation.

Estimated Impact of US Preventive Services Task Force Recommendations on Use and Cost of Statins for Cardiovascular Disease Prevention.

BACKGROUND: US Preventive Services Task Force (USPSTF) released new recommendations on statin use for atherosclerotic cardiovascular disease (ASCVD) prevention. The Affordable Care Act (ACA) mandates USPSTF recommendations with an "A" or "B" grade receive insurance coverage without copayment. We assessed the potential impact of these recommendations. OBJECTIVE: To assess the US population meeting criteria for statin use and factors associated with use, and calculate associated costs. DESIGN AND MEASURES: We estimated 10-year ASCVD event risk scores from National Health and Nutrition Examination Survey data using Pooled Cohort Equations from the American College of Cardiology/American Heart Association and applied them to Medical Expenditure Panel Survey data. We estimated the population meeting USPSTF criteria and calculated the number of statin prescription fills and out-of-pocket and total costs. We assessed associations between statin use and sociodemographic and health characteristics and national trends in use from 1996 to 2014. PARTICIPANTS: A nationally representative sample of people aged ≥ 40 years, representing 150 million people living in the USA. KEY RESULTS: Of 26.8 million adults recommended for statins, only 41.8% were taking them. Female sex, Hispanic ethnicity, uninsured status, or living in the South was associated with lower odds of using statins. Under ACA, people with private insurance would avoid out-of-pocket cost of $9 for each generic prescription, resulting in savings of approximately $44 in annual costs. ACA's mandate for insurance coverage would result in a $193 million shift in out-of-pocket cost for statins from patients to private insurers. CONCLUSIONS: New USPSTF recommendations may result in decreased out-of-pocket costs and expanded access to statins. Previous research has shown that eliminating copayments increased adherence and decreased rates of ASCVD events without increasing overall healthcare costs. Future research will determine whether the USPSTF's recommendations will result in similar findings.

Social and Geographic Determinants of Hysterectomy in Ontario: A Population-Based Retrospective Cross-Sectional Analysis.

OBJECTIVES: This study sought to determine whether social factors (neighbourhood education and income) and geographic factors (urban or rural dwelling and local service area) are associated with hysterectomy rates, proportion of hysterectomies performed minimally invasively, and hysterectomy complication and readmission rates in Ontario. METHODS: The Canadian Institute for Health Information Discharge Abstract Database was used to perform a population-based retrospective cross-sectional study on women who had an abdominal, vaginal, and laparoscopic hysterectomy in 2007 for benign gynaecologic conditions in hospitals in Ontario, Canada. Crude and age-standardized rates of hysterectomy, proportion of hysterectomy performed minimally invasively (vaginal or laparoscopic), and rates of surgical complications were analyzed by neighbourhood educational attainment, neighbourhood income, rural or urban residency, and health service delivery area (Canadian Task Force Classification of Study Design II). RESULTS: A total of 13 511 women who underwent hysterectomy were included. Age-standardized hysterectomy rates were higher for the lowest neighbourhood educational quartile compared with the highest (relative risk [RR] 1.49; 95% CI 1.39-1.60), higher with rural compared with urban dwelling (RR 1.54; 95% CI 1.47-1.61), varied with local health service delivery area (Local Health Integration Network [LHIN]) (range 133.4-439.5 per 100 000 women), and also varied non-linearly with neighbourhood income quintile. Proportion of hysterectomies performed minimally invasively did not vary with neighbourhood education or income, were higher for rural compared with urban areas (RR 1.10; 95% CI 1.03-1.19), and varied with LHIN (range 30.0-62.9 per 100 hysterectomies). Surgical complications varied with neighbourhood educational quartile, but not with income or urban or rural residence. CONCLUSIONS: Considerable social and geographic variation exists in rates of hysterectomy in Ontario, whereas only geographic variation is seen in use of minimally invasive routes. Surgical complication rates vary only by neighbourhood education. Such findings suggest inequities in hysterectomy practice in Ontario, and there is a need to evaluate factors influencing patients' decision making, physicians' clinical and surgical practice, and health system policies to help address the observed disparities.

Unintentional Continuation of Medications Intended for Acute Illness After Hospital Discharge: A Population-Based Cohort Study.

BACKGROUND: Patients are vulnerable to medication-related errors during transitions in care. Patients discharged from acute care hospitals may be at an elevated risk for the unintentional continuation of medications prescribed to prevent or treat complications that are associated with acute illness but are no longer indicated. We sought to evaluate rates of (primary objective) and risk factors for (secondary objective) potentially unintentional medication continuation following hospitalization. METHODS: A population-based cohort study of more than one million patients 66 years of age or older who were hospitalized in Ontario, Canada, between 2003 and 2011 and followed for 1 year (2004 to 2012). We created distinct cohorts by identifying seniors not previously receiving four classes of medications typically used to treat or prevent complications of acute illness: (1) antipsychotic medications, (2) gastric acid suppressants (histamine-2 blockers and proton pump inhibitors), (3) benzodiazepines, and (4) inhaled bronchodilators and steroids. After excluding documented indications, we followed patients to ascertain whether these medications were continued after hospital discharge, and assessed risk factors for their continuation using generalized estimating equations. The primary outcome was the new dispensation of any of the selected medications within 7 days of hospital discharge. RESULTS: Prescription without documented indication occurred across all medication classes, from 12,209 patients (1.4 %) for antipsychotic medications to 34,140 patients (6.1 %) for gastric acid suppressants. Risk factors for unintentional continuation varied across medication groups, but rates were consistently higher for older patients, those with multiple comorbidities, and emergency hospitalizations. The largest absolute risk factor across all medications was a hospitalization > 7 days [OR 2.03 (95 % CI 1.94-2.11) for respiratory inhalers, 6.35 (95 % CI 5.91-6.82) for antipsychotic medications]. These medications were often continued at 1 year of follow-up, and accounted for a total additional medication cost of over CAD$18 million for the study population. CONCLUSION: Discharged patients are at risk of being prescribed and dispensed medications that are typically intended to prevent or treat complications of acute illness, despite having no documented indication for chronic use.

Using decision trees for measuring gender equity in the timing of angiography in patients with acute coronary syndrome: a novel approach to equity analysis.

BACKGROUND: Methods to measure or quantify equity in health care remain scarce, if not difficult to interpret. A novel method to measure health equity is presented, applied to gender health equity, and illustrated with an example of timing of angiography in patients following a hospital admission for an acute coronary syndrome. METHODS: Linked administrative hospital discharge and survey data was used to identify a retrospective cohort of patients hospitalized with Acute Coronary Syndrome (ACS) between 2002 and 2008 who also responded to the Canadian Community Health Survey (CCHS), was analyzed using decision trees to determine whether gender impacted the delay to angiography following an ACS. RESULTS: Defining a delay to angiography as 1 day or more, resulted in a non-significant difference in an equity score of 0.14 for women and 0.12 for men, where 0 and 1 represents perfect equity and inequity respectively. Using 2 and 3 day delays as a secondary outcome resulted in women and men producing scores of 0.19 and 0.17 for a 2 day delay and 0.22 and 0.23 for a 3 day delay. CONCLUSIONS: A technique developed expressly for measuring equity suggests that men and women in Ontario receive equitable care in access to angiography with respect to timeliness following an ACS.

Single item measures of self-rated mental health: a scoping review.

BACKGROUND: A single-item measure of self-rated mental health (SRMH) is being used increasingly in health research and population health surveys. The item asks respondents to rate their mental health on a five-point scale from excellent to poor. This scoping study presents the first known review of the SRMH literature. METHODS: Electronic databases of Medline, CINAHL, PsycINFO, EMBASE and Cochrane Reviews were searched using keywords. The databases were also searched using the titles of surveys known to include the SRMH single item. The search was supplemented by manually searching the bibliographic sections of the included studies. Two independent reviewers coded articles for inclusion or exclusion based on whether articles included SRMH. Each study was coded by theme and data were extracted about study design, sample, variables, and results. RESULTS: Fifty-seven studies included SRMH. SRMH correlated moderately with the following mental health scales: Kessler Psychological Distress Scale, Patient Health Questionnaire, mental health subscales of the Short-Form Health Status Survey, Behaviour and Symptom Identification Scale, and World Mental Health Clinical Diagnostic Interview Schedule. However, responses to this item may differ across racial and ethnic groups. Poor SRMH was associated with poor self-rated health, physical health problems, increased health service utilization and less likelihood of being satisfied with mental health services. Poor or fair SRMH was also associated with social determinants of health, such as low socioeconomic position, weak social connections and neighbourhood stressors. Synthesis of this literature provides important information about the relationships SRMH has with other variables. CONCLUSIONS: SRMH is associated with multi-item measures of mental health, self-rated health, health problems, service utilization, and service satisfaction. Given these relationships and its use in epidemiologic surveys, SRMH should continue to be assessed as a population health measure. More studies need to examine relationships between SRMH and clinical mental illnesses. Longitudinal analyses should look at whether SRMH is predictive of future mental health problems.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis.

STUDY QUESTION: What are the rates of serious cardiovascular events in those who undergo primary total joint arthroplasty (TJA) compared with those who do not within three years of initial assessment? SUMMARY ANSWER: Undergoing elective primary TJA within three years of initial assessment was associated with a significant 12.4% absolute reduction in subsequent risk of serious cardiovascular events. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Osteoarthritis is associated with increased mortality, particularly secondary to cardiovascular disease, with the risk for mortality proportional to the degree of disability secondary to the arthritis. This study suggests that management of hip or knee osteoarthritis with arthroplasty decreases the risk for subsequent serious cardiovascular events.

Beyond barriers in studying disparities in women's access to health services in Ontario, Canada: a qualitative metasynthesis.

Women live within complex and differing social, economic, and environmental circumstances that influence options to seek health care. In this article we report on a metasynthesis of qualitative research concerning access disparities for women in the Canadian province of Ontario, where there is a publicly funded health care system. We took a metastudy approach to analysis of results from 35 relevant qualitative articles to understand the conditions and conceptualizations of women's inequitable access to health care. The articles' authors attributed access disparities to myriad barriers. We focused our analysis on these barriers to understand the contributing social and political forces. We found that four major, sometimes countervailing, forces shaped access to health care: (a) contextual conditions, (b) constraints, (c) barriers, and (d) deterrents. Complex convergences of these forces acted to push, pull, obstruct, and/or repel women as they sought health care, resulting in different patterns of inequitable access.