Does regulating private long-term care facilities lead to better care? A study from Quebec, Canada.

OBJECTIVE: In the province of Quebec, Canada, long-term residential care is provided by two types of facilities: publicly funded accredited facilities and privately owned facilities in which care is privately financed and delivered. Following evidence that private facilities were delivering inadequate care, the provincial government decided to regulate this industry. We assessed the impact of regulation on care quality by comparing quality assessments made before and after regulation. In both periods, public facilities served as a comparison group. DESIGN: A cross-sectional study conducted in 2010-12 that incorporates data collected in 1995-2000. SETTINGS: Random samples of private and public facilities from two regions of Quebec. PARTICIPANTS: Random samples of disabled residents aged 65 years and over. In total, 451 residents from 145 care settings assessed in 1995-2000 were compared with 329 residents from 102 care settings assessed in 2010-12. INTERVENTION: Regulation introduced by the province in 2005, effective February 2007. MAIN OUTCOME MEASURE: Quality of care measured with the QUALCARE Scale. RESULTS: After regulation, fewer small-size facilities were in operation in the private market. Between the two study periods, the proportion of residents with severe disabilities decreased in private facilities whereas it remained >80% in their public counterparts. Meanwhile, quality of care improved significantly in private facilities, while worsening in their public counterparts, even after controlling for confounding. CONCLUSIONS: The private industry now provides better care to its residents. Improvement in care quality likely results in part from the closure of small homes and change in resident case-mix.

Fertilizer Rate-Associated Increase in Foliar Jasmonate Burst Observed in Wounded Arabidopsis thaliana Leaves is Attenuated at eCO2.

The predicted future increase in tropospheric carbon dioxide (CO2) levels will have major effects on C3 plants and their interactions with other organisms in the biosphere. In response to attack by chewing arthropod herbivores or nectrotrophic pathogens, many plants mount a rapid and intense increase in jasmonate-related phytohormones that results in a robust defense response; however, previous studies have shown that C3 plants grown at elevated CO2 may have lower induced jasmonate levels, particularly in well nitrate-fertilized plants. Given the relationship between atmospheric CO2, photorespiration, cellular reductant and redox status, nitrogen assimilation and phytohormones, we compared wound-induced responses of the C3 plant Arabidopsis thaliana. These plants were fertilized at two different rates (1 or 10 mM) with nitrate or ammonium and grown at ambient or elevated CO2. In response to artificial wounding, an increase in cellular oxidative status leads to a strong increase in jasmonate phytohormones. At ambient CO2, increased oxidative state of nitrate-fertilized plants leads to a robust 7-iso-jasmonyl-L-isoleucine increase; however, the strong fertilizer rate-associated increase is alleviated in plants grown at elevated CO2. As well, the changes in ascorbate in response to wounding and wound-induced salicylic acid levels may also contribute to the suppression of the jasmonate burst. Understanding the mechanism underlying the attenuation of the jasmonate burst at elevated CO2 has important implications for fertilization strategies under future predicted climatic conditions.

[Is merging organizations the solution to service integration?]. / L'intégration des services passe-t-elle par des fusions d'établissements?

Organizational models inherited from the time when institutionalizing patients was common practice are now obsolete. Service coordination, undergone earlier within a same institution, is now governed by professionnals linked to various organizations and different settings. One of the difficulties of integration of these services is that contributing organizations often continue to operate individually, consequently going against the pursued goal. The solution most often proposed to counter this compartimentalization consists in reinforcing integration of organizations, which will in time favor integration of various services. One of the ways to realize this organizational integration is to reduce the number of existing organizations, by merging for example, a certain number of them. It is this path of hierarchical organization that the Québec health care system has taken during the 1990. Other paths that of networking have also been experienced during the same period. To judge of the relevance of these options, the authors propose a reversal of the dominating perspective according to which service integration necessarily pass through installing mecanisms of organizational integration. Withought minimizing the importance of such mecanisms, the authors put forth that integration of services commands first and foremost collaboration between professional health workers. Through this angle, the relevance of an organizational integration model depends on the impact it will have on the capacity and willingness of health workers to work in a concerted way. The authors submit that the fact of giving to a sole authority the govern of existing organizations is not the panacea some would like to believe.

Mergers and integrated care: the Quebec experience.

As a researcher, I have studied the efforts to increase the integration of health and social services in Quebec, as well as the mergers in the Quebec healthcare system. These mergers have often been presented as a necessary transition to break down the silos that compartmentalize the services dispensed by various organisations. A review of the studies about mergers and integrated care projects in the Quebec healthcare system, since its inception, show that mergers cannot facilitate integrated care unless they are desired and represent for all of the actors involved an appropriate way to deal with service organisation problems. Otherwise, mergers impede integrated care by creating increased bureaucratisation and standardisation and by triggering conflicts and mistrust among the staff of the merged organisations. It is then preferable to let local actors select the most appropriate organisational integration model for their specific context and offer them resources and incentives to cooperate.