The vitamin A ester retinyl propionate has a unique metabolic profile and higher retinoid-related bioactivity over retinol and retinyl palmitate in human skin models.

Human skin is exposed daily to environmental stressors, which cause acute damage and inflammation. Over time, this leads to morphological and visual appearance changes associated with premature ageing. Topical vitamin A derivatives such as retinol (ROL), retinyl palmitate (RPalm) and retinyl propionate (RP) have been used to reverse these changes and improve the appearance of skin. This study investigated a stoichiometric comparison of these retinoids using in vitro and ex vivo skin models. Skin biopsies were treated topically to compare skin penetration and metabolism. Treated keratinocytes were evaluated for transcriptomics profiling and hyaluronic acid (HA) synthesis and treated 3D epidermal skin equivalents were stained for epidermal thickness, Ki67 and filaggrin. A retinoic acid receptor-alpha (RARα) reporter cell line was used to compare retinoid activation levels. Results from ex vivo skin found that RP and ROL have higher penetration levels compared with RPalm. RP is metabolized primarily into ROL in the viable epidermis and dermis whereas ROL is esterified into RPalm and metabolized into the inactive retinoid 14-hydroxy-4,14-retro-retinol (14-HRR). RP treatment yielded higher RARα activation and HA synthesis levels than ROL whereas RPalm had a null effect. In keratinocytes, RP and ROL stimulated similar gene expression patterns and pathway theme profiles. In conclusion, RP and ROL show a similar response directionality whereas RPalm response was inconsistent. Additionally, RP has a consistently higher magnitude of response compared with ROL or RPalm.

Improving hospital safety for patients with chronic kidney disease: a mixed methods study.

BACKGROUND: People living with chronic kidney disease (CKD) require complex medical management and may be frequently hospitalized. Patient safety incidents during hospitalization can result in serious complications which may negatively affect health outcomes. There has been limited examination of how these patients perceive their own safety. OBJECTIVES: This study compared the safety perceptions of patients hospitalized with CKD using two approaches: (a) the Patient Measure of Safety (PMOS) questionnaire and (b) qualitative interviews. The study objectives were to: (1) assess concordance between qualitative and quantitative data on safety perceptions and (2) better understand safety as perceived by study participants. METHODS: A cross-sectional convergent mixed methods design was used. Integration at the reporting level occurred by weaving together patient narratives and survey domains through the use of a joint display. Interview data were merged with results of the PMOS on a case-by-case basis for analysis to assess for concordance or discordance between these approaches to safety data collection. RESULTS: Of the 30 inpatients with CKD, almost one quarter (23.3 %) of participants reported low levels of perceived safety in hospitals. Four major themes emerged from the interviews: receiving safe care; expecting to be taken care of; expecting to be cared for; and reporting safety concerns. Suboptimal communication, delays in care and concerns about technical aspects of care were common to both forms of data collection. Concordance was noted between qualitative and quantitative data with respect to communication/teamwork, respect and dignity, staff roles, and ward type/lay-out. While interviews allowed for participants to share specific concerns related to safety about quality of interpersonal interactions, use of the questionnaire alone did not capture this concern. CONCLUSIONS: Safety issues are a concern for in-patients with CKD. Both quantitative and qualitative approaches provided important and complementary insights into these issues. Narratives were mostly concordant with questionnaire scores. Findings from this mixed methods study suggest that communication, interpersonal interactions, and delays in care were more concerning for participants than technical aspects of care. Eliciting the concerns of people with CKD in a systematic fashion, either through interviews or a survey, ensures that hospital safety improvement efforts focus on issues important to patients.

"I just have to take it" - patient safety in acute care: perspectives and experiences of patients with chronic kidney disease.

BACKGROUND: Frequent hospitalizations and dependency on technology and providers place individuals with chronic kidney disease (CKD) at high risk for multiple safety events. Threats to their safety may be physical, emotional, or psychological. This study sought to explore patient safety from the perspectives and experiences of patients with CKD in acute care settings, and to describe willingness to report incidents utilizing an existing safety reporting system. METHODS: This study was conducted using a qualitative interpretive descriptive approach. Face to face interviews were conducted with 30 participants at their bedside during their current hospital admission. The majority of the participants were 50 years or older, of which 75% had a confirmed diagnosis of end stage renal disease with the remainder at stages 3 or 4 of CKD. Eighty percent of the participants were either on hemo- or peritoneal dialysis. RESULTS: Participants expected to receive safe care, to be taken care of, and to be cared for. Safety threats included: sharing a room with patients who were on precautions; lack of cleanliness; and roommates perceived to be threatening. The concepts of being taken care of and being cared for constituted the safety threats identified within the interpersonal environment. Participants felt taken care of when their physical needs are met and cared for when their psychological and emotional needs are met. There was a general lack of awareness of the presence of a safety reporting system that was to be accessible to patients and families by telephone. There was also an overall unwillingness to report perceived safety incidents, although participants did distinguish between speaking up and reporting. CONCLUSIONS: A key finding was the unwillingness to report incidents using the safety reporting system. Fear of reprisals was the most significant reporting impediment expressed. Actively inviting patients to speak up may be more effective when combined with a psychologically safe environment in order to encourage the involvement of patients in patient safety. System-wide organizational changes may be necessary to mitigate emotional and physical harm for this client population.

Qualitative exploration of the education and skill needs of community pharmacists in Saskatoon concerning substance use disorder.

BACKGROUND: Identifying the skills and educational needs of community pharmacists concerning addiction is critical to improving the services provided for people who suffer from addiction disease (PWSAD). METHODS: Eleven one-to-one semi-structured interviews were conducted with community pharmacists practising in the Saskatoon Health Region, Canada. The interviews were recorded and transcribed verbatim and verified with the participants. Thematic analysis was employed to analyze the transcripts. RESULTS: Four major themes were identified: 1) effect of the work setting on pharmacists' encounters with PWSAD, 2) pharmacists' knowledge of key aspects of addiction, 3) level of support within the health care system, and 4) educational and training needs. CONCLUSION: Participants indicated that a lack of knowledge and training were major hindrances to improving the quality of the services provided to people who suffer from addiction disease. Additional practicum experience at the undergraduate level and interprofessional interactive educational sessions at the continuing educational level were key recommendations emerging from the study.

Assessing the implementation processes of a large-scale, multi-year quality improvement initiative: survey of health care providers.

BACKGROUND: Beginning in 2012, Lean was introduced to improve health care quality and promote patient-centredness throughout the province of Saskatchewan, Canada with the aim of producing coordinated, system-wide change. Significant investments have been made in training and implementation, although limited evaluation of the outcomes have been reported. In order to better understand the complex influences that make innovations such as Lean "workable" in practice, Normalization Process Theory guided this study. The objectives of the study were to: a) evaluate the implementation processes associated with Lean implementation in the Saskatchewan health care system from the perspectives of health care professionals; and b) identify demographic, training and role variables associated with normalization of Lean. METHODS: Licensed health care professionals were invited through their professional associations to complete a cross-sectional, modified, online version of the NoMAD questionnaire in March, 2016. Analysis was based on 1032 completed surveys. Descriptive and univariate analyses were conducted. Multivariate multinomial regressions were used to quantify the associations between five NoMAD items representing the four Normalization Process Theory constructs (coherence, cognitive participation, collective action and reflexive monitoring). RESULTS: More than 75% of respondents indicated that neither sufficient training nor resources (collective action) had been made available to them for the implementation of Lean. Compared to other providers, nurses were more likely to report that Lean increased their workload. Significant differences in responses were evident between: leaders vs. direct care providers; nurses vs. other health professionals; and providers who reported increased workload as a result of Lean vs. those who did not. There were no associations between responses to normalization construct proxy items and: completion of introductory Lean training; participation in Lean activities; age group; years of professional experience; or employment status (full-time or part-time). Lean leader training was positively associated with proxy items reflecting coherence, cognitive participation and reflexive monitoring. CONCLUSIONS: From the perspectives of the cross-section of health care professionals responding to this survey, major gaps remain in embedding Lean into healthcare. Strategies that address the challenges faced by nurses and direct care providers, in particular, are needed if intended goals are to be achieved.

Lean and leadership practices: development of an initial realist program theory.

BACKGROUND: Lean as a management system has been increasingly adopted in health care settings in an effort to enhance quality, capacity and safety, while simultaneously containing or reducing costs. The Ministry of Health in the province of Saskatchewan, Canada has made a multi-million dollar investment in Lean initiatives to create "better health, better value, better care, and better teams", affording a unique opportunity to advance our understanding of the way in which Lean philosophy, principles and tools work in health care. METHODS: In order to address the questions, "What changes in leadership practices are associated with the implementation of Lean?" and "When leadership practices change, how do the changed practices contribute to subsequent outcomes?", we used a qualitative, multi-stage approach to work towards developing an initial realist program theory. We describe the implications of realist assumptions for evaluation of this Lean initiative. Formal theories including Normalization Process Theory, Theories of Double Loop and Organization Leaning and the Theory of Cognitive Dissonance help understand this initial rough program theory. Data collection included: key informant consultation; a stakeholder workshop; documentary review; 26 audiotaped and transcribed interviews with health region personnel; and team discussions. RESULTS: A set of seven initial hypotheses regarding the manner in which Lean changes leadership practices were developed from our data. We hypothesized that Lean, as implemented in this particular setting, changes leadership practices in the following ways. Lean: a) aligns the aims and objectives of health regions; b) authorizes attention and resources to quality improvement and change management c) provides an integrated set of tools for particular tasks; d) changes leaders' attitudes or beliefs about appropriate leadership and management styles and behaviors; e) demands increased levels of expertise, accountability and commitment from leaders; f) measures and uses data effectively to identify actual and relevant local problems and the root causes of those problems; and g) creates or supports a 'learning organization' culture. CONCLUSIONS: This study has generated initial hypotheses and realist program theory that can form the basis for future evaluation of Lean initiatives. Developing leadership capacity and culture is theorized to be a necessary precursor to other systemic and observable changes arising from Lean initiatives.

"The largest Lean transformation in the world": the implementation and evaluation of lean in Saskatchewan healthcare.

The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.

The contribution of work environment to nurses' assessments of the quality of patient care.

The quality of patient care was found to be significantly correlated with work environment measures in a quasi-experimental study in the Saskatoon Health Region. Since first line supervisors face multiple pressures in organizing the work of their units, they need to be supported by senior leadership for continuity in instilling a common purpose and shared values to the patient care staff. The role of supervision and leadership is crucial in strategically managing the human, financial and technical resources in our healthcare system, especially when such resources are likely to remain limited.

Refinement of the Peroxidase Peptide Reactivity Assay and Prediction Model for Assessing Skin Sensitization Potential.

A peptide reactivity assay with an activation component was developed for use in screening chemicals for skin sensitization potential. A horseradish peroxidase-hydrogen peroxide (HRP/P) oxidation system was incorporated into the assay for characterizing reactivity of hapten and pre-/prohapten sensitizers. The assay, named the Peroxidase Peptide Reactivity Assay (PPRA) had a predictive accuracy of 83% (relative to the local lymph node assay) with the original protocol and prediction model. However, apparent false positives attributed to cysteine depletion at relatively high chemical concentrations and, for some chemicals expected to react with the -NH2 group of lysine, little to no depletion of the lysine peptide were observed. To improve the PPRA, cysteine peptide reactions with and without HRP/P were modified by increasing the number of test concentrations and refining their range. In addition, removal of DL-dithiothreitol from the reaction without HRP/P increased cysteine depletion and improved detection of reactive aldehydes and thiazolines without compromising the assay's ability to detect prohaptens. Modification of the lysine reaction mixture by changing the buffer from 0.1 M ammonium acetate buffer (pH 10.2) to 0.1 M phosphate buffer (pH 7.4) and increasing the level of organic solvent from 1% to 25% resulted in increased lysine depletion for known lysine reactive chemicals. Refinement of the prediction model improved the sensitivity, specificity, and accuracy for hazard identification. These changes resulted in significant improvement of the PPRA making it is a reliable method for predicting the skin sensitization potential of all chemicals, including pre-/prohaptens and directly reactive haptens.

Association Between Prerequisites and Academic Success at a Canadian University's Pharmacy Program.

Objective. To identify pharmacy prerequisites associated with academic success in the current Bachelor of Science in Pharmacy (BSP) program and anticipated success in the planned Doctor of Pharmacy (PharmD) program at the University of Saskatchewan. Methods. Statistical analysis was conducted on retrospective data of the grades of 1,236 pharmacy students admitted from 2002 to 2015. BSP success was calculated using a weighted average of all required courses within the BSP program. Anticipated success in the PharmD program was calculated from the BSP grades after excluding PharmD prerequisites currently part of the BSP. Models of BSP and PharmD prerequisites and demographic variables associated with pharmacy program success were constructed using stepwise and forced linear regression. Results. For the current BSP program, modelling explained more than half of academic success in year 1. Explicable variance declined each year, explaining less than 20% in year 4. After removing PharmD prerequisites from the program, the BSP prerequisites associated with success were the same as the first model but explained less of the variance in years 1 and 2. Using both BSP and the new PharmD prerequisites explained nearly three-quarters of the variance in year 1 for the remaining pharmacy courses. Explicable variance increased slightly in year 2, declined to approximately two-thirds in year 3 and just over one-half in year 4. Conclusion. Consistency of instructor and course content, along with instructional design and higher-level learning, may explain these stronger associations for the PharmD prerequisites.

Atenolol as initial antihypertensive therapy: an observational study comparing first-line agents.

OBJECTIVE: The role of atenolol in the management of patients with hypertension is currently under scrutiny. Our aim was to evaluate the real-world consequences of recent clinical trial findings. METHODS: We conducted a retrospective, cohort study using linked administrative data from the province of Saskatchewan, Canada. Eligible subjects were first-ever users of antihypertensive medications between 1 January 1994 and 31 December 2003 and were grouped into four cohorts: atenolol, angiotensin-converting enzyme inhibitors (ACEI), thiazide diuretics, or calcium antagonists. Patients remained eligible during monotherapy only. RESULTS: We identified 19 249 eligible individuals (mean age 60.6 years) who were followed for a mean of 2.3 years (SD 2.0). The rate of myocardial infarction, unstable angina, stroke, or death occurred in similar frequencies among all cohorts: atenolol (2.3%), ACEI (3.6%), thiazide diuretics (2.9%), and calcium antagonists (3.9%). After adjustment for potential confounders, atenolol therapy was not associated with higher event rates than the other first-line agents, with hazard ratios ranging between 1.03 [95% confidence intervals (CI) 0.72-1.46] and 1.24 (95% CI 0.91-1.68) for all cohorts compared with atenolol. Similar results were observed upon stratifying the sample into subjects above and below 60 years of age. CONCLUSION: The low event rates for all cohorts suggest that atenolol has not been associated with a significant burden of cardiovascular morbidity or mortality in its traditional role for uncomplicated hypertension. Further study is needed to identify the specific types of patients that should avoid atenolol as an antihypertensive agent.

Perceptions of Saskatchewan community pharmacists regarding a prior-authorization program.

BACKGROUND: In 1999, Saskatchewan Health authorized pharmacists to initiate exception drug status (EDS) requests, also known as prior authorization (PA). Before 1999, only those licensed to prescribe medications were authorized to initiate EDS requests. A pharmacist who submits an EDS request must obtain a patient diagnosis from the physician or agent of the physician; a diagnosis presented by the patient is insufficient. OBJECTIVE: To obtain pharmacists' opinions about the benefits of the PA program of the Saskatchewan drug Plan and to identify factors associated with pharmacist-initiated EDS requests. METHODS: A census survey of community pharmacy managers was conducted via a self-administered postal questionnaire in the province of Saskatchewan, Canada, in the fall of 2004. The survey questionnaire was addressed to pharmacy managers, some of whom may have delegated the response to a staff pharmacist. Pharmacy managers or their delegates were asked to respond on behalf of all pharmacists in their pharmacies. RESULTS: A response rate of 82.6% was achieved (275/333). A majority of respondents agreed that the province's PA program (EDS) benefited patients (87.3%) and the Saskatchewan drug Plan (82.5%), whereas only 33.4% of respondents agreed that the EDS program benefited pharmacists. Pharmacists' ability to obtain the requisite information (87.6%) and to contact the prescribing physician (87.3%), as well as patient-centered concerns such as the patient's ability to pay for the prescription (85.1%), were the most important factors. The time required by the pharmacist to initiate the request was not important relative to other factors. community pharmacies reported receipt of an average of 36.4 prescriptions for restricted and nonformulary drugs per week, of which 22 were submitted for PA coverage, 17 by the pharmacy and 5 by the pharmacy at the request of the physician. CONCLUSION: The results of this study indicate that community pharmacists in Saskatchewan acknowledge that the EdS process is beneficial for their patients. However, pharmacists are burdened by an administrative process in which necessary information, particularly the patient diagnosis, is not readily available.

Consumer expectations of nonprescription medications according to location of sale.

OBJECTIVE: To determine whether the public has different expectations of nonprescription medications based on location of sale. DESIGN: Cross-sectional, descriptive. SETTING: Saskatoon, Saskatchewan, Canada, during the summer of 2003. PARTICIPANTS: 2,102 randomly selected citizens. INTERVENTION: Mail survey. MAIN OUTCOME MEASURES: Differences in expectations for potency, safety, adverse effects, effectiveness, and package information of products sold in pharmacies versus convenience stores. RESULTS: The response rate was 57.2%. Most participants (81.2%) were aware that nonprescription medications could be purchased in convenience stores, but far fewer (42.3%) had done so. As one potential resource during purchases, pharmacists were held in reasonably high regard. Expectations with the greatest difference were of a merchandising nature. Respondents expected pharmacies to have a better quality and selection of products and lower prices. For drug-related attributes, differences were minimal but statistically significant. CONCLUSION: Location of sale does not appear to have any practical influence on consumer expectations of the drug-related attributes of nonprescription medications. Buyers of such products expect similar properties to be present regardless of location.

Factors associated with career satisfaction among general practitioners in Canada.

INTRODUCTION: There are important differences in rural, regional and urban general practice environments. The purpose of this study was to articulate models that explain career satisfaction among general practitioners (GPs) in these practice environments. METHODS: Of 4958 eligible physicians across Canada, 2810 (56.7%) completed a 12- page survey between January and March 2004, from whom a total of 256 GPs in rural, regional and urban communities were selected. Response bias was checked and found to be negligible. We used hierarchical regression analysis to record cumulative R2, standardized beta and significance levels as each predictor was entered. We applied weighting factors to reflect the actual physician population in Canada. RESULTS: The models explained 88.5% of the variance in career satisfaction for GPs in small towns, 88.9% for GPs in regional communities and 86.3% for GPs in urban cities. The explanatory variables consisted of distress and coping, role in community activities, the quality of health care services and access to them, intrinsic and extrinsic rewards, workload and organizational structure. CONCLUSION: Career satisfaction for small-town doctors is associated with being able to cope with stress in handling a wide variety of clinical conditions, largely on their own, but with effective collaboration from physicians in larger centres. Rural GPs also enjoy academic responsibilities. Satisfaction for GPs in regional communities also depends on coping with stress and the ability to maintain an efficiently operating set of secondary- level health services in their community. Satisfaction for urban GPs is associated with collegiality, which dampens stress, and access to a full range of health services, including community, hospital, mental health and rehabilitation services. Career satisfaction for all GPs is associated with equity, manageable workloads and effective practice management; however, all of these professional issues contribute, in small increments, to satisfaction.

The Pharmacological Profile of a Novel Highly Potent Bisphosphonate, OX14 (1-Fluoro-2-(Imidazo-[1,2-α]Pyridin-3-yl)-Ethyl-Bisphosphonate).

Bisphosphonates are widely used in the treatment of clinical disorders characterized by increased bone resorption, including osteoporosis, Paget's disease, and the skeletal complications of malignancy. The antiresorptive potency of the nitrogen-containing bisphosphonates on bone in vivo is now recognized to depend upon two key properties, namely mineral binding affinity and inhibitory activity on farnesyl pyrophosphate synthase (FPPS), and these properties vary independently of each other in individual bisphosphonates. The better understanding of structure activity relationships among the bisphosphonates has enabled us to design a series of novel bisphosphonates with a range of mineral binding properties and antiresorptive potencies. Among these is a highly potent bisphosphonate, 1-fluoro-2-(imidazo-[1,2 alpha]pyridin-3-yl)-ethyl-bisphosphonate, also known as OX14, which is a strong inhibitor of FPPS, but has lower binding affinity for bone mineral than most of the commonly studied bisphosphonates. The aim of this work was to characterize OX14 pharmacologically in relation to several of the bisphosphonates currently used clinically. When OX14 was compared to zoledronate (ZOL), risedronate (RIS), and minodronate (MIN), it was as potent at inhibiting FPPS in vitro but had significantly lower binding affinity to hydroxyapatite (HAP) columns than ALN, ZOL, RIS, and MIN. When injected i.v. into growing Sprague Dawley rats, OX14 was excreted into the urine to a greater extent than the other bisphosphonates, indicating reduced short-term skeletal uptake and retention. In studies in both Sprague Dawley rats and C57BL/6J mice, OX14 inhibited bone resorption, with an antiresorptive potency equivalent to or greater than the comparator bisphosphonates. In the JJN3-NSG murine model of myeloma-induced bone disease, OX14 significantly prevented the formation of osteolytic lesions (p < 0.05). In summary, OX14 is a new, highly potent bisphosphonate with lower bone binding affinity than other clinically relevant bisphosphonates. This renders OX14 an interesting potential candidate for further development for its potential skeletal and nonskeletal benefits. © 2017 American Society for Bone and Mineral Research.

The effects of distress and the dimensions of coping strategies on physicians' satisfaction with competence.

OBJECTIVES: The purposes of this study were to (1) articulate the dimensions of Coping strategies used by physicians, and (2) determine whether Coping strategies alleviated Distress and enhanced Satisfaction with Competence. METHODS: Comprehensive questionnaires on factors associated with Satisfaction with Competence were sent to a stratified sample of 5300 physicians across Canada. The response rate was 57% with negligible bias. Factor analysis was used to articulate the dimensions of Coping strategies. The classic Baron and Kenny regression series was used to establish whether Coping mediates the effects of Distress on Satisfaction with Competence. Years in Practice, Self-Reported Health, and Duties of Physicians were control factors. RESULTS: A reliable 15-item measure of Coping was confirmed (α = .76) with four reasonably reliable dimensions: Collegiality (α = .80), Attitude (α = .63), Managing Work (α = .60), and Self-Care (α = .62). Physicians reported a mean Satisfaction with Competence of (M = 4.26 out of 6.0, standard deviation (SD) = 0.64) with General practitioners reporting slightly lower levels of Satisfaction with Competence than average. Conversely, chronic disease, clinical, and procedural specialists reported higher levels of Satisfaction with Competence. The mean Distress level for all physicians was (M = 3.66 out of 7.0, SD = 0.93). The highest levels of distress were reported by emergency physicians, general practitioners, and surgeons. Clinical specialists, anesthesiologists, and psychiatrists reported the lowest levels of distress. Physicians reported (M = 4.48 out of 7.0, SD = 0.78) as the mean level of Coping ability with clinical specialists and general practitioners reporting lower than average abilities to cope. Laboratory and chronic care specialists reported greater than average coping abilities. Regression analyses established Coping as a mediator of Distress which predicted physicians' Satisfaction with Competence. CONCLUSION: Four groups of coping strategies were significant in relieving the pressures of work: (1) Collegiality, (2) Self-Care, (3) Managing Work, and (4) Positive Attitude.

Cardiovascular morbidity associated with nonadherence to statin therapy.

STUDY OBJECTIVE: To measure the extent of cardiovascular morbidity associated with nonadherence to 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy. DESIGN: Retrospective cohort study. DATA SOURCE: Linked administrative health databases in Saskatchewan, Canada. PATIENTS: A total of 1221 patients aged 30-70 years who received a new prescription for a statin drug between 1994 and 2001, within 1 year of their first cardiovascular event (i.e., myocardial infarction, unstable angina, ischemic stroke, percutaneous transluminal coronary angioplasty [PTCA], or coronary artery bypass graft [CABG]). MEASUREMENTS AND MAIN RESULTS: Adherence was measured by the fill frequency (number of prescriptions filled during the observation period divided by months of observation). Patients with a fill frequency of 80% or greater were classified as adherent (661 patients); those with a fill frequency of 60% or less were classified as nonadherent (395 patients). The remaining 165 patients who had adherence rates of 61-79% were excluded from the analysis. The primary end point included a composite of myocardial infarction, unstable angina, PTCA, CABG, and death. Among 1056 patients, adherence was not associated with a reduction of the primary end point. However, patients in the adherent group were half as likely to experience a subsequent myocardial infarction as the patients in the nonadherent group (hazard ratio [HR] 0.45, 95% confidence interval [CI] 0.20-0.99, p=0.047). In patients younger than 65 years (both adherent and not), the associated reduction in myocardial infarction was even more profound (HR 0.14, 95% CI 0.04-0.46, p=0.001) and was accompanied by a trend for a lower frequency of unstable angina (HR 0.37, 95% CI 0.13-1.03, p=0.06). In patients 65 years or older (301 patients), adherence was not associated with significant changes in cardiovascular end points. CONCLUSION: A detectable excess of cardiovascular morbidity appears to be associated with nonadherence to statin therapy. Our analysis suggests that many occurrences of myocardial infarction could be prevented with improvements in adherence. Larger studies are necessary to determine the association between adherence and other cardiovascular end points.

Developing a scale for measuring professional equity among Canadian physicians.

This paper reports on progress made in defining and measuring the concept of professional equity through the development of a summative measure of professional equity and three of its components: financial, intrinsic and recognition equity. The study sample consisted of a stratified sample of 8375 Canadian physicians with usable responses from 2749 (32.8%). Following preliminary components analysis, items were grouped into constructs. Reliability of the constructs was then determined using Cronbach's alpha and total inter-item correlations followed by confirmatory factor analysis. A summary scale using all 15 equity items yielded a reliability: Cronbach's alpha=0.86. The sub-scales reliabilities were: financial equity (Cronbach's alpha=0.91); intrinsic equity (Cronbach's alpha=0.86); and recognition equity (Cronbach's alpha=0.70). The professional equity measures reported are therefore capable of assessing different aspects of equity and represent an advance over more general effort-reward scales or those that only measure the range of rewards.

Adherence to statins, beta-blockers and angiotensin-converting enzyme inhibitors following a first cardiovascular event: a retrospective cohort study.

BACKGROUND: Population studies of statin adherence are generally restricted to one to two years of follow-up and do not analyze adherence to other drugs. OBJECTIVES: To report long-term adherence rates for statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers in patients who recently experienced a first cardiovascular event. METHODS: Linked administrative databases in the province of Saskatchewan were used in this retrospective cohort study. Eligible patients received a new statin prescription within one year of their first cardiovascular event between 1994 and 2001. Adherence to statins, beta-blockers and ACE inhibitors was assessed from the first statin prescription to a subsequent cardiovascular event. RESULTS: Of 1221 eligible patients, the proportion of patients adherent to statin medications dropped to 60.3% at one year and 48.8% at five years. The decline in the proportion of adherent patients was most notable during the first two years (100% to 53.7%). Several factors were associated with statin adherence, including age (P = 0.012), number of physician service days (P = 0.037), chronic disease score (P = 0.032), beta-blocker adherence (P < 0.001) and ACE inhibitor adherence (P < 0.001). Adherence to beta-blockers and ACE inhibitors was very similar to adherence to statin medications at each year of follow-up. CONCLUSIONS: Patients who exhibit optimal adherence over one to two years after their initial cardiovascular event generally remain adherent over subsequent years. Also, adherence to beta-blockers and ACE inhibitors is significantly associated with statin adherence in a subset of patients; however, overall adherence to all three drugs was similarly poor.

Modeling factors explaining physicians' satisfaction with competence.

OBJECTIVE: Attention to physician wellness has increased as medical practice gains in complexity. Physician satisfaction with practice is critical for quality of care and practice growth. The purpose of this study was to model physicians' self-reported Satisfaction with Competence as a function of their perceptions of the Quality of Health Services, Distress, Coping, Practice Management, Personal Satisfaction and Professional Equity. METHODS: Comprehensive questionnaires were sent to a stratified sample of 5300 physicians across Canada. This cross-sectional study focused on physicians who examined and treated individual patients for a final study population of 2639 physicians. Response bias was negligible. The questionnaires contained measures of Satisfaction with Competence, Quality of Health Services, Distress, Coping, Personal Satisfaction, Practice Management and Professional Equity. Exploring relationships was done using Pearson correlations and one-way analysis of variance. Modeling was by hierarchical regressions. RESULTS: The measures were reliable: Satisfaction with Competence (α = .86), Quality (α = .86), Access (α = .82), Distress (α = .82), Coping (α = .76), Personal Satisfaction (α = .78), Practice Management (α = .89) and the dimensions of Professional Equity (Fulfillment, α = .81; Financial, α = .93; and Recognition, α = .75) with comparative validity. Satisfaction with Competence was positively correlated with Quality (r = .32), Efficiency (r = .37) and Access (r = .32); negatively correlated with Distress (r = -.54); and positively correlated with Coping strategies (r = .43), Personal Satisfaction (r = .57), Practice Management (r = .17), Fulfillment (r = .53), Financial (r = .36) and Recognition (r = .54). Physicians' perceptions on Quality, Efficiency, Access, Distress, Coping, Personal Satisfaction, Practice Management, Fulfillment, Pay and Recognition explained 60.2% of the variation in Satisfaction with Competence, controlling for years in practice, self-reported health and duties of physicians. CONCLUSION: Satisfaction with Competence could be affected by excessive accumulation of duties, concerns about quality, efficiency, access, excessive distress, inadequate coping abilities, personal satisfaction with life as a physician, challenges in managing practices and persistent inequities among physicians.