Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time

OBJECTIVE

To obtain improved quality information regarding psychiatrist waiting times by use of a novel methodological approach in which accessibility and wait times are determined by a real-time patient referral procedure.

METHOD

An adult male patient with depression was referred for psychiatric assessment by a family physician. Consecutive calls were made to all registered psychiatrists (n = 297) in Vancouver. A semistructured call procedure was used to collect information about the psychiatrists' availability for receipt of this and similar referrals, identify factors that affect psychiatrist accessibility, and determine the availability of cognitive-behavioural therapy (CBT).

RESULTS

Efforts were made to contact 297 psychiatrists and 230 (77%) were reached successfully. Among the 230 psychiatrists contacted, 160 (70%) indicated that they were unable to accept the referral. Although 70 (30%) indicated that they might be able to consider accepting a referral, 64 (91% of those who would consider accepting the referral) indicated that they would need to review detailed, written referral information and could not provide estimates of the length of wait times if the patient was to be accepted. Only 6 (3% of the 230 psychiatrists contacted) offered immediate appointment times and their wait times ranged from 4 to 55 days. When asked whether they could provide CBT, most (56%) psychiatrists in clinical practice answered maybe.

CONCLUSIONS

Substantial barriers exist for family physicians attempting to refer patients for psychiatric referral. Consolidated efforts to improve access to psychiatric assessment are needed.

Differences and over-time changes in levels of prescription opioid analgesic dispensing from retail pharmacies in Canada, 2005-2010

PURPOSE

To examine qualitative and quantitative levels and trends of prescription opioid analgesics ("opioids") use and the potential impact of prescription monitoring programs (PMPs), in the 10 Canadian provinces, for 2005-2010.

METHODS

Opioid dispensing data from a representative sample of 2700 retail pharmacies were obtained. Individual opioid dispensing values were translated into defined daily doses per day/1000 population and categorized into "weak opioids" and "strong opioids" by standardized methods. Opioid prescription rates between provinces and over time, as well as the impact of PMPs, were examined using regression analyses techniques (i.e., Poisson, ANOVAs).

RESULTS

Significant differences between provinces in the overall standardized rates of dispensing for total opioids, as well as for "weak opioids" and "strong opioids" categories, were found. The majority of provinces featured increases or curvilinear trends in the standardized amounts of opioids dispensed over time, mainly driven by increases in "strong opioids" use. In addition, significant inter-provincial differences in the levels of dispensing of individual opioids were found. Comparisons of changes in opioid dispensing between provinces with and without PMPs did not indicate significant differences.

CONCLUSIONS

Opioid use featured significant quantitative and qualitative differences between provinces in Canada and showed an overall increasing trend mainly driven by changes in "strong opioids" in the study period. Reasons for the observed differences are not clear yet require systematic examination to allow evidence-based interventions in the interest of equitable pain treatment as well as the reduction of high levels of opioid-related morbidity and mortality in Canada.

Pillaring of Layered Double Hydroxides Possessing Variable Layer Charge with Vanadium Polyoxoanions

A range of layered double hydroxides (LDHs) with Ni/Al and Mg/Al as the M(II)/M(III) cations and containing carbonate as the charge balancing anion have been synthesised. A variation in the M(II)/M(III) ratio between 2 and 6 has been attempted with the influence of the M(II)/M(III) ratio upon the subsequent exchange of carbonate by [V10O28]6- (at pH 4.5) examined. Complete exchange is obtained for all ratios, although the crystallinity of the products varies. For M(II)/M(III) ratios > 4, the product crystallinity is poor. In addition, a second phase is detected for all ratios. In the case of Ni/Al, the amount of vanadium incorporated is found to depend upon the Al content whereas for Mg/Al the amount incorporated is constant. Overall, the replacement of carbonate by decavanadate does not appear to have any significant effect on the textural characteristics (e.g. surface area or porosity) of the pillared products.

The introduction of a checking technician programme in community pharmacy and its impact on pharmacist activities

Focal points

Quality measures for primary mental healthcare: a multistakeholder, multijurisdictional Canadian consensus

OBJECTIVE

To develop quality measures using a consensus-based, multistakeholder process to improve delivery of mental health services within primary healthcare settings.

METHODS

A three-stage consensus model culminating in a two-round, modified Delphi postal survey ranking quality measures according to 'actionability,' relevance and overall importance.

PARTICIPANTS

More than 800 people from all 10 provinces and three territories in Canada participated in the study, representing consumers/advocates, clinicians, academics and government decision-makers from regional, provincial and federal levels. A small group with expertise in First Nations and rural-setting health issues was also included, as well as international experts.

RESULTS

The top overall pan-Canadian measure was 'Education about Depression.' 'Actionability' was a key criterion for many of the top 30 measures. Fifty per cent of these measures focused on three major themes: depression, self-harm and access to a broader spectrum of treatment (such as outreach services and psychotherapy). Additional themes included the need for greater collaboration, respectful treatment of patients and families, and improved evaluation of patients. One-way ANOVA results indicated statistically significant differences (p <0.05) between academics, clinicians, consumers and decision-makers on approximately 5% of quality measure ratings. The majority (85% of the 5%) of these differences involved consumer stakeholders.

CONCLUSION

A small set of specific consensus measures were identified through a rigorous, evidence-informed process. These measures can be used for system-wide changes or at the individual practice level. Although these measures have been developed within a Canadian context, the methodology utilised and the measures selected can be adapted elsewhere.

Toluene degradation kinetics for planktonic and biofilm-grown cells of Pseudomonas putida 54G

Toluene degradation kinetics by biofilm and planktonic cells of Pseudomonas putida 54G were compared in this study. Batch degradation of (14)C toluene was used to evaluate kinetic parameters for planktonic cells. The kinetic parameters determined for toluene degradation were: specific growth rate, micro(max) = 10.08 +/- 1.2/day; half-saturation constant, K(S) = 3.98 +/- 1.28 mg/L; substrate inhibition constant, K(I) = 42.78 +/- 3.87 mg/L. Biofilm cells, grown on ceramic rings in vapor phase bioreactors, were removed and suspended in batch cultures to calculate (14)C toluene degradation rates. Specific activities measured for planktonic and biofilm cells were similar based on toluene degrading cells and total biomass. Long-term toluene exposure reduced specific activities that were based on total biomass for both biofilm and planktonic cells. These results suggest that long-term toluene exposure caused a large portion of the biomass to become inactive, even though the biofilm was not substrate limited. Conversely, specific activities based on numbers of toluene-culturable cells were comparable for both biofilm and planktonically grown cultures. Planktonic cell kinetics are often used in bioreactor models to model substrate degradation and growth of bacteria in biofilms, a procedure we found to be appropriate for this organism. For superior bioreactor design, however, changes in cellular activity that occur during biofilm development should be investigated under conditions relevant to reactor operation before predictive models for bioreactor systems are developed.

Following the surface response of caffeine cocrystals to controlled humidity storage by atomic force microscopy

Active pharmaceutical ingredient (API) stability in solid state tablet formulation is frequently a function of the relative humidity (RH) environment in which the drug is stored. Caffeine is one such problematic API. Previously reported caffeine cocrystals, however, were found to offer increased resistance to caffeine hydrate formation. Here we report on the use of atomic force microscopy (AFM) to image the surface of two caffeine cocrystal systems to look for differences between the surface and bulk response of the cocrystal to storage in controlled humidity environments. Bulk responses have previously been assessed by powder X-ray diffraction. With AFM, pinning sites were identified at step edges on caffeine/oxalic acid, with these sites leading to non-uniform step movement on going from ambient to 0% RH. At RH >75%, areas of fresh crystal growth were seen on the cocrystal surface. In the case of caffeine/malonic acid the cocrystals were observed to absorb water anisotropically after storage at 75% RH for 2 days, affecting the surface topography of the cocrystal. These results show that AFM expands on the data gathered by bulk analytical techniques, such as powder X-ray diffraction, by providing localised surface information. This surface information may be important for better predicting API stability in isolation and at a solid state API-excipient interface.

Projecting effects of improvements in passive safety of the New Zealand light vehicle fleet

OBJECTIVES

In the year 2000, as part of the process for setting New Zealand road safety targets, a projection was made for a reduction in social cost of 15.5 percent associated with improvements in crashworthiness, which is a measure of the occupant protection of the light passenger vehicle fleet. Since that document was produced, new estimates of crashworthiness have become available, allowing for a more accurate projection. The objective of this paper is to describe a methodology for projecting changes in casualty rates associated with passive safety features and to apply this methodology to produce a new prediction.

METHOD

The shape of the age distribution of the New Zealand light passenger vehicle fleet was projected to 2010. Projected improvements in crashworthiness and associated reductions in social cost were also modeled based on historical trends. These projections of changes in the vehicle fleet age distribution and of improvements in crashworthiness together provided a basis for estimating the future performance of the fleet in terms of secondary safety.

RESULTS AND CONCLUSIONS

A large social cost reduction of about 22 percent for 2010 compared to the year 2000 was predicted due to the expected huge impact of improvements in passive vehicle features on road trauma in New Zealand. Countries experiencing improvements in their vehicle fleets can also expect significant reductions in road injury compared to a less crashworthy passenger fleet. Such road safety gains can be analyzed using some of the methodology described here.

Examination Under Anesthesia Prior Laparoscopic Appendicectomy

The clinical finding of a mass in the right iliac fossa during the course of diagnosis of acute appendicitis may affect the management approach. A mass is sometimes only evident when the abdomen is examined under anesthesia. This study was conducted to assess the significance of examination under anesthesia and analyze the outcome of laparoscopic exploration and its correlation with the finding of a mass that can be felt only under anesthesia. We conducted a prospective study over 12 months on patients diagnosed with acute appendicitis who were treated with laparoscopic approach. There were 179 patients (101 females) who underwent laparoscopic appendicectomy; 20 cases (11%) were converted to open appendicectomy. Examination under anesthesia revealed a mass in 20 patients (11%). The rate of conversion to open operation was 65% (13 patients) in those who had palpable mass and 4% (7 patients) in those who had no mass (P<0.0001). This study has shown that most patients with a mass found under anesthesia will need conversion of the laparoscopic procedure to an open operation. The recommendation from this study therefore is that all patients planned to have a laparoscopic appendicectomy should have examination under anesthesia; if a mass is found, then the procedure should be converted to open operation from the beginning.

Health service patterns indicate potential benefit of supported self-management for depression in primary care

OBJECTIVE

To examine health service delivery in a Canadian province (British Columbia) to consider how Canadian health care services might be developed to best address the large number of individuals with mildly to moderately severe depressive illnesses.

METHOD

We used provincial administrative data to describe patterns of medical services provided to individuals suffering from depression during 3 different time periods (1991-1992, 1995-1996, and 2000-2001) and to determine the frequency with which depression patients receive treatment from primary care physicians and psychiatrists. We then used these findings to consider the feasibility and potential applicability of the various approaches that have been described to decrease the burden of disease related to depression.

RESULTS

In the fiscal year 1991-1992, the "treated prevalence" rate was 7.7%; in 1995-1996, it was 8.7%; and in 2000-2001, it was 9.5%. In each cohort over the 10-year period, the proportion of individuals who received a diagnosis of depression and who were then treated by primary care physicians alone (no psychiatric services were provided) remained constant at 92%.

CONCLUSIONS

Supported self-management is identified as a promising intervention that could be integrated into primary health care within the context of the Canadian health care system. It constitutes a feasible and practical approach to enhance the role of family physicians in the delivery of services to individuals with milder forms of depression and promotes the active engagement of individuals in their recovery and in prevention of future episodes.