Exploring Sex Differences in Risk Factors and Quality of Life Among Tuberculosis Patients in Herat, Afghanistan: A Case-Control Study

Objectives: Tuberculosis (TB) is a significant public health concern in Afghanistan, with a high burden of disease in the western province of Herat. This study explored the risk factors of TB and TB's impact on the quality of life of patients in Herat. Methods: A total of 422 TB patients and 514 controls were recruited at Herat Regional Hospital and relevant TB laboratories between October 2020 and February 2021. Data was collected through interviews using a structured questionnaire and the SF-36 questionnaire. Descriptive statistics, chi-square tests, Multivariate General Linear Model, and logistic regression analysis were used to analyze the data. Results: The results showed that male sex (p = 0.023), chronic disease (p = 0.038), lower education levels (p < 0.001), and worse health status (p < 0.001) were significantly associated with higher odds of TB infection. The study also found that TB patients had significantly lower quality of life scores in almost all components (p < 0.05). Conclusion: This study provides important insights into the specific ways in which TB affects the wellbeing of patients in Afghanistan. The findings highlight the importance of addressing the psychological and social dimensions of TB.

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada

INTRODUCTION

It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status.

METHODS

Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions).

RESULTS

6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits.

CONCLUSION

Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

Predictors of Multimorbidity (Defined as Diabetes + Hypertension) Amongst Males Aged 15-54 in India: An Urban/Rural Split Analysis

Objectives: This study aimed to determine which sociodemographic and lifestyle factors may act as predictors of multimorbidity (defined as diabetes + hypertension) amongst men aged 15-54 within urban and rural areas of India. Methods: Data from the latest 2019-2021 India NFHS-5 survey were utilized. Presumed cases of multimorbidity were defined as men who had DM + HTN. A total of 22,411 men in urban areas and 66,768 rural men were analyzed using mixed-effect multi-level binary logistic regression models. Results: Various predictors were found to have a statistically significant association to multimorbidity. Urban areas: Age, region of residence, wealth, religion, occupation, and BMI. Rural areas: Age, education, region of residence, wealth, occupation, caste, BMI, alcohol consumption, media exposure, and tobacco consumption. Conclusion: Departing from the broad operational definitions often studied within literature, this study provided insight into one of the most prevalent specific multimorbidities across India. The urban/rural split analyses revealed substantial differences in high-risk characteristics across both areas, which have commonly been overlooked. These findings may better inform policymakers and assist in effectively reducing multimorbidity-related burden through area-specific preventative programs.

Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal

Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

Enacting care by being experts and managing relationships: A discourse analysis of chief medical officer of health media briefings during the COVID-19 pandemic

In Canada, Chief Medical Officers of Health (CMOHs) are responsible for protecting and promoting the health of their respective populations, but few studies have examined this role and its connections with the practice of medicine. In Canada and elsewhere, CMOHs and other public health physicians have articulated their actions as caring for their populations as patients. In order to understand the components of enacted care, this study is a functional discourse analysis of transcribed CMOH media briefings at three time points in five Canadian jurisdictions during the first full year of the COVID-19 pandemic (2020). Transcripts were coded and analysed in an iterative, comparative process to understand the content, actions and purpose of CMOH communication during media briefings. CMOHs used their public communications to enact their care of populations by "being experts" and "managing relationships". "Being experts" involved describing disease characteristics, assessing risk and evidence, framing risk and evidence, and making judgments about intervention and exemption. "Managing relationships" involved self-regulating emotions, acknowledging the emotions of others, seeking adherence and collaboration, and setting expectations and boundaries. The findings suggest that traditional biomedical roles were performed by CMOHs in media briefings, implying the existence of a patient (or multiple patient-like relationships) and supporting further research into the processes by which public health physicians care for populations as patients.

Natural history of abdominal pain in family practice: Longitudinal study of electronic medical record data in southwestern Ontario

OBJECTIVE

To examine the frequency, natural history, and outcomes of 3 subtypes of abdominal pain (general abdominal pain, epigastric pain, localized abdominal pain) among patients visiting Canadian family practices.

DESIGN

Retrospective cohort study with a 4-year longitudinal analysis.

SETTING

Southwestern Ontario.

PARTICIPANTS

A total of 1790 eligible patients with International Classification of Primary Care codes for abdominal pain from 18 family physicians in 8 group practices.

MAIN OUTCOME MEASURES

The symptom pathways, the length of an episode, and the number of visits.

RESULTS

Abdominal pain accounted for 2.4% of the 15,149 patient visits and involved 14.0% of the 1790 eligible patients. The frequencies of each of the 3 subtypes were as follows: localized abdominal pain, 89 patients, 1.0% of visits, and 5.0% of patients; general abdominal pain, 79 patients, 0.8% of visits, and 4.4% of patients; and epigastric pain, 65 patients, 0.7% of visits, and 3.6% of patients. Those with epigastric pain received more medications, and patients with localized abdominal pain underwent more investigations. Three longitudinal outcome pathways were identified. Pathway 1, in which the symptom remains at the end of the visit with no diagnosis, was the most common among patients with all subtypes of abdominal symptoms at 52.8%, 54.4%, and 50.8% for localized, general, and epigastric pain, respectively, and the symptom episodes were relatively short. Less than 15% of patients followed pathway 2, in which a diagnosis is made and the symptom persists, and yet the episodes were long with 8.75 to 16.80 months' mean duration and 2.70 to 4.00 mean number of visits. Pathway 3, in which a diagnosis is made and there are no further visits for that symptom, occurred approximately one-third of the time, with about 1 visit over about 2 months. Prior chronic conditions were common across all 3 subtypes of abdominal pain ranging from 72.2% to 80.0%. Psychological symptoms consistently occurred at a rate of approximately one-third.

CONCLUSION

The 3 subtypes of abdominal pain differed in clinically important ways. The most frequent pathway was that the symptom remained with no diagnosis, suggesting a need for clinical approaches and education programs for care of symptoms themselves, not merely in the service of coming to a diagnosis. The importance of prior chronic conditions and psychological conditions was highlighted by the results.

Examining Variations in the Prevalence of Diagnosed Mood or Anxiety Disorders Among Migrant Groups in Ontario, 1995-2015: A Population-Based, Repeated Cross-Sectional Study

BACKGROUND

International evidence on the frequency of mood or anxiety disorders among migrant groups is highly variable, as it is dependent on the time since migration and the socio-political context of the host country. Our objective was to estimate trends in the prevalence of diagnosed mood or anxiety disorders among recent (<5 years in Canada) and settled (5-10 years in Canada) migrant groups, relative to the general population of Ontario, Canada.

METHODS

We used a repeated cross-sectional design consisting of four cross-sections spanning 5 years each, constructed using health administrative databases from 1995 to 2015. We included all Ontario residents between the ages of 16 and 64 years. We assessed differences in the prevalence of mood or anxiety disorders adjusting for age, sex, and neighbourhood-level income. We further evaluated the impact of migrant class and region of birth.

RESULTS

The prevalence of mood or anxiety disorders was lower among recent (weighted mean  =  4.10%; 95% confidence interval [CI], 3.59% to 4.60%) and settled (weighted mean  =  4.77%; 95% CI, 3.94% to 5.61%) migrant groups, relative to the general population (weighted mean  =  7.39%; 95% CI,  6.83% to 7.94%). Prevalence estimates varied greatly by region of birth and migrant class. We found variation in prevalence estimates over time, with refugee groups having the largest increases between 1995 and 2015.

CONCLUSIONS

Our findings highlight the complexity of mood and anxiety disorders among migrant groups, and that not all groups share the same risk profile. These results can be used to help inform health service allocation and the development of supportive programs for specific migrant groups.

Effect of reproductive and lifestyle factors on anti-mullerian hormone levels in women of Indian origin

Background:

Infertility is a world-wide problem and one third females. Over the years, anti-mullerian hormone (AMH) has emerged as a major marker of ovarian reserve. There is also increasing interest in determining the factors which can impact AMH levels.

Aims:

To correlate the association of reproductive and lifestyle factors on AMH levels in women of Indian origin.

Settings and Design:

Multicentric cross sectional study.

Materials and Methods:

The study was conducted using data extracted from the patient records of seven private fertility practices located in North India. Women who were attending these clinics for fertility treatment were requested to fill the questionnaire related to reproductive and lifestyle factors.

Statistical Analysis used:

Our outcome variable was level of AMH measured in the past 3 months, and was assessed as normal or low. All analyses were conducted using STATA 17.

Results:

We found a direct association of low AMH with increasing age, short cycles, amenorrhea and women with family history of premature menopause. We found a direct correlation of high AMH and women with polycystic ovary syndrome and those whose partners had Oligoasthenoteratozoospermia (OATS) or azoospermia. There was no correlation with smoking, sleep, diet, body mass index, cell phone or laptop use in our study.

Conclusion:

Reproductive and lifestyle factors may affect ovarian reserve and but there was a dearth of human studies in this area. To the best of our knowledge this is the first human study on the effect of AMH on Laptop and Cell phone use. We urgently need more studies to confirm or refute our findings so that we can counsel our patients well.

Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study

BACKGROUND:

Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada.

METHODS:

We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits.

RESULTS:

The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval −1.48 to −1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of −1.24 to −1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department.

INTERPRETATION:

Ontario’s experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.

A Bayesian approach to estimating the population prevalence of mood and anxiety disorders using multiple measures

AIMS

There is currently no universally accepted measure for population-based surveillance of mood and anxiety disorders. As such, the use of multiple linked measures could provide a more accurate estimate of population prevalence. Our primary objective was to apply Bayesian methods to two commonly employed population measures of mood and anxiety disorders to make inferences regarding the population prevalence and measurement properties of a combined measure.

METHODS

We used data from the 2012 Canadian Community Health Survey - Mental Health linked to health administrative databases in Ontario, Canada. Structured interview diagnoses were obtained from the survey, and health administrative diagnoses were identified using a standardised algorithm. These two prevalence estimates, in addition to data on the concordance between these measures and prior estimates of their psychometric properties, were used to inform our combined estimate. The marginal posterior densities of all parameters were estimated using Hamiltonian Monte Carlo (HMC), a Markov Chain Monte Carlo technique. Summaries of posterior distributions, including the means and 95% equally tailed posterior credible intervals, were used for interpretation of the results.

RESULTS

The combined prevalence mean was 8.6%, with a credible interval of 6.8-10.6%. This combined estimate sits between Bayesian-derived prevalence estimates from administrative data-derived diagnoses (mean = 7.4%) and the survey-derived diagnoses (mean = 13.9%). The results of our sensitivity analysis suggest that varying the specificity of the survey-derived measure has an appreciable impact on the combined posterior prevalence estimate. Our combined posterior prevalence estimate remained stable when varying other prior information. We detected no problematic HMC behaviour, and our posterior predictive checks suggest that our model can reliably recreate our data.

CONCLUSIONS

Accurate population-based estimates of disease are the cornerstone of health service planning and resource allocation. As a greater number of linked population data sources become available, so too does the opportunity for researchers to fully capitalise on the data. The true population prevalence of mood and anxiety disorders may reside between estimates obtained from survey data and health administrative data. We have demonstrated how the use of Bayesian approaches may provide a more informed and accurate estimate of mood and anxiety disorders in the population. This work provides a blueprint for future population-based estimates of disease using linked health data.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

Geographic variation in preventable hospitalisations across Canada: a cross-sectional study

OBJECTIVE

The objective of this study is to examine the magnitude and pattern of small-area geographic variation in rates of preventable hospitalisations for ambulatory care-sensitive conditions (ACSC) across Canada (excluding Québec).

DESIGN AND SETTING

A cross-sectional study conducted in Canada (excluding Québec) using data from the 2006 Canadian Census Health and Environment Cohort (CanCHEC) linked prospectively to hospitalisation records from the Discharge Abstract Database (DAD) for the three fiscal years: 2006-2007, 2007-2008 and 2008-2009.

PRIMARY OUTCOME MEASURE

Preventable hospitalisations (ACSC).

PARTICIPANTS

The 2006 CanCHEC represents a population of 22 562 120 individuals in Canada (excluding Québec). Of this number, 2 940 150 (13.03%) individuals were estimated to be hospitalised at least once during the 2006-2009 fiscal years.

METHODS

Age-standardised annualised ACSC hospitalisation rates per 100 000 population were computed for each of the 190 Census Divisions. To assess the magnitude of Census Division-level geographic variation in rates of preventable hospitalisations, the global Moran's I statistic was computed. 'Hot spot' analysis was used to identify the pattern of geographic variation.

RESULTS

Of all the hospitalisation events reported in Canada during the 2006-2009 fiscal years, 337 995 (7.10%) events were ACSC-related hospitalisations. The Moran's I statistic (Moran's I=0.355) suggests non-randomness in the spatial distribution of preventable hospitalisations. The findings from the 'hot spot' analysis indicate a cluster of Census Divisions located in predominantly rural and remote parts of Ontario, Manitoba and Saskatchewan and in eastern and northern parts of Nunavut with significantly higher than average rates of preventable hospitalisation.

CONCLUSION

The knowledge generated on the small-area geographic variation in preventable hospitalisations can inform regional, provincial and national decision makers on planning, allocation of resources and monitoring performance of health service providers.

Concordance between health administrative data and survey-derived diagnoses for mood and anxiety disorders

OBJECTIVE

To assess whether estimates of survey structured interview diagnoses of mood and anxiety disorders were concordant with diagnoses of these disorders obtained from health administrative data.

METHODS

All Ontario respondents to the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH) were linked to health administrative databases at ICES (formerly known as the Institute for Clinical Evaluative Sciences). Survey structured interview diagnoses were compared with health administrative data diagnoses obtained using a standardized algorithm. We used modified Poisson regression analyses to assess whether socio-demographic factors were associated with concordance between the two measures.

RESULTS

Of the 4157 Ontarians included in our sample, 20.4% had either a structured interview diagnosis (13.9%) or health administrative diagnosis (10.4%) of a mood or anxiety disorder. There was high discordance between measures, with only 19.4% agreement. Migrant status, age, employment, and income were associated with discordance between measures.

CONCLUSIONS

Our findings indicate that previous estimates of the 12-month prevalence of mood and anxiety disorders in Ontario may be underestimating the true prevalence, and that population-based surveys and health administrative data may be capturing different groups of people. Understanding the limitations of data commonly used in epidemiologic studies is a key foundation for improving population-based estimates of mental disorders.

Ratios and determinants of maternal mortality: a comparison of geographic differences in the northern and southern regions of Cameroon

BACKGROUND

While maternal mortality has declined worldwide in the past 25 years, this is not the case for Cameroon. Since there is a predominantly young population in this country, high maternal mortality ratios may persist. Maternal mortality ratios vary within countries, yet it is unknown if the North and South, the most distinct parts of Cameroon, differ in terms of ratios and determinants of maternal mortality.

METHODS

This study explored ratios and determinants of maternal mortality in women of childbearing age (15-49 years) and assessed differences between the North and South. We used the Cameroon Demographic and Health Surveys (2004 and 2011) to extract a sample of 18,665 living or deceased women who had given birth. Multivariable logistic regression was used to explore the relationship between maternal mortality and sociocultural, economic and healthcare factors.

RESULTS

Maternal mortality ratios were different for the two regions and increased in the North in 2011 compared to 2004. In the North, any level of education and being Muslim were protective against maternal mortality. Meanwhile, the odds of maternal mortality decreased with increasing age, and having secondary or higher education in the South. Domestic violence and ethnicity were associated with maternal death in the South. Increasing parity was protective of maternal death in both the North and South.

CONCLUSIONS

Maternal mortality ratios and determinants varied between women of childbearing age in the North and South of Cameroon. These reinforce recommendations for region specific strategies that will improve health communication, community education programs, curb domestic violence and train more community health workers to connect pregnant women with the health system. Programs to reduce maternal death among women with low parity and little or no education should be national priority.

Surgical margins for borderline and malignant phyllodes tumours

BACKGROUND

Phyllodes tumours represent less than 1% of all UK breast neoplasms. Histological features allow classification into benign, borderline or malignant, which has a significant impact on prognosis and recurrence. Currently, there is no consensus for the optimal surgical excision margin. This systematic review aims to provide a comparative summary of outcomes (local recurrence, metastasis and survival) for borderline and malignant phyllodes tumours resected with either ≥1cm or <1cm margins.

METHODS

MEDLINE and Embase were systematically searched (1990 to July 2019), in line with PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Ten retrospective studies were included (Newcastle-Ottawa scale mean score: 5.6, range: 8-4). Nine reported local recurrence rates, four reported distant metastasis and four reported survival. Meta-analysis pooling demonstrated no statistically significant difference between <1cm and ≥1cm margins in terms of local recurrence rates (relative risk [RR] 1.43, 95% confidence interval [95% CI] 0.70 - 2.93; p=0.33, n=456), distant metastasis (RR 1.93, 95% CI 0.35 - 10.63; p=0.45, n=72) or mortality (RR 1.93, 95% CI 0.42 - 8.77; p=0.40, n=58) for borderline and malignant tumours. Additionally, two studies demonstrated no significant difference in local recurrence for borderline tumours excised with <0.1cm margins compared to ≥1cm.

CONCLUSION

Current evidence suggests that margins <1cm may provide adequate tumour excision. This could enable breast conservation in patients with smaller breast-to-tumour volume ratios, with improved cosmetic outcomes and patient satisfaction. A prospective, multi-institutional trial would be appropriate to further elucidate the safety of smaller margins.

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

Levels and determinants of maternal mortality in northern and southern Nigeria

Background

Maternal mortality is still a major risk for women of childbearing age in Nigeria. In 2008, Nigeria bore 14% of the global burden of maternal mortality. The national maternal mortality ratio has remained elevated despite efforts to reduce maternal deaths. Though health disparities exist between the North and South of Nigeria, there is a dearth of evidence on the estimates and determinants of maternal mortality for these regions.

Methods

This study aimed to assess differences in the levels and determinants of maternal mortality in women of childbearing age (15–49 years) in the North and South of Nigeria. The Nigeria Demographic and Health Surveys (2008 and 2013) were used. The association between maternal mortality (outcome) and relevant sociocultural, economic and health factors was tested using multivariable logistic regression in a sample of 51,492 living or deceased women who had given birth.

Results

There were variations in the levels of maternal mortality between the two regions. Maternal mortality was more pronounced in the North and increased in 2013 compared to 2008. For the South, the levels slightly decreased. Media exposure and education were associated with maternal mortality in the North while contraceptive method, residence type and wealth index were associated with maternal death in the South. In both regions, age and community wealth were significantly associated with maternal mortality.

Conclusions

Differences in the levels and determinants of maternal mortality between the North and South of Nigeria stress the need for efforts to cut maternal deaths through new strategies that are relevant for each region. These should improve education of girls in the North and access to health information and services in the South. Overall, new policies to improve women’s socioeconomic status should be adopted.

Gaps in Understanding of the Epidemiology of Mood and Anxiety Disorders among Migrant Groups in Canada: A Systematic Review

OBJECTIVE

Estimates of mood and anxiety disorders are highly variable among migrant groups, as they are influenced by the socio-political context. Our objective was to conduct a systematic review and meta-analysis to synthesize available Canadian evidence on the prevalence and incidence of mood and anxiety disorders among migrant groups.

METHODS

Studies were identified from MEDLINE, EMBASE, and PsycINFO. They were included if they used population-based samples, presented data on the incidence or prevalence of diagnosed or self-reported mood or anxiety disorders for first-generation migrant groups in Canada, and used a Canadian-born or long-term resident reference group.

RESULTS

Nineteen studies met our inclusion criteria. Prevalence ratios ranged from 0.48 to 0.87, and nearly all estimates were obtained from population health surveys. Prevalence estimates among migrant groups were lower than the reference group, with the 90th percentile of estimates ranging from 1.5% to 8.2%. Risk factors for mood and anxiety disorders among migrants included being female, younger, unemployed, having lower income, and living in neighborhoods with a lower proportion of migrants.

CONCLUSIONS

There remain many gaps in our current understanding of mood and anxiety disorders among migrant groups in Canada. Although evidence suggests the prevalence of mood and anxiety disorders are consistently lower among migrant groups, a lack of incidence estimates limits the strength of this conclusion. Future research should focus on comparisons of self-reported and diagnosed estimates, the use of a range of different primary or secondary data sources, and consideration of important risk factors.

PROSPERO CITATION

Jordan Edwards, Malini Hu, Amardeep Thind, Saverio Stranges, Maria Chiu, Kelly Anderson. The burden of mood and anxiety disorders among immigrant and refugee populations in Canada: a systematic review. PROSPERO 2018 CRD42018087869 Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018087869 .

Do four or more antenatal care visits increase skilled birth attendant use and institutional delivery in Bangladesh? A propensity-score matched analysis

BACKGROUND

With Bangladesh's adoption of the third Sustainable Development Goal to reduce maternal mortality, the impetus for Bangladesh to continue to improve uptake of maternal healthcare is strong.

METHODS

Using a propensity-score matched analysis, the present study utilized data from the 2014 Bangladesh Demographic Health survey to examine the impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery.

RESULTS

The results revealed a significant and positive impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery after matching treated and untreated mothers on included socio-demographic characteristics.

CONCLUSIONS

Implementation of policies to provide at least four antenatal care visits may serve as an effective strategy to increase SBA use and institutional delivery in Bangladesh, which could contribute to the reduction of maternal mortality.

Ethnic variations in risk of preterm birth in an ethnically dense socially disadvantaged area in the UK: a retrospective cross-sectional study

OBJECTIVE

To investigate ethnic variations in risk of preterm birth (PTB), including extreme preterm birth (EPTB) and moderately preterm birth (MPTB), among mothers in an ethnically dense, socially disadvantaged area, and to examine whether any variations were dependent of area deprivation and maternal biological and behavioural factors.

DESIGN

Retrospective cross-sectional study using routinely collected data.

SETTING

A large UK National Health Service maternity unit.

PARTICIPANTS

46 307 women who gave singleton births between April 2007 and March 2016.

OUTCOME MEASURES

PTB defined as <37 weeks of gestation and further classified into EPTB (<28 weeks of gestation) and MPTB (28 to <37 weeks of gestation).

RESULTS

Overall prevalence of PTB was higher (8.3%) compared with the national average (7.8%). Black Caribbean (2.2%) and black African (2.0%) mothers had higher absolute risk of EPTB than white British mothers (1.3%), particularly black Caribbean mothers whose relative risk ratio (RRR) was nearly twice after adjustment for all covariates (RRR=1.93[1.20 to 3.10]). Excess relative risk of EPTB among black African mothers became non-significant after adjustment for prenatal behavioural factors (RRR=1.41[0.99 to 2.01]). Bangladeshi mothers had the lowest absolute risk of EPTB (0.6%), substantially lower than white British mothers (1.3%); the difference in relative risk remained significant after adjustment for area deprivation (RRR=0.59[0.36 to 0.96]), but became non-significant after adjustment for maternal biological factors. Changes were evident in the relative risk of EPTB and MPTB among some ethnic groups compared with the white British on adjustment for different covariates.

CONCLUSIONS

Higher than national rates of PTB point to the need for evidence-based antenatal and neonatal care programmes to support preterm babies and their families in ethnically dense socially disadvantaged areas. Differential impact of area deprivation and the role of modifiable behavioural factors highlight the need for targeted preventive interventions for groups at risk.

A basic model for assessing primary health care electronic medical record data quality

Background

The increased use of electronic medical records (EMRs) in Canadian primary health care practice has resulted in an expansion of the availability of EMR data. Potential users of these data need to understand their quality in relation to the uses to which they are applied. Herein, we propose a basic model for assessing primary health care EMR data quality, comprising a set of data quality measures within four domains. We describe the process of developing and testing this set of measures, share the results of applying these measures in three EMR-derived datasets, and discuss what this reveals about the measures and EMR data quality. The model is offered as a starting point from which data users can refine their own approach, based on their own needs.

Methods

Using an iterative process, measures of EMR data quality were created within four domains: comparability; completeness; correctness; and currency. We used a series of process steps to develop the measures. The measures were then operationalized, and tested within three datasets created from different EMR software products.

Results

A set of eleven final measures were created. We were not able to calculate results for several measures in one dataset because of the way the data were collected in that specific EMR. Overall, we found variability in the results of testing the measures (e.g. sensitivity values were highest for diabetes, and lowest for obesity), among datasets (e.g. recording of height), and by patient age and sex (e.g. recording of blood pressure, height and weight).

Conclusions

This paper proposes a basic model for assessing primary health care EMR data quality. We developed and tested multiple measures of data quality, within four domains, in three different EMR-derived primary health care datasets. The results of testing these measures indicated that not all measures could be utilized in all datasets, and illustrated variability in data quality. This is one step forward in creating a standard set of measures of data quality. Nonetheless, each project has unique challenges, and therefore requires its own data quality assessment before proceeding.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0740-0) contains supplementary material, which is available to authorized users.

In-Home Rehabilitation Resources and Avoidable Admissions to Inpatient Rehabilitation after Stroke: An Ecological Study

Background and purpose:

In Ontario (Canada’s most populous province), it has been suggested that mildly impaired stroke patients are being admitted to inpatient rehabilitation unnecessarily due to a lack of alternative options in the community. This ecological study aimed to formally test this hypothesis.

Methods:

Patients admitted to an inpatient rehabilitation bed in Ontario’s most highly functioning patient classification group (Rehabilitation Patient Group 1160) were retrospectively identified as potentially avoidable admissions, and the proportion of such patients was calculated for each Local Health Integration Network every year between 2006/2007 and 2010/2011. Five indicators of community-based rehabilitation availability were used to test the relationships between avoidable admissions and resource indicators.

Results:

Of the 25 correlations tested, 21 agreed with the hypothesized direction of effect and 4 reached statistical significance. Logistic-linear regressions on combined data from each of the 5 years demonstrated statistically significant associations between all 5 resource indicators and the proportion of potentially avoidable admissions.

Conclusions:

This study confirms the suggestion of variation in the proportion of mildly impaired patients admitted to inpatient rehabilitation across Ontario’s Local Health Integration Networks. It also adds evidence to support the concern that a lack of community-based rehabilitation is contributing to these potentially avoidable admissions.

Trends in obesity and multimorbidity in Canada

Very few studies have examined trends in multimorbidity over time and even fewer have examined trends over time across different body mass index (BMI) groups. Given a general decline in death rates but increased cardiovascular risk factors among individuals with obesity, the trend in the association between obesity and multimorbidity is hypothesized to be increasing over time. The data for our study came from the 1996-97 National Population Health Survey and the 2005 and 2012-13 Canadian Community Health Surveys (N = 277,366 across all 3 surveys). We examined trends in the association between BMI groups and multimorbidity using a logistic regression model. We also investigated trends in the prevalence of specific chronic conditions, pairs of chronic conditions and different levels of multimorbidity across BMI groups. We found significantly greater levels of multimorbidity in 2005 (OR = 1.42; p < 0.001) and 2012-13 (OR = 1.58; p < 0.001) relative to 1996-97. Changes in multimorbidity levels were much greater among individuals with class II/III (OR = 1.48; p = 0.005) and class I obesity (OR = 1.38; p = 0.001) in 2012-13 relative to 1996-97. Much of the increase in multimorbidity among individuals living with obesity was due to increases in 3+ chronic conditions and conditions in combination with hypertension, and the greatest increase was found among seniors living with obesity. Our results highlight the need for interventions aimed at preventing obesity and the prevention of chronic conditions among individuals with obesity, especially among seniors.

Towards optimal electronic medical record use: perspectives of advanced users

BACKGROUND

While primary health care electronic medical record (EMR) adoption has increased in Canada, the use of advanced EMR features is limited. Realizing the potential benefits of primary health care EMR use is dependent not only on EMR acquisition, but also on its comprehensive use and integration into practice; yet, little is known about the advanced use of EMRs in primary health care.

OBJECTIVE

To explore the views of advanced primary health care EMR users practising in a team-based environment.

METHODS

A descriptive qualitative approach was used to explore the views of primary health care practitioners who were identified as advanced EMR users. Twelve individual semi-structured interviews were held with primary health care practitioners in Southwestern Ontario, Canada. Field notes were created after each interview. Interviews were audio recorded and transcribed verbatim. Researchers independently coded the transcripts and then met to discuss the results of the coding. We used a thematic approach to data analysis.

RESULTS

Three themes emerged from the data analysis: advanced EMR users as individuals with signature characteristics, advanced EMR users as visionaries and advanced EMR users as agents of change. In any one participant, these elements could overlap, illuminating the important interplay between these themes. Taken together, these themes defined advanced use among this group of primary health care practitioners.

CONCLUSIONS

To realize the potential benefits of EMR use in improved patient care and outcomes, we need to understand how to support EMR use. This study provides a necessary building block in furthering this understanding.

Canadian family physician job satisfaction - is it changing in an evolving practice environment? An analysis of the 2013 National Physician Survey database

Background

To explore the determinants of job satisfaction and work-life balance satisfaction of family physicians in Canada.

Methods

This is a secondary analysis of the Canadian 2013 National Physician’s Survey using descriptive statistics and binomial logistic regression. An estimated 34,753 family physicians practicing in Canada at the time of survey administration in 2013 were eligible for the survey. The main outcome measures were respondent satisfaction with professional life and satisfaction with work-life balance.

Results

The survey had a response rate of 17%. Seventy-two percent of respondents were satisfied with their professional lives, and 49% were satisfied with their work-life balance. Male family physicians had lower odds of satisfaction with their work-life balance than their female counterparts (OR = 0.86, 95% CI 0.82–0.92). Family physicians using an electronic medical record had higher odds of dissatisfaction with their professional lives (OR = 1.13, 95% CI 1.05–1.22) and work-life balance (OR = 1.22, 95% CI 1.15–1.30) than those not using an EMR. Family physicians not in a focused practice had greater odds of dissatisfaction (OR = 1.61, 95% CI 1.50–1.72) with both their professional lives and work-life balance (OR = 1.29, 95% CI 1.22–1.37) compared to their colleagues who have one or more areas of clinical focus.

Conclusions

Canadian family physicians are more satisfied with their professional lives than with their work-life balance. Novel findings that family physicians with one or more clinical areas of focus are more satisfied with their work and work-life balance satisfaction, and that family physicians using electronic health records are less satisfied with their work and their work-life balance merit further inquiry.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0786-6) contains supplementary material, which is available to authorized users.

Disparities in the survivorship experience among Latina survivors of breast cancer

BACKGROUND

The authors investigated disparities in the survivorship experience among Latinas with breast cancer (BC) in comparison with non-Latinas.

METHODS

A cross-sectional bilingual telephone survey was conducted among 212 Latina and non-Latina women within 10 to 24 months after a diagnosis of BC (AJCC TNM staging system stage 0-III) at 2 Los Angeles County public hospitals. Data were collected using the Preparing for Life as a (New) Survivor (PLANS) scale, Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI), Breast Cancer Prevention Trial (BCPT) Symptom Checklist, Satisfaction with Care and Information Scale, Consumer Assessment of Healthcare Providers and Systems (CAHPS) tool, Charlson Comorbidity Index adapted for patient self-report, and the 12-item Short Form Health Survey. Controlling variables included age, stage as determined by the American Joint Committee on Cancer (AJCC) TNM staging system, educational level, and study site in multivariate analyses.

RESULTS

The mean ages of Latinas and non-Latinas were 51.5 years and 56.6 years, respectively. Compared with non-Latinas, Latinas reported less BC survivorship knowledge (27.3 vs 30.7; P<.0001), were more dissatisfied with BC care information (2.3 vs 3.4; P<.0001), reported lower PEPPI scores (38.2 vs 42.2; P = .03), and experienced more BCPT symptoms (6.4 vs 5.0; P = .04). No differences were noted regarding their confidence in survivorship care preparedness (42.7 vs 41; P = .191), satisfaction with BC survivorship care (9.6 vs 8.8; P = .298), or their discussion with physicians (9.6 vs 8.1; P = .07). These ethnic group differences persisted in multivariate analyses, with the exception of PEPPI.

CONCLUSIONS

Latina survivors of BC experienced disparities in BC knowledge and satisfaction with information received, but believed themselves to be prepared for survivorship and were as satisfied with providers, care received, and discussions with physicians as non-Latinas. Cancer 2018;124:2373-80. © 2018 American Cancer Society.

Inequitable health service use in a Canadian paediatric population: A cross-sectional study of individual- and contextual-level factors

BACKGROUND

Health service use may be influenced by multilevel predisposing, enabling, and need factors but is equitable when driven by need. The study's objectives were as follows: (a) to investigate residential context's effect on child health service use and (b) to examine inequity of child health service use by testing for effect measure modification of need factors.

METHODS

The sample of 1,451 children was from a prenatal cohort recruited from London, Ontario, between 2002 and 2004, with follow-up until children were toddler/preschooler-aged. Individual-level data were linked by residential address to neighbourhood contextual-level data sourced from Statistics Canada. Multilevel logistic regression modelled factors associated with child health service use. Interaction terms were included in the model to test for effect measure modification of need factors by predisposing and enabling factors.

RESULTS

Contextual-level factors were not associated with child health service use. Maternal parity and nativity to Canada modified the effect of the need factor, paediatric health condition, on health service use. Health condition's effect was lowest in children of Canadian-born mothers with one child only (OR = 1.58, p = .04) and highest in children of Canadian-born mothers with three or more children (OR = 3.52, p < .01). Further, its effect was higher in children of Canadian-born mothers compared to children of mothers who migrated to Canada; however, odds ratios were not statistically significant for the latter.

CONCLUSIONS

Results may inform future investigation of the potential inequity of health service use for subgroups of children whose mothers are of lower parity and not Canadian-born. An understanding of these inequities may inform future healthcare policy and care for paediatric populations.

The Multimorbidity Cluster Analysis Tool: Identifying Combinations and Permutations of Multiple Chronic Diseases Using a Record-Level Computational Analysis

INTRODUCTION

Multimorbidity, or the co-occurrence of multiple chronic health conditions within an individual, is an increasingly dominant presence and burden in modern health care systems.  To fully capture its complexity, further research is needed to uncover the patterns and consequences of these co-occurring health states.  As such, the Multimorbidity Cluster Analysis Tool and the accompanying Multimorbidity Cluster Analysis Toolkit have been created to allow researchers to identify distinct clusters that exist within a sample of participants or patients living with multimorbidity. Development: The Tool and Toolkit were developed at Western University in London, Ontario, Canada.  This open-access computational program (JAVA code and executable file) was developed and tested to support an analysis of thousands of individual records and up to 100 disease diagnoses or categories. APPLICATION: The computational program can be adapted to the methodological elements of a research project, including type of data, type of chronic disease reporting, measurement of multimorbidity, sample size and research setting.  The computational program will identify all existing, and mutually exclusive, combinations and permutations within the dataset.  An application of this computational program is provided as an example, in which more than 75,000 individual records and 20 chronic disease categories resulted in the detection of 10,411 unique combinations and 24,647 unique permutations among female and male patients. DISCUSSION: The Tool and Toolkit are now available for use by researchers interested in exploring the complexities of multimorbidity.  Its careful use, and the comparison between results, will be valuable additions to the nuanced understanding of multimorbidity.

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data

BACKGROUND

  A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. OBJECTIVE:  To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. METHOD: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location.  Proportion of variance in referral rates attributable to the patient and practice levels. RESULTS:  On average, males had 0.26, and females 0.31 referrals in a 12-month period.  Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p<.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. CONCLUSIONS:  Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time.

Caregivers: Do They Make a Difference to Patient Recovery in Subacute Stroke?

OBJECTIVE

To evaluate the relationship between caregiver nature and availability, and rehabilitation outcomes in subacute stroke.

DESIGN

Retrospective cohort study.

SETTING

Four community rehabilitation hospitals.

PARTICIPANTS

Patients with subacute, first-time stroke (N=4042; 48.5% men; mean age ± SD, 70.12±10.4y; 51.5% women; mean age ± SD, 72.54 ±10.0y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehabilitation effectiveness, defined as the percentage of potential improvement eventually achieved with rehabilitation; and rehabilitation efficiency, defined as the rate of functional improvement during rehabilitation.

RESULTS

In our cohort, 96.7% had available caregiver(s), of which 42.0% were primarily supported by foreign domestic workers (FDWs), 25.9% by spouses, 19.3% by first-degree relatives, 7.8% by other relatives, and 5.1% by other caregivers. Using quantile regression, we found that having a caregiver was independently associated with rehabilitation efficiency (β=-3.83; 95% confidence interval [CI], -6.99 to -0.66; P=.018). The relationship between caregiver availability and rehabilitation effectiveness was modified by patient sex in that the negative association was significantly greater in men (β=-22.81; 95% CI, -32.70 to -12.94; P<.001) than women (β=-5.64; 95% CI, -14.72 to 3.44; P=.223). Having a FDW as a caregiver compared with a spousal caregiver was negatively associated with rehabilitation effectiveness (β=-3.95; 95% CI, -6.94 to -0.95; P=.01) and rehabilitation efficiency (β=-1.83; 95% CI, -3.14 to -0.53; P=.006). The number of potential caregivers was only significantly associated with rehabilitation effectiveness at the bivariate level (P=.006).

CONCLUSIONS

Caregiver identity, and possibly availability, appears to negatively affect rehabilitation outcomes in subacute stroke. A better understanding of these relationships has potential implications on clinical practice and policy directions.

Impact of a primary healthcare quality improvement program on diabetes in Canada: evaluation of the Quality Improvement and Innovation Partnership (QIIP)

OBJECTIVE

Primary healthcare (PHC) quality improvement (QI) initiatives are designed to improve patient care and health outcomes. We evaluated the Quality Improvement and Innovation Partnership (QIIP), an Ontario-wide PHC QI program on access to care, diabetes management and colorectal cancer screening. This manuscript highlights the impact of QIIP on diabetes outcomes and associated vascular risk factors.

RESEARCH DESIGN AND METHODS

A cluster matched-control, retrospective prechart and postchart audit was conducted. One physician per QIIP-PHC team (N=34) and control (N=34) were recruited for the audit. Eligible charts were reviewed for prespecified type 2 diabetes mellitus clinical process and outcome data at baseline, during (intervention range: 15-17.5 months) and post. Primary outcome measures were the A1c of patients above study target and proportion of patients with an annual foot exam. Secondary outcome measures included glycemic, hypertension and lipid outcomes and management, screening for diabetes-related complications, healthcare utilization, and diabetes counseling, education and self-management goal setting.

RESULTS

More patients in the QIIP group achieved statistically improved lipid testing, eye examinations, peripheral neuropathy exams, and documented body mass index. No statistical differences in A1c, low-density lipoprotein or systolic/diastolic blood pressure values were noted, with no significant differences in medication prescription, specialist referrals, or chart-reported diabetes counseling, education or self-management goals. Patients of QIIP physicians had significantly more PHC visits.

CONCLUSION

The QIIP-learning collaborative program evaluation using stratified random selection of participants and the inclusion of a control group makes this one of the most rigorous and promising efforts to date evaluating the impact of a QI program in PHC. The chart audit component of this evaluation highlighted that while QIIP improved some secondary diabetes measures, no improvements in clinical outcomes were noted. This study highlights the importance of formalized evaluation of QI initiatives to provide an evidence base to inform future program planning and scale-up.

Stepping Up to the Plate: An Agenda for Research and Policy Action on Electronic Medical Records in Canadian Primary Healthcare

Building on a previous study, which identified gaps in primary healthcare electronic medical record (emr) research and knowledge, a one-day conference was held to facilitate a strategic discussion of these issues. This paper offers a multi-faceted research agenda and suggestions for policy actions as a way forward in bridging the gaps. one facet focuses on the need for research. The second facet focuses on harnessing the knowledge of primary healthcare emr stakeholders. finally, the third facet focuses on policy actions. this paper offers consensus-based suggestions with a view to improving the overall primary healthcare emr landscape in canada.

Adapting to the Needs of the Public Health Workforce: An Integrated Case-Based Training Program

The goal of any public health education at the Masters level is to transmit knowledge and skills to meet current and future public health challenges. We suggest an innovative multi-modal approach to public health education using a case-based pedagogy combined with competency-based curriculum and a team-based approach to foster truly experiential learning. We describe each pedagogical approach in connection to the relevance of optimal methods for training public health professionals. Western University’s Schulich Interfaculty Masters of Public Health (MPH) program (ON, Canada) provides a unique interprofessional education through case-based learning and competency-based curriculum. This Masters program has attracted applicants from around the world to learn in a supportive interprofessional environment and to foster them as they become learners and leaders in public health changes. To our knowledge, we are the first condensed MPH program using integrated case-based pedagogy as our main pedagogical approach.

Financial Incentives and Cervical Cancer Screening Participation in Ontario's Primary Care Practice Models

OBJECTIVES

The primary objective of this paper is to compare cervical cancer screening rates of family physicians in Ontario's two dominant reformed practice models, Family Health Group (FHG) and Family Health Organization (FHO), and traditional fee-for-service (FFS) model. Both reformed models formally enrol patients and offer extensive pay-for-performance incentives; however, they differ by remuneration for core services (FHG is FFS; FHO is capitated). The secondary objective is to estimate the average and marginal costs of screening in each model.

METHODS

Using administrative data on 7,298 family physicians and their 2,083,633 female patients aged 35-69 eligible for cervical cancer screening in 2011, we assessed screening rates after adjusting for patient and physician characteristics. Predicted screening rates, fees and bonus payments were used to estimate the average and marginal costs of cervical cancer screening.

RESULTS

Adjusted screening rates were highest in the FHG (81.9%), followed by the FHO (79.6%), and then the traditional FFS model (74.2%). The cost of a cervical cancer screening was $18.30 in the FFS model. The estimated average cost of screening in the FHGs and FHOs were $29.71 and $35.02, respectively, while the corresponding marginal costs were $33.05 and $39.06.

DISCUSSION

We found significant differences in cervical cancer screening rates across Ontario's primary care practice models. Cervical screening rates were significantly higher in practice models eligible for incentives (FHGs and FHOs) than the traditional FFS model. However, the average and marginal cost of screening were lowest in the traditional FFS model and highest in the FHOs.

Implementing and Using a Patient Portal: A qualitative exploration of patient and provider perspectives on engaging patients

BACKGROUND

The use of portals might be expected to rise; however, adoption has been slow. Development of portals has occurred with limited patient involvement. This paper fills a need for literature concerning perspectives regarding the value of portals, how best to organize and provide portals, and critically how to seek patient involvement in implementation.ObjectiveThe objective was to explore the feelings, ideas, and expectations of patients and primary care providers concerning the implementation and use of patient portals.

METHOD

The study employed a descriptive qualitative design interviewing seven patients and four providers from an interdisciplinary primary health care clinic in Ontario, Canada. Patients were older with at least one chronic condition. Interviews were analysed independently by three coders who then met to synthesize the findings.

RESULTS

There was limited experience of portals and substantial convergence between patients and providers regarding concerns and potential benefits with an overall positive view. Four themes emerged: 1) the Context in which patient portal use takes place; 2) the Necessary conditions for use of a patient portal; 3) the Implementation of a patient portal; and 4) the Use of a patient portal for care.

CONCLUSIONS

Findings highlight that it is not sufficient to engage patients in the use of a portal; it is critical that patients be engaged in the early stages of implementation. With many health and fitness electronic tools available (e.g. Fitbit©), this study remind us that tools are not enough. Patient engagement requires patient-centred partnerships between patients and health care providers.

Determinants of tetanus toxoid immunization in pregnancy in rural Bihar

In order to increase the uptake of tetanus toxoid (TT) vaccination, we need to understand the factors that underlie the decision of the pregnant woman to undergo vaccination, especially in rural areas, where 75% of India's population resides. This paper constructs a model from a data-set of 2398 women in order to understand the determinants of TT vaccine immunization by women during their most recent pregnancy and applies it to the National Family Health Survey-2 data. The object of the model is to predict the likelyhood of a pregnant woman receiving the recommended two doses of TT vaccine subject to other factors such as birth order, maternal education, prenatal care provider, household standard of living, health-care-seeking decision-maker and service availability. Policy implications of these findings are discussed.

Costs of cervical cancer treatment: population-based estimates from Ontario

OBJECTIVES

The objectives of the present study were to estimate the overall and specific medical care costs associated with cervical cancer in the first 5 years after diagnosis in Ontario.

METHODS

Incident cases of invasive cervical cancer during 2007-2010 were identified from the Ontario Cancer Registry and linked to administrative databases held at the Institute for Clinical Evaluative Sciences. Mean costs in 2010 Canadian dollars were estimated using the arithmetic mean and estimators that adjust for censored data.

RESULTS

Mean age of the patients in the study cohort (779 cases) was 49.3 years. The mean overall medical care cost was $39,187 [standard error (se): $1,327] in the 1st year after diagnosis. Costs in year 1 ranged from $34,648 (se: $1,275) for those who survived at least 1 year to $69,142 (se: $4,818) for those who died from cervical cancer within 1 year. At 5 years after diagnosis, the mean overall unadjusted cost was $63,131 (se: $3,131), and the cost adjusted for censoring was $68,745 (se: $2,963). Inpatient hospitalizations and cancer-related care were the two largest components of cancer treatment costs.

CONCLUSIONS

We found that the estimated mean costs that did not account for censoring were consistently undervalued, highlighting the importance of estimates based on censoring-adjusted costs in cervical cancer. Our results are reliable for estimating the economic burden of cervical cancer and the cost-effectiveness of cervical cancer prevention strategies.

Prehospital and Emergency Care: Updates from the Disease Control Priorities, Version 3

BACKGROUND

It is increasingly understood that emergency care systems can be cost-effective in low- and middle-income countries (LMICs). The development of such systems, however, is still a work in progress. This article updates previous work in providing the most recent estimates of the burden of disease sensitive to emergency care, the current state of knowledge on the feasibility of emergency care, effect on outcomes, and cost-effectiveness in LMICs, and future directions for research, policy, and implementation.

METHODS

We calculated the potential impact of prehospital and emergency care systems using updated and revised data based on the global burden of disease study. We then assessed the state of current knowledge and potential future directions for research and policy by conducting a review of the literature on current systems in LMICs.

RESULTS

According to these newest updates, 24 million deaths related to emergency medical conditions occur in LMICs annually, accounting for an estimated 932 million years of life lost. Evidence shows that multiple emergency care models can function in different local settings, depending on resources and urbanicity. Emergency care can significantly improve mortality rates from emergent conditions and be highly cost-effective. Further research is needed on implementation of emergency care systems as they become a necessary reality in developing nations worldwide.

CONCLUSIONS

Emergency care implementation in LMICs presents both challenges and opportunities. Investment in evidence-based emergency care, research on implementation, and system coordination in LMICs could lead to a more cost- and outcome-effective emergency care system than exists in advanced economies.

Factors Impacting Transgender Patients' Discomfort with Their Family Physicians: A Respondent-Driven Sampling Survey

Background

Representing approximately 0.5% of the population, transgender (trans) persons in Canada depend on family physicians for both general and transition-related care. However, physicians receive little to no training on this patient population, and trans patients are often profoundly uncomfortable and may avoid health care. This study examined factors associated with patient discomfort discussing trans health issues with a family physician in Ontario, Canada.

Methods

433 trans people age 16 and over were surveyed using respondent-driven sampling for the Trans PULSE Project; 356 had a family physician. Weighted logistic regression models were fit to produce prevalence risk ratios (PRRs) via average marginal predictions, for transmasculine (n = 184) and transfeminine (n = 172) trans persons.

Results

Among the 83.1% (95% CI = 77.4, 88.9) of trans Ontarians who had a family physician, approximately half reported discomfort discussing trans health issues. 37.2% of transmasculine and 38.1% of transfeminine persons reported at least one trans-specific negative experience. In unadjusted analysis, sociodemographics did not predict discomfort, but those who planned to medically transition sex, but had not begun, were more likely to report discomfort (transmasculine: PRR = 2.62 (95% CI = 1.44, 4.77); transfeminine: PRR = 1.85 (95% CI = 1.08, 3.15)). Adjusted for other factors, greater perceived physician knowledge about trans issues was associated with reduced likelihood of discomfort, and previous trans-specific negative experiences with a family physician with increased discomfort. Transfeminine persons who reported three or more types of negative experiences were 2.26 times as likely, and transmasculine persons 1.61 times as likely, to report discomfort. In adjusted analyses, sociodemographic associations differed by gender, with being previously married or having higher education associated with increased risk of discomfort among transfeminine persons, but decreased risk among transmasculine persons.

Conclusions

Within this transgender population, discomfort in discussing trans health issues with a family physician was common, presenting a barrier to accessing primary care despite having a regular family physician and “universal” health insurance.

Influence of a quality improvement learning collaborative program on team functioning in primary healthcare

Quality improvement (QI) programs are frequently implemented to support primary healthcare (PHC) team development and to improve care outcomes. In Ontario, Canada, the Quality Improvement and Innovation Partnership (QIIP) offered a learning collaborative (LC) program to support the development of interdisciplinary team function and improve chronic disease management, disease prevention, and access to care. A qualitative study using a phenomenological approach was conducted as part of a mixed-method evaluation to explore the influence of the program on team functioning in participating PHC teams. A purposive sampling strategy was used to identify PHC teams (n = 10), from which participants of different professional roles were selected through a purposeful recruitment process to reflect maximum variation of team roles. Additionally, QI coaches working with the interview participants and the LC administrators were also interviewed. Data were collected through semistructured telephone interviews that were audiotaped and transcribed verbatim. Thematic analysis was conducted through an iterative and interpretive approach. The shared experience of participating in the program appeared to improve team functioning. Participants described increased trust and respect for each other's clinical and administrative roles and were inspired by learning about different approaches to interdisciplinary care. This appeared to enhance collegial relationships, collapse professional silos, improve communication, and increase interdisciplinary collaboration. Teamwork involves more than just physically grouping healthcare providers from multiple disciplines and mandating them to work together. The LC program provided opportunities for participants to learn how to work collaboratively, and participation in the LC program appeared to enhance team functioning.

A Population-Based Study of 30-day Incidence of Ischemic Stroke Following Surgical Neck Dissection

The objective of this study was to determine the 30-day incidence of ischemic stroke following neck dissection compared to matched patients undergoing non-head and neck surgeries.A surgical dissection of the neck is a common procedure performed for many types of cancer. Whether such dissections increase the risk of ischemic stroke is uncertain.A retrospective cohort study using data from linked administrative and registry databases (1995-2012) in the province of Ontario, Canada was performed. Patients were matched 1-to-1 on age, sex, date of surgery, and comorbidities to patients undergoing non-head and neck surgeries. The primary outcome was ischemic stroke assessed in hospitalized patients using validated database codes.A total of 14,837 patients underwent surgical neck dissection. The 30-day incidence of ischemic stroke following the dissection was 0.7%. This incidence decreased in recent years (1.1% in 1995 to 2000; 0.8% in 2001 to 2006; 0.3% in 2007 to 2012; P for trend <0.0001). The 30-day incidence of ischemic stroke in patients undergoing neck dissection is similar to matched patients undergoing thoracic surgery (0.5%, P = 0.26) and colectomy (0.5%, P = 0.1). Factors independently associated with a higher risk of stroke in 30 days following neck dissection surgery were of age ≥75 years (odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.53), and a history of diabetes (OR 1.60, 95% CI 1.02-2.49), hypertension (OR 2.64, 95% CI 1.64-4.25), or prior stroke (OR 4.06, 95% CI 2.29-7.18).Less than 1% of patients undergoing surgical neck dissection will experience an ischemic stroke in the following 30 days. This incidence of stroke is similar to thoracic surgery and colectomy.

Secular trends in the survival of patients with laryngeal carcinoma, 1995-2007

BACKGROUND

Recent reports suggest a decline over time in the survival of patients newly diagnosed with laryngeal cancer in spite of developments in treatment practices. Our study set out to determine whether the survival of patients with laryngeal cancer in Ontario has changed over time.

METHODS

This population-based cohort study of patients diagnosed with laryngeal cancer in the province of Ontario between 1995 and 2007 used data extracted from linked provincial administrative and registry databases. Its main outcomes were overall survival, laryngectomy-free survival, and survival ratio relative to an age- and sex-matched general population.

RESULTS

The 4298 patients newly diagnosed with laryngeal cancer during the period of interest were predominantly men (n = 3615, 84.1%) with glottic cancer (n = 2787, 64.8%); mean age in the group was 66 years (interquartile range: 59-74 years). Patient demographics did not significantly change over time. Overall, 5-year survival was 57.4%; laryngectomy-free survival was 45.4%. Comparing patients from three eras (1995-1998, 1999-2003, 2004-2007) and adjusting for age, sex, and comorbidity status, we observed no differences in overall survival or laryngectomy-free survival over time. The 5-year relative survival ratio for patients with laryngeal cancer compared with an age- and sex-matched group from the general population was 81.1% for glottic cancer and 44.5% for supraglottic cancer.

CONCLUSIONS

In patients with a new diagnosis of laryngeal cancer, overall and laryngectomy-free survival have remained unchanged since the mid-1990s. New methods to improve survival and the rate of laryngeal preservation in this patient population are needed.

Examining the symptom of fatigue in primary care: a comparative study using electronic medical records

BACKGROUND

The symptom of fatigue is one of the top five most frequently presented health complaints in primary care, yet it remains underexplored in the Canadian primary care context.

OBJECTIVE

The objective of this study was to examine the prevalence and impact of patients presenting with fatigue in primary care, using the only known electronic database in Canada to capture patient-reported symptoms.

METHODS

Data were extracted from the Deliver Primary Healthcare Information (DELPHI) database, an electronic medical record database located in Ontario, Canada. Patients were identified using the International Classification of Primary Care, Revised Second Edition coding system. Two groups of patients (fatigue or non-fatigue symptom) were followed for one year and compared. Both descriptive and multivariable analyses were conducted.

RESULTS

A total of 103 fatigue symptom patients, and 103 non-fatigue symptom patients, were identified in the DELPHI database. The period prevalence of fatigue presentation was 8.2%, with the majority of patients being female and over 60 years of age. These patients experienced numerous co-occurring morbidities, in addition to the fatigue itself. During the one year follow-up period, fatigue symptom patients had significantly higher rates of subsequent visits (IRR = 1.19, p = 0.038) and investigations (IRR = 1.68, p < 0.001), and markedly high levels of referrals following their index visit.

CONCLUSIONS

This research used an electronic database to examine the symptom, fatigue. Using these data, fatigue symptom patients were found to have higher rates of health care utilisation, compared to non-fatigue symptom patients.