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Fuller J, Chin-Yee B, Upshur REG. The argument framework is a flexible approach to evidence in healthcare. Nat Med 2024:10.1038/s41591-024-02930-x. [PMID: 38671239 DOI: 10.1038/s41591-024-02930-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Affiliation(s)
- Jonathan Fuller
- Department of History and Philosophy of Science, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Benjamin Chin-Yee
- Division of Hematology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of History and Philosophy of Science, University of Cambridge, Cambridge, UK
| | - Ross E G Upshur
- Dalla Lana School of Public Health and Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Salamanca-Buentello F, Katz R, Silva DS, Upshur REG, Smith MJ. Research ethics review during the COVID-19 pandemic: An international study. PLoS One 2024; 19:e0292512. [PMID: 38626030 PMCID: PMC11020390 DOI: 10.1371/journal.pone.0292512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/23/2024] [Indexed: 04/18/2024] Open
Abstract
Research ethics review committees (ERCs) worldwide faced daunting challenges during the COVID-19 pandemic. There was a need to balance rapid turnaround with rigorous evaluation of high-risk research protocols in the context of considerable uncertainty. This study explored the experiences and performance of ERCs during the pandemic. We conducted an anonymous, cross-sectional, global online survey of chairs (or their delegates) of ERCs who were involved in the review of COVID-19-related research protocols after March 2020. The survey ran from October 2022 to February 2023 and consisted of 50 items, with opportunities for descriptive responses to open-ended questions. Two hundred and three participants [130 from high-income countries (HICs) and 73 from low- and middle-income countries (LMICs)] completed our survey. Respondents came from diverse entities and organizations from 48 countries (19 HICs and 29 LMICs) in all World Health Organization regions. Responses show little of the increased global funding for COVID-19 research was allotted to the operation of ERCs. Few ERCs had pre-existing internal policies to address operation during public health emergencies, but almost half used existing guidelines. Most ERCs modified existing procedures or designed and implemented new ones but had not evaluated the success of these changes. Participants overwhelmingly endorsed permanently implementing several of them. Few ERCs added new members but non-member experts were consulted; quorum was generally achieved. Collaboration among ERCs was infrequent, but reviews conducted by external ERCs were recognized and validated. Review volume increased during the pandemic, with COVID-19-related studies being prioritized. Most protocol reviews were reported as taking less than three weeks. One-third of respondents reported external pressure on their ERCs from different stakeholders to approve or reject specific COVID-19-related protocols. ERC members faced significant challenges to keep their committees functioning during the pandemic. Our findings can inform ERC approaches towards future public health emergencies. To our knowledge, this is the first international, COVID-19-related study of its kind.
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Affiliation(s)
- Fabio Salamanca-Buentello
- Lunenfeld-Tanenbaum Research Institute, Bridgepoint Collaboratory for Research and Innovation, Sinai Health, Toronto, Canada
| | - Rachel Katz
- Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Canada
| | - Diego S. Silva
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Ross E. G. Upshur
- Lunenfeld-Tanenbaum Research Institute, Bridgepoint Collaboratory for Research and Innovation, Sinai Health, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Aggarwal M, Katz A, Kokorelias KM, Wong ST, Aghajafari F, Ivers NM, Martin-Misener R, Aubrey-Bassler K, Breton M, Upshur REG, Kwong JC. What are effective vaccine distribution approaches for equity-deserving and high-risk populations during COVID-19? Exploring best practices and recommendations in Canada: protocol for a mixed-methods multiple case codesign study. BMJ Open 2023; 13:e072238. [PMID: 37940159 PMCID: PMC10632871 DOI: 10.1136/bmjopen-2023-072238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION The WHO has stated that vaccine hesitancy is a serious threat to overcoming COVID-19. Vaccine hesitancy among underserved and at-risk communities is an ongoing challenge in Canada. Public confidence in vaccine safety and effectiveness and the principles of equity need to be considered in vaccine distribution. In Canada, governments of each province or territory manage their own healthcare system, providing an opportunity to compare and contrast distribution strategies. The overarching objective of this study is to identify effective vaccine distribution approaches and advance knowledge on how to design and implement various strategies to meet the different needs of underserved communities. METHODS AND ANALYSIS Multiple case studies in seven Canadian provinces will be conducted using a mixed-methods design. The study will be informed by Experience-Based CoDesign techniques and theoretically guided by the Socio-Ecological Model and the Vaccine Hesitancy Matrix frameworks. Phase 1 will involve a policy document review to systematically explore the vaccine distribution strategy over time in each jurisdiction. This will inform the second phase, which will involve (2a) semistructured, in-depth interviews with policymakers, public health officials, researchers, providers, groups representing patients, researchers and stakeholders and (2b) an analysis of population-based administrative health data of vaccine administration. Integration of qualitative and quantitative data will inform the identification of effective vaccine distribution approaches for various populations. Informed by this evidence, phase 3 of the study will involve conducting focus groups with multiple stakeholders to codesign recommendations for the design and implementation of effective vaccine delivery strategies for equity-deserving and at-risk populations. ETHICS AND DISSEMINATION This study is approved by the University of Toronto's Health Sciences Research Ethics Board (#42643), University of British Columbia Behavioural Research Ethics Board (#H22-01750-A002), Research Ethics Board of the Nova Scotia Health Authority (#48272), Newfoundland and Labrador Health Research Ethics Board (#2022.126), Conjoint Health Research Ethics Board, University of Calgary (REB22-0207), and University of Manitoba Health Research Board (H2022-239). The outcome of this study will be to produce a series of recommendations for implementing future vaccine distribution approaches from the perspective of various stakeholders, including equity-deserving and at-risk populations.
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Affiliation(s)
- Monica Aggarwal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Alan Katz
- Department of Community Health Sciences, Rady Faculty of Health Sciences University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Family Medicine, Rady Faculty of Health Sciences University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristina Marie Kokorelias
- Rehabiliation Sciences Institute, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Rehabiliation Sciences Institute, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Sabrina T Wong
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Noah M Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University, St. John's, Newfoundland, Canada
| | - Mylaine Breton
- Department of Community Health Sciences, University of Sherbrooke, Longueuil, Quebec, Canada
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
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Aggarwal M, Scott G, Kokorelias KM, Kulasegaram K, Katz A, Upshur REG. Defining the capabilities and competencies of high-performing family physicians: a mixed methods study. BMJ Open 2023; 13:e072266. [PMID: 37591643 PMCID: PMC10441087 DOI: 10.1136/bmjopen-2023-072266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/27/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION High-performing primary care is recognised as the foundation of an effective and efficient healthcare system. Many medical graduates report they are not prepared for independent practice. To date, no research has been conducted to identify the key capabilities and competencies of high-performing family medicine graduates in Canada. This pilot project aims to identify the capabilities and competencies of high-performing early-career family physicians in Ontario, Canada, and explore opportunities for enhancing learning, teaching and assessment within family medicine residency programmes. METHODS AND ANALYSIS Employing a mixed-methods explanatory sequential study design, this research will use a theory-driven Professional Capability Framework, previously validated in studies across nine professions, to guide the investigation. The first (quantitative) phase involves surveying ~50 high-performing early-career family physicians identified as high performing by educators, colleagues and leaders. The objective of the survey is to identify the key competencies and personal, interpersonal and cognitive capabilities of high-performing family physicians. The second (qualitative) phase involves conducting workshops with stakeholders, including educators, professional associations, regulators and colleges, to test the veracity of the results. Quantitative data will be analysed using descriptive statistics, and qualitative data will be analysed using Braun and Clarke's thematic analysis. The first and second phases will identify the key capabilities and competencies required to confidently adapt to the independent practice of comprehensive family medicine and inform fit-for-purpose educational strategies for teaching, learning and assessment. ETHICS AND DISSEMINATION The study is approved by the University of Toronto's Health Sciences Research Ethics Board (#41799). Research findings will be discussed with professional bodies, educators responsible for family medicine curricula and universities. Study findings will also be disseminated through academic conferences and academic publications in peer-reviewed journals. Project summaries and infographics will be developed and disseminated to key stakeholders.
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Affiliation(s)
- Monica Aggarwal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Geoffrey Scott
- Learning Futures, University of Western Sydney, Penrith South, New South Wales, Australia
| | - Kristina Marie Kokorelias
- Department of Geriatric Medicine, Sinai Health and University Health Network, Toronto, Ontario, Canada
- Rehabiliation Sciences Institute and Department of Occupational Therapy and Occupational Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Kulamakan Kulasegaram
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alan Katz
- Department of Community Health Sciences and Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Aggarwal M, Kokorelias KM, Glazier RH, Katz A, Shiers-Hanley JE, Upshur REG. What is the role of primary care in the COVID-19 vaccine roll-out and the barriers and facilitators to an equitable vaccine roll-out? A rapid scoping review of nine jurisdictions. BMJ Open 2023; 13:e065306. [PMID: 37076148 PMCID: PMC10123853 DOI: 10.1136/bmjopen-2022-065306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVES This study aimed to: (1) examine the experience of nine global jurisdictions that engaged primary care providers (PCPs) to administer COVID-19 vaccines during the pandemic; (2) describe how vaccine hesitancy and principles of equity were incorporated in the COVID-19 vaccine roll-out strategies and (3) identify the barriers and facilitators to the vaccine roll-out. DESIGN Rapid scoping review. DATA SOURCES Searches took place in MEDLINE, CINAHL, Embase, the Cochrane Library, SCOPUS and PsycINFO, Google, and the websites of national health departments. Searches and analyses took place from May 2021 to July 2021. RESULTS Sixty-two documents met the inclusion criteria (35=grey literature; 56% and 27=peer reviewed; 44%). This review found that the vaccine distribution approach started at hospitals in almost all jurisdictions. In some jurisdictions, PCPs were engaged at the beginning, and the majority included PCPs over time. In many jurisdictions, equity was considered in the prioritisation policies for various marginalised communities. However, vaccine hesitancy was not explicitly considered in the design of vaccine distribution approaches. The barriers to the roll-out of vaccines included personal, organisational and contextual factors. The vaccine roll-out strategy was facilitated by establishing policies and processes for pandemic preparedness, well-established and coordinated information systems, primary care interventions, adequate supply of providers, education and training of providers, and effective communications strategy. CONCLUSIONS Empirical evidence is lacking on the impact of a primary care-led vaccine distribution approach on vaccine hesitancy, adoption and equity. Future vaccine distribution approaches need to be informed by further research evaluating vaccine distribution approaches and their impact on patient and population outcomes.
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Affiliation(s)
- Monica Aggarwal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kristina Marie Kokorelias
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
| | - Richard H Glazier
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alan Katz
- Department of Community Health Sciences, Rady Faculty of Health Sciences University, Winnipeg, Manitoba, Canada
| | | | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Haldane V, Ariyarajah A, Berry I, Loutet M, Salamanca-Buentello F, Upshur REG. Global inequity creates local insufficiency: A qualitative study of COVID-19 vaccine implementation challenges in low-and-middle-income countries. PLoS One 2023; 18:e0281358. [PMID: 36780502 PMCID: PMC9925066 DOI: 10.1371/journal.pone.0281358] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/22/2023] [Indexed: 02/15/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has amplified pre-existing challenges to health promotion and care across the world, and particularly in low- and middle-income countries (LMICs). This qualitative study draws on data from a panel of immunisation experts and uses a novel framework of vaccine delivery domains to explore perspectives from those who live and work in these settings on the challenges to implementing COVID-19 vaccine programs in LMICs. METHODS We conducted a thematic content analysis of 96 participant free text replies to questions from Round I of a three-round Delphi consensus study amongst global experts on COVID-19 vaccine implementation. RESULTS Participant responses highlighted challenges to vaccine program implementation including issues related to equity; governance, decision-making, and financing; regulatory structures, planning, and coordination; prioritisation, demand generation, and communication; vaccine, cold chain, logistics, and infrastructure; service delivery, human resources, and supplies; and surveillance, monitoring, and evaluation. CONCLUSION We reflect on our findings in light of global efforts to address vaccine inequity and emphasise three key areas salient to improving vaccination efforts during novel infectious disease outbreaks: 1) Ensuring safe and sustainable service delivery in communities and at points of care; 2) Strengthening systems for end-to-end delivery of vaccines, therapeutics, diagnostics, and essential supplies; 3) Transforming structural paradigms towards vaccine equity.
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Affiliation(s)
- Victoria Haldane
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Archchun Ariyarajah
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Isha Berry
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Miranda Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Fabio Salamanca-Buentello
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
| | - Ross E. G. Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
- * E-mail:
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Emanuel EJ, Upshur REG, Smith MJ. What Covid Has Taught the World about Ethics. N Engl J Med 2022; 387:1542-1545. [PMID: 36301580 DOI: 10.1056/nejmp2210173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ezekiel J Emanuel
- From the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia (E.J.E.); and the Dalla Lana School of Public Health, University of Toronto, Toronto (R.E.G.U.), and the School of Health Studies, Faculty of Health Sciences, Western University, London, ON (M.J.S.) - both in Canada
| | - Ross E G Upshur
- From the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia (E.J.E.); and the Dalla Lana School of Public Health, University of Toronto, Toronto (R.E.G.U.), and the School of Health Studies, Faculty of Health Sciences, Western University, London, ON (M.J.S.) - both in Canada
| | - Maxwell J Smith
- From the Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia (E.J.E.); and the Dalla Lana School of Public Health, University of Toronto, Toronto (R.E.G.U.), and the School of Health Studies, Faculty of Health Sciences, Western University, London, ON (M.J.S.) - both in Canada
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Langlois-Thérien T, Dewar B, Upshur REG, Shamy M. Use of evidence in acute stroke decision-making: Implications for evidence-based medicine. J Eval Clin Pract 2022; 28:733-740. [PMID: 34258832 DOI: 10.1111/jep.13597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Evidence-Based Medicine proposes a prescriptive model of physician decision-making in which 'best evidence' is used to guide best practice. And yet, proponents of EBM acknowledge that EBM fails to offer a systematic theory of physician decision-making. METHODS In this paper, we explore how physicians from the neurology and emergency medicine communities have responded to an evolving body of evidence surrounding the acute treatment of patients with ischemic stroke. Through analysis of this case study, we argue that EBM's vision of evidence-based medical decision-making fails to appreciate a process that we have termed epistemic evaluation. RESULTS AND CONCLUSIONS Physicians are required to interpret and apply any knowledge-even what EBM would term 'best evidence'-in light of their own knowledge, background and experience. This is consequential for EBM as understanding what physicians do and why they do it would appear to be essential to achieving optimal practice in accordance with best evidence.
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Affiliation(s)
- Timothé Langlois-Thérien
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Sud A, Strang M, Buchman DZ, Spithoff S, Upshur REG, Webster F, Grundy Q. How the Suboxone Education Programme presented as a solution to risks in the Canadian opioid crisis: a critical discourse analysis. BMJ Open 2022; 12:e059561. [PMID: 35820738 PMCID: PMC9277368 DOI: 10.1136/bmjopen-2021-059561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Pharmaceutical industry involvement in medical education, research and clinical practice can lead to conflicts of interest. Within this context, this study examined how the 'Suboxone Education Programme', developed and delivered by a pharmaceutical company as part of a federally regulated risk management program, was presented as a solution to various kinds of risks relating to opioid use in public documents from medical institutions across Canada. SETTING These documents were issued during the Canadian opioid crisis, a time when the involvement of industry in health policy was being widely questioned given industry's role in driving the overprescribing of opioid analgesics and contributing to population-level harms. DESIGN A critical discourse analysis of 69 documents collected between July 2020 and May 2021 referencing the Suboxone Education Program spanning 13 years (2007-2021) from medical, nursing and pharmacy institutions sourced from every Canadian province and territory. Discursive themes were identified through iterative and duplicate analyses using a semistructured data extraction instrument. RESULTS Documents characterised the Programme as addressing iatrogenic risks from overprescribing opioid analgesics, environmental risks from a toxic street drug supply and pharmacological risks relating to the dominant therapeutic alternative of methadone. The programme was identified as being able to address these risks by providing mechanisms to surveil healthcare professionals and to facilitate the prescribing of Suboxone. Medical institutions legitimised the Suboxone Education Programme by lending their regulatory, epidemiological and professional authority. CONCLUSIONS Addressing risk is considered as a central, moral responsibility of contemporary healthcare services. In this case, moral imperatives to address opioid crisis-related risks overrode other ethical concerns regarding conflicts of interest between industry and public welfare. Failing to address these conflicts potentially imperils efforts of mitigating population health harms by propagating an important driving force of the opioid crisis.
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Affiliation(s)
- Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Toronto, Ontario, Canada
| | - Matthew Strang
- Department of Sociology, York University, Toronto, Ontario, Canada
| | - Daniel Z Buchman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Bioethics Program, University Health Network, Toronto, Ontario, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Ross E G Upshur
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Fiona Webster
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Quinn Grundy
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Singh JA, Kochhar S, Wolff J, Atuire C, Bhan A, Emanuel E, Faden R, Ghimire P, Greco D, Ho C, Moon S, Shamsi-Gooshki E, Touré A, Thomé B, Smith MJ, Upshur REG. WHO guidance on COVID-19 vaccine trial designs in the context of authorized COVID-19 vaccines and expanding global access: Ethical considerations. Vaccine 2022; 40:2140-2149. [PMID: 35248422 PMCID: PMC8882397 DOI: 10.1016/j.vaccine.2022.02.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/04/2023]
Abstract
While the degree of COVID-19 vaccine accessibility and uptake varies at both national and global levels, increasing vaccination coverage raises questions regarding the standard of prevention that ought to apply to different settings where COVID-19 vaccine trials are hosted. A WHO Expert Group has developed guidance on the ethical implications of conducting placebo-controlled trials in the context of expanding global COVID-19 vaccine coverage. The guidance also considers alternative trial designs to placebo controlled trials in the context of prototype vaccines, modified vaccines, and next generation vaccines.
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Affiliation(s)
- Jerome Amir Singh
- Howard College School of Law, University of KwaZulu-Natal, Durban, South Africa; Scientific Advisory Group on Emergencies (SAGE), Academy of Science of South Africa (ASSAf), Pretoria, South Africa; Department of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Sonali Kochhar
- Department of Global Health, University of Washington, Seattle, WA, USA; Global Healthcare Consulting, Delhi, India
| | - Jonathan Wolff
- Blavatnik School of Government, University of Oxford, Oxford, UK
| | - Caesar Atuire
- Department of Philosophy and Classics, University of Ghana, Accra, Ghana
| | - Anant Bhan
- Department of Community Medicine and Centre for Ethics, Yenepoya University, Mangalore, India
| | - Ezekiel Emanuel
- Global Initiatives and Healthcare Transformation Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Ruth Faden
- Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | | | - Dirceu Greco
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Calvin Ho
- Faculty of Law and Centre for Medical Ethics, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Suerie Moon
- International Relations and Political Science Department & Interdisciplinary Programmes, Global Health Centre, Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Ehsan Shamsi-Gooshki
- Department of Medical Ethics, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Beatriz Thomé
- Departamento de Medicina Preventiva, Universidade Federal de São Paulo, Rua Botucatu,Sao Paolo, Brazil
| | - Maxwell J Smith
- Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Ross E G Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health University of Toronto, Toronto, Ontario, Canada
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11
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Sud A, Buchman DZ, Furlan AD, Selby P, Spithoff SM, Upshur REG. Chronic Pain and Opioid Prescribing: Three Ways for Navigating Complexity at the Clinical‒Population Health Interface. Am J Public Health 2022; 112:S56-S65. [PMID: 35143271 PMCID: PMC8842204 DOI: 10.2105/ajph.2021.306500] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/04/2022]
Abstract
Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically. We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty. We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56-S65. https://doi.org/10.2105/AJPH.2021.306500).
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Affiliation(s)
- Abhimanyu Sud
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Daniel Z Buchman
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Andrea D Furlan
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Peter Selby
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Sheryl M Spithoff
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
| | - Ross E G Upshur
- Abhimanyu Sud is with the Department of Family and Community Medicine and Institute for Health Policy, Management, and Evaluation, University of Toronto, Canada. Daniel Z. Buchman is with Centre for Addiction and Mental Health and Dalla Lana School of Public Health, Toronto. Andrea D. Furlan is with the Institute for Work and Health and Department of Medicine, University of Toronto. Peter Selby is with the Centre for Addiction and Mental Health and Department of Family and Community Medicine, Department of Psychiatry, University of Toronto. Sheryl M. Spithoff is with Department of Family and Community Medicine, University of Toronto. Ross E. G. Upshur is with the Bridgepoint Collaboratory for Research and Innovation, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto
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12
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Ariyarajah A, Berry I, Haldane V, Loutet M, Salamanca-Buentello F, Upshur REG. Identifying priority challenges and solutions for COVID-19 vaccine delivery in low- and middle-income countries: A modified Delphi study. PLOS Glob Public Health 2022; 2:e0000844. [PMID: 36962787 PMCID: PMC10021567 DOI: 10.1371/journal.pgph.0000844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The rapid implementation of global COVID-19 vaccination programs has surfaced many challenges and inequities, particularly in low- and middle-income countries (LMICs). However, there continues to be a lack of consensus on which challenges are global priorities for action, and how to best respond to them. This study uses consensus-based methods to identify and rank the most important challenges and solutions for implementation of COVID-19 vaccination programs in LMICs. METHODS We conducted a three-round modified Delphi study with a global panel of vaccine delivery experts. In Round I, panelists identified broad topical challenges and solutions. Responses were collated and coded into distinct items. Through two further rounds of structured, iterative surveys panelists reviewed and ranked the identified items. Responses were analyzed qualitatively and quantitatively to achieve consensus on the most important COVID-19 vaccine delivery challenges and solutions. RESULTS Of the 426 invited panelists, 96 completed Round I, 56 completed Round II, and 39 completed Round III. Across all three rounds there was equal representation by gender, and panelists reported work experience in all World Bank regions and across a variety of content areas and organizations. Of the 64 initially identified items, the panel achieved consensus on three challenges and 10 solutions. Challenges fell under themes of structural factors and infrastructure and human and material resources, while solutions also included items within themes of communication, community engagement, and access and planning, processes, and operations. CONCLUSION COVID-19 vaccine delivery is challenged by long-standing and structural inequities that disadvantage health service delivery in LMICs. These findings can, and should, be used by global health organizations to efficiently and optimally direct resources to respond to these key challenges and solutions.
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Affiliation(s)
- Archchun Ariyarajah
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Isha Berry
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Victoria Haldane
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Miranda Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Fabio Salamanca-Buentello
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada
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13
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Carter C, Leanza F, Mohammed S, Upshur REG, Kontos P. A rapid scoping review of end-of-life conversations with frail older adults in Canada. Can Fam Physician 2021; 67:e298-e305. [PMID: 34772723 DOI: 10.46747/cfp.6711e298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To explore what is known about end-of-life (EOL) conversations with frail older adults across all settings including primary care in Canada, and to understand the barriers to, and recommendations for, EOL conversations. DATA SOURCES Comprehensive searches were conducted in CINAHL (EBSCO), Embase (Ovid), MEDLINE (Ovid), AgeLine (EBSCO), Sociological Abstracts (ProQuest), and Applied Social Sciences Index and Abstracts (ProQuest). Searches used text words and subject headings (eg, MeSH, Emtree) related to 3 concepts: frailty, Canada, and EOL conversations. STUDY SELECTION Twenty-one English-language articles were selected (ie, 4 reviews, 10 commentaries, 3 quantitative studies, 3 qualitative studies, 1 mixed-methods study) that included information about EOL conversations with frail older adults in the Canadian health care context. SYNTHESIS In terms of having EOL conversations with frail older adults, this study found that many clinicians do not often and adequately discuss frailty and impending death with their older patients. Moreover, patients and their care partners do not have enough knowledge about frailty and death to make informed EOL decisions, leading to patients choosing more aggressive therapies instead of care focused on symptom management. In terms of barriers to EOL discussions, common barriers included a lack of trust between clinician and patient, inadequate EOL training for clinicians, and ineffective clinician communication with patients and families. Recommendations for improving EOL conversations include regular screening for frailty to prompt conversations about care and the use of an interprofessional approach. CONCLUSION More empirical research is needed that uses exploratory methods to shed light on the contextual factors that may act as a barrier to EOL conversations. More research is also needed on the roles and responsibilities of interprofessional teams in screening for frailty and engaging in EOL conversations. Moreover, there is a need to better understand how frail older patients and their families want EOL conversations to unfold and what best facilitates these conversations.
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Affiliation(s)
- Celina Carter
- PhD candidate in the Dalla Lana School of Public Health at the University of Toronto in Ontario.
| | - Francesco Leanza
- Family physician and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto
| | - Shan Mohammed
- Assistant Professor, Teaching Stream, in the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto, and a faculty member in the Global Institute of Psychosocial, Palliative and End-of-Life Care, at the University Health Network in Toronto
| | - Ross E G Upshur
- Family physician and Professor in the Department of Family and Community Medicine and the Dalla Lana School of Public Health at the University of Toronto, Head of the Division of Clinical Public Health at the Dalla Lana School of Public Health, and Scientific Director of the Bridgepoint Collaboratory for Research and Innovation
| | - Pia Kontos
- Senior Scientist in the KITE-Toronto Rehabilitation Institute at the University Health Network, and Professor in the Dalla Lana School of Public Health at the University of Toronto
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14
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Sturmberg JP, Getz LO, Stange KC, Upshur REG, Mercer SW. Beyond multimorbidity: What can we learn from complexity science? J Eval Clin Pract 2021; 27:1187-1193. [PMID: 33588522 DOI: 10.1111/jep.13521] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022]
Abstract
Multimorbidity - the occurrence of two or more long-term conditions in an individual - is a major global concern, placing a huge burden on healthcare systems, physicians, and patients. It challenges the current biomedical paradigm, in particular conventional evidence-based medicine's dominant focus on single-conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification, and optimal management cannot be deduced from clinical practice guidelines. In this article, we argue that person-focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. The approach offers an integrated and coherent perspective on the person's living environment, relationships, somatic, emotional and cognitive experiences and physiological function. The underlying principles include non-linearity, tipping points, emergence, importance of initial conditions, contextual factors and co-evolution, and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole people, given the constraints of their socio-ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? These questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical and contextual factors, to guide an integrated approach to the care of people with multimorbidity.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Foundation President, International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont
| | - Linn O Getz
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kurt C Stange
- Department of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology and Sociology, Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ross E G Upshur
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stewart W Mercer
- Department of Primary Care and Multimorbidity, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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15
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Nowak DA, Sheikhan NY, Naidu SC, Kuluski K, Upshur REG. Why does continuity of care with family doctors matter? Review and qualitative synthesis of patient and physician perspectives. Can Fam Physician 2021; 67:679-688. [PMID: 34521712 DOI: 10.46747/cfp.6709679] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To summarize and synthesize qualitative studies that report patient and physician perspectives on continuity of care in family practice. DATA SOURCES MEDLINE (Ovid), EMBASE (Ovid), and PsycInfo (Ovid) were searched for qualitative primary research reporting perspectives of patients, physicians, or both, on continuity of care in family practice. STUDY SELECTION English-language qualitative studies were selected (eg, interviews, focus groups, mixed methods) that were conducted in Canada, the United States, the United Kingdom, the European Union, New Zealand, or Australia. SYNTHESIS Themes were extracted, summarized, and synthesized. Six overarching themes emerged: continuity of care enables person-centred care; continuity of care increases quality of care; continuity of care leads to greater confidence in medical decision making; continuity of care comes with drawbacks; the absence of continuity of care may lead to medical and psychological harm; and continuity of care can foster greater joy and meaning in a physician's work. Out of the 6 themes, patients and physicians shared the first 5. CONCLUSION To the authors' knowledge, this is the first qualitative review reporting the unique perspectives of both patients and family physicians on continuity of care. The findings add nuanced insight to the importance of continuity of care in family practice.
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Affiliation(s)
- Dominik Alex Nowak
- Family physician and adjunct faculty in the Department of Family and Community Medicine at the University of Toronto in Ontario
| | - Natasha Yasmin Sheikhan
- Doctoral student in the Institute of Health Policy, Management and Evaluation at the University of Toronto, and a recent graduate of Johns Hopkins Bloomberg School of Public Health in Baltimore, MD
| | | | - Kerry Kuluski
- Associate Professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto, the inaugural Dr Mathias Gysler Research Chair in Patient & Family Centred Care, and a scientist in the Institute for Better Health at Trillium Health Partners
| | - Ross E G Upshur
- Family physician and Professor in the Department of Family and Community Medicine and the Dalla Lana School of Public Health at the University of Toronto, Head of the Division of Clinical Public Health at the Dalla Lana School of Public Health, and Scientific Director of the Bridgepoint Collaboratory for Research and Innovation
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16
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Wei X, Zhang Z, Chong MKC, Hicks JP, Gong W, Zou G, Zhong J, Walley JD, Upshur REG, Yu M. Evaluation of a package of risk-based pharmaceutical and lifestyle interventions in patients with hypertension and/or diabetes in rural China: A pragmatic cluster randomised controlled trial. PLoS Med 2021; 18:e1003694. [PMID: 34197452 PMCID: PMC8284676 DOI: 10.1371/journal.pmed.1003694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 07/16/2021] [Accepted: 06/13/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Primary prevention of cardiovascular disease (CVD) requires adequate control of hypertension and diabetes. We designed and implemented pharmaceutical and healthy lifestyle interventions for patients with diabetes and/or hypertension in rural primary care, and assessed their effectiveness at reducing severe CVD events. METHODS AND FINDINGS We used a pragmatic, parallel group, 2-arm, controlled, superiority, cluster trial design. We randomised 67 township hospitals in Zhejiang Province, China, to intervention (34) or control (33). A total of 31,326 participants were recruited, with 15,380 in the intervention arm and 15,946 in the control arm. Participants had no known CVD and were either patients with hypertension and a 10-year CVD risk of 20% or higher, or patients with type 2 diabetes regardless of their CVD risk. The intervention included prescription of a standardised package of medicines, individual advice on lifestyle change, and adherence support. Control was usual hypertension and diabetes care. In both arms, as usual in China, most outpatient drug costs were out of pocket. The primary outcome was severe CVD events, including coronary heart disease and stroke, during 36 months of follow-up, as recorded by the CVD surveillance system. The study was implemented between December 2013 and May 2017. A total of 13,385 (87%) and 14,745 (92%) participated in the intervention and control arms, respectively. Their mean age was 64 years, 51% were women, and 90% were farmers. Of all participants, 64% were diagnosed with hypertension with or without diabetes, and 36% were diagnosed with diabetes only. All township hospitals and participants completed the 36-month follow-up. At 36 months, there were 762 and 874 severe CVD events in the intervention and control arms, respectively, yielding a non-significant effect on CVD incidence rate (1.92 and 2.01 per 100 person-years, respectively; crude incidence rate ratio = 0.90 [95% CI: 0.74, 1.08; P = 0.259]). We observed significant, but small, differences in the change from baseline to follow-up for systolic blood pressure (-1.44 mm Hg [95% CI: -2.26, -0.62; P < 0.001]) and diastolic blood pressure (-1.29 mm Hg [95% CI: -1.77, -0.80; P < 0.001]) in the intervention arm compared to the control arm. Self-reported adherence to recommended medicines was significantly higher in the intervention arm compared with the control arm at 36 months. No safety concerns were identified. Main study limitations include all participants being informed about their high CVD risk at baseline, non-blinding of participants, and the relatively short follow-up period available for judging potential changes in rates of CVD events. CONCLUSIONS The comprehensive package of pharmaceutical and healthy lifestyle interventions did not reduce severe CVD events over 36 months. Improving health system factors such as universal coverage for the cost of essential medicines is required for successful risk-based CVD prevention programmes. TRIAL REGISTRATION ISRCTN registry ISRCTN58988083.
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Affiliation(s)
- Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Marc K. C. Chong
- School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Joseph P. Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Weiwei Gong
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - Guanyang Zou
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jieming Zhong
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
| | - John D. Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Ross E. G. Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Min Yu
- Zhejiang Provincial Centre for Disease Control and Prevention, Hangzhou, China
- * E-mail:
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17
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Moin JS, Glazier RH, Kuluski K, Kiss A, Upshur REG. Examine the association between key determinants identified by the chronic disease indicator framework and multimorbidity by rural and urban settings. J Comorb 2021; 11:26335565211028157. [PMID: 34262879 PMCID: PMC8252380 DOI: 10.1177/26335565211028157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022]
Abstract
Background Multimorbidity, often defined as having two or more chronic conditions is a global phenomenon. This study examined the association between key determinants identified by the chronic disease indicator framework and multimorbidity by rural and urban settings. The prevalence of individual diseases was also investigated by age and sex. Methods The Canada Community Health Survey and linked health administrative databases were used to examine the association between multimorbidity, sociodemographic, behavioral, and other risk factors in the province of Ontario. A multivariable logistic regression model was used to conduct the main analysis. Results Analyses were stratified by age (20-64 and 65-95) and area of residence (rural and urban). A total sample of n = 174,938 residents between the ages of 20-95 were examined in the Ontario province, of which 18.2% (n = 31,896) were multimorbid with 2 chronic conditions, and 23.4% (n = 40,883) with 3+ chronic conditions. Females had a higher prevalence of 2 conditions (17.9% versus 14.6%) and 3+ conditions (19.7% vs. 15.6%) relative to males. Out of all examined variables, poor self-perception of health, age, Body Mass Index, and income were most significantly associated with multimorbidity. Smoking was a significant risk factor in urban settings but not rural, while drinking was significant in rural and not urban settings. Income inequality was associated with multimorbidity with greater magnitude in rural areas. Prevalence of multimorbidity and having three or more chronic conditions were highest among low-income populations. Conclusion Interventions targeting population weight, age/sex specific disease burdens, and additional focus on stable income are encouraged.
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Affiliation(s)
- John S Moin
- University of Toronto, Institute of Health Policy Management and Evaluation (Dalla Lana School of Public Health), Toronto, ON, Canada
| | - Richard H Glazier
- Central Site (ICES Central), Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Kerry Kuluski
- University of Toronto, Institute of Health Policy Management and Evaluation (Dalla Lana School of Public Health), Toronto, ON, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Alex Kiss
- University of Toronto, Institute of Health Policy Management and Evaluation (Dalla Lana School of Public Health), Toronto, ON, Canada.,Central Site (ICES Central), Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Ross E G Upshur
- University of Toronto, Institute of Health Policy Management and Evaluation (Dalla Lana School of Public Health), Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Sinai Health Systems, Toronto, ON, Canada
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18
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Smith MJ, Ahmad A, Arawi T, Dawson A, Emanuel EJ, Garani-Papadatos T, Ghimire P, Iliyasu Z, Lei R, Mastroleo I, Mathur R, Okeibunor J, Parker M, Saenz C, Thomé B, Upshur REG, Voo TC. Top five ethical lessons of COVID-19 that the world must learn. Wellcome Open Res 2021; 6:17. [PMID: 33693063 PMCID: PMC7919608 DOI: 10.12688/wellcomeopenres.16568.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 01/30/2023] Open
Abstract
As the world reflects upon one year since the first cases of coronavirus disease 2019 (COVID-19) and prepare for and experience surges in cases, it is important to identify the most crucial ethical issues that might lie ahead so that countries are able to plan accordingly. Some ethical issues are rather obvious to predict, such as the ethical issues surrounding the use of immunity certificates, contact tracing, and the fair allocation of vaccines globally. Yet, the most significant ethical challenge that the world must address in the next year and beyond is to ensure that we learn the ethical lessons of the first year of this pandemic. Learning from our collective experiences thus far constitutes our greatest moral obligation. Appreciating that decision-making in the context of a pandemic is constrained by unprecedented complexity and uncertainty, beginning in June 2020, an international group of 17 experts in bioethics spanning 15 countries (including low-, middle-, and high-income countries) met virtually to identify what we considered to be the most significant ethical challenges and accompanying lessons faced thus far in the COVID-19 pandemic. Once collected, the group met over the course of several virtual meetings to identify challenges and lessons that are analytically distinct in order to identify common ethical themes under which different challenges and lessons could be grouped. The result, described in this paper, is what this expert group consider to be the top five ethical lessons from the initial experience with COVID-19 that must be learned.
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Affiliation(s)
| | - Aasim Ahmad
- The Kidney Centre Post Graduate Training Institute, Karachi, Pakistan
| | | | - Angus Dawson
- University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | | | - Ruipeng Lei
- Huazhong University of Science and Technology, Wuhan, China
| | - Ignacio Mastroleo
- National Scientific and Technical Research Council, Buenos Aires, Argentina
| | - Roli Mathur
- National Center for Disease Informatics and Research (ICMR-NCDIR), Bengaluru, India
| | | | | | - Carla Saenz
- Pan American Health Organization, Washington, DC, USA
| | - Beatriz Thomé
- Universidade Federal de São Paulo, São Paulo, Brazil
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Haldane V, Zhang Z, Abbas RF, Dodd W, Lau LL, Kidd MR, Rouleau K, Zou G, Chao Z, Upshur REG, Walley J, Wei X. National primary care responses to COVID-19: a rapid review of the literature. BMJ Open 2020; 10:e041622. [PMID: 33293398 PMCID: PMC7725079 DOI: 10.1136/bmjopen-2020-041622] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/13/2020] [Accepted: 11/22/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The aim of this review, conducted in April 2020, is to examine available national primary care guidelines for COVID-19 and to explore the ways in which these guidelines support primary care facilities in responding to the demands of the COVID-19 pandemic. DESIGN Rapid review and narrative synthesis. DATA SOURCES PubMed, Embase and Google, as well as the websites of relevant national health departments, were searched from 1 January 2020 to 24 April 2020. ELIGIBILITY CRITERIA Documents included must be issued by a national health authority, must be specific to COVID-19 care, directed at healthcare workers or managers, and must refer to the role of primary care in the COVID-19 response. RESULTS We identified 17 documents from 14 countries. An adapted framework on primary care challenges and responses to pandemic influenza framed our analysis. Guidelines generally reported on COVID-19 service delivery and mostly made specific recommendations for ensuring continued delivery of essential primary care services through telehealth or other virtual care modalities. Few offered guidance to support surveillance as a public health function. All offered guidance on implementing outbreak control measures, largely through flexible and coordinated organisational models with partners from various sectors. There was a lack of guidance to support supply chain management and practice resilience in primary care, and lack of personal protective equipment represents a serious threat to the provision of quality care during the pandemic. CONCLUSIONS Current national primary care guidelines for COVID-19 provide guidance on infection control and minimising the risk of spread in primary care practices, while supporting the use of new technology and coordinated partnerships. However, to ensure primary care practice resilience and quality of care are upheld, guidelines must offer recommendations on supply chain management and operational continuity, supported by adequate resources.
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Affiliation(s)
- Victoria Haldane
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Raja Faisal Abbas
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Warren Dodd
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Lincoln L Lau
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- International Care Ministries, Manila, Philippines
| | - Michael R Kidd
- Australian National University, Canberra, Australian Capital Territory, Australia
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Katherine Rouleau
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Guanyang Zou
- School of Economics and Management, Guangzhou University of Traditional Chinese Medicine, Guangzhou, Guangdong, China
| | - Zhuo Chao
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Walley
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Singh JA, Upshur REG. The granting of emergency use designation to COVID-19 candidate vaccines: implications for COVID-19 vaccine trials. Lancet Infect Dis 2020; 21:e103-e109. [PMID: 33306980 PMCID: PMC7832518 DOI: 10.1016/s1473-3099(20)30923-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 01/02/2023]
Abstract
An efficacious COVID-19 vaccine is currently the world's leading research priority. Several nations have indicated that if there is a compelling case for use of a vaccine before it is licensed, they would be prepared to authorise its emergency use or conditional approval on public health grounds. As of Dec 1, 2020, several developers of leading COVID-19 candidate vaccines have indicated that they have applied, or intend to apply, for emergency authorisation for their vaccines. Should candidate vaccines attain emergency use designation and be programmatically deployed before their phase 3 trials conclude, such a strategy could have far reaching consequences for COVID-19 vaccine research and the effective control of the COVID-19 pandemic. These issues merit careful consideration.
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Affiliation(s)
- Jerome Amir Singh
- Howard College School of Law, University of Kwazulu-Natal, Durban, South Africa; Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Ross E G Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Abstract
The most powerful lesson learned from the 2013-2016 outbreak of Ebola in West Africa was that we do not learn our lessons. A common sentiment at the time was that Ebola served as a "wake-up call"-an alarm which signalled that an outbreak of that magnitude should never have occurred and that we are ill-prepared globally to prevent and respond to them when they do. Pledges were made that we must learn from the outbreak before we were faced with another. Nearly five years later the world is in the grips of a pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19). It is therefore of no surprise that we are now yet again hearing that the COVID-19 pandemic serves as the "wake-up call" we need and that there are many lessons to be learned to better prepare us for future outbreaks. Will anything be different this time around? We argue that nothing will fundamentally change unless we truly understand and appreciate the nature of the lessons we should learn from these outbreaks. Our past failures must be understood as moral failures that offer moral lessons. Unless we appreciate that we have a defect in our collective moral attitude toward remediating the conditions that precipitate the emergence of outbreaks, we will never truly learn.
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Affiliation(s)
- Maxwell J. Smith
- School of Health Studies, Western University, Arthur & Sonia Labatt Health Sciences Building, 1151 Richmond Street, London, Ontario N6A 5B9 Canada
| | - Ross E. G. Upshur
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7 Canada
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Komesaroff PA, Chapman M, Kerridge I, Upshur REG. Lead Essay-Inside the Pandemic. J Bioeth Inq 2020; 17:461-463. [PMID: 32845462 PMCID: PMC7447846 DOI: 10.1007/s11673-020-10037-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Paul A. Komesaroff
- Faculty of Medicine, Monash University Alfred Hospital, Commercial Road, Prahran, Victoria 3181 Australia
| | - Michael Chapman
- Department of Palliative Care, Canberra Hospital, Canberra, ACT Australia
- ANU Medical School, ACT, Canberra, Australia
- University of Technology Sydney, Sydney, NSW Australia
| | - Ian Kerridge
- Sydney Health Ethics, Faculty of Medicine and Health, University of Sydney Haematology Department, Royal North Shore Hospital, Sydney, NSW Australia
| | - Ross E. G. Upshur
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7 Canada
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Affiliation(s)
- Maxwell J Smith
- Faculty of Health Sciences, Western University, London, ON N6A 5B9, Canada.
| | - Samuel Ujewe
- Faculty of Health Sciences, Western University, London, ON N6A 5B9, Canada
| | - Rachel Katz
- Faculty of Health Sciences, Western University, London, ON N6A 5B9, Canada
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Salamanca-Buentello F, Seeman MV, Daar AS, Upshur REG. The ethical, social, and cultural dimensions of screening for mental health in children and adolescents of the developing world. PLoS One 2020; 15:e0237853. [PMID: 32834012 PMCID: PMC7446846 DOI: 10.1371/journal.pone.0237853] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 08/04/2020] [Indexed: 01/14/2023] Open
Abstract
Despite their burden and high prevalence, mental health disorders of children and adolescents remain neglected in many parts of the world. In developing countries, where half of the population is younger than 18 years old, one of every five children and adolescents is estimated to suffer from a mental health disorder. It is then essential to detect these conditions through screening in a timely and accurate manner. But such screening is fraught with considerable ethical, social, and cultural challenges. This study systematically identifies, for the first time, these challenges, along with potential solutions to address them. We report on the results of an international multi- and inter-disciplinary three-round Delphi survey completed by 135 mental health experts from 37 countries. We asked these experts to identify and rank the main ethical, social, and cultural challenges of screening for child and adolescent mental health problems in developing nations, and to propose solutions for each challenge. Thirty-nine significant challenges emerged around eight themes, along with 32 potential solutions organized into seven themes. There was a high degree of consensus among the experts, but a few interesting disagreements arose between members of the panel from high-income countries and those from low- and middle-income nations. The panelists overwhelmingly supported mental health screening for children and adolescents. They recommended ensuring local acceptance and support for screening prior to program initiation, along with careful and comprehensive protection of human rights; integrating screening procedures into primary care; designing and implementing culturally appropriate screening tools, programs, and follow-up; securing long-term funding; expanding capacity building; and task-shifting screening to local non-specialists. These recommendations can serve as a guide for policy and decision-making, resource allocation, and international cooperation. They also offer a novel approach to reduce the burden of these disorders by encouraging their timely and context-sensitive prevention and management.
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Affiliation(s)
| | - Mary V. Seeman
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Abdallah S. Daar
- Departments of Clinical Public Health and Surgery, University of Toronto, Toronto, Ontario, Canada
- Stellenbosch Institute for Advanced Study, Stellenbosch, Western Cape, South Africa
| | - Ross E. G. Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld - Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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Abstract
Public health emergencies require real-time, accurate information to guide effective responses. Rapid publication of information can, therefore, advance both the scientific validity and the social value of research conducted in these contexts. Consequently, medical journals place a high priority on rapidly publishing reports on these emergencies, which the media often report on to the public. Today, the focus is on the rapid publication of research related to the COVID-19 outbreak. Tomorrow, it might be an influenza pandemic or a crisis related to a vaping-related illness. (Am J Public Health. Published online ahead of print May 14, 2020: e1-e2. doi:10.2105/AJPH.2020.305686).
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Affiliation(s)
- Maxwell J Smith
- Maxwell J. Smith is with the School of Health Studies, Western University, London, ON. Ross E.G. Upshur is with the Dalla Lana School of Public Health, University of Toronto, Toronto, ON. Ezekiel J. Emanuel is with the Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Ross E G Upshur
- Maxwell J. Smith is with the School of Health Studies, Western University, London, ON. Ross E.G. Upshur is with the Dalla Lana School of Public Health, University of Toronto, Toronto, ON. Ezekiel J. Emanuel is with the Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Ezekiel J Emanuel
- Maxwell J. Smith is with the School of Health Studies, Western University, London, ON. Ross E.G. Upshur is with the Dalla Lana School of Public Health, University of Toronto, Toronto, ON. Ezekiel J. Emanuel is with the Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Boulanger RF, Komparic A, Dawson A, Upshur REG, Silva DS. Developing and Implementing new TB Technologies: Key Informants' Perspectives on the Ethical Challenges. J Bioeth Inq 2020; 17:65-73. [PMID: 31858386 DOI: 10.1007/s11673-019-09954-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 11/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To identify the ethical challenges associated with the development and implementation of new tuberculosis (TB) drugs and diagnostics. METHODS Twenty-three semi-structured qualitative interviews conducted between December 2015 and September 2016 with programme administrators, healthcare workers, advocates, policymakers, and funders based in the Americas, Europe, and Africa. Interviews were analysed using thematic analysis. RESULTS Divergent interests and responsibilities, coupled with power imbalances, are a primary source of ethical challenges; the uncertain risk profiles of new drugs present an additional one. Although this challenge can be partially mitigated through stringent pharmacovigilance, respondents highlighted that high-burden countries tend to lack the resources to facilitate safe implementation. Increased advocacy and community engagement are considered an ethical imperative for future TB development and implementation. CONCLUSIONS This project helps identify some of the ethical challenges of new TB technologies. It demonstrates that investigating ethical challenges through qualitative research is one way to apprehend the difficulty of implementing new TB technologies. Addressing this difficulty will require that those in positions of power reconsider their interests in relation to disempowered communities. POLICY IMPLICATIONS Efforts to build consensus regarding what values should underpin the global governance of TB research, prevention, and care are essential to facilitate the ethical implementation of new TB technologies.
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Affiliation(s)
- Renaud F Boulanger
- Centre for Applied Ethics, McGill University Health Centre, 2155 Guy Street, 2nd floor, Montreal, Quebec, H3H 2R9, Canada
| | - Ana Komparic
- Leslie Dan Faculty of Pharmacy & Joint Centre for Bioethics, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada
| | - Angus Dawson
- Sydney Health Ethics & Marie Bashir Institute for Infectious Diseases and Biosecurity, Level 1, Medical Foundation Building, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Ross E G Upshur
- Dalla Lana School of Public Health & Joint Centre for Bioethics, University of Toronto, 155 College Street, Toronto, ON, M5T 1P8, Canada
| | - Diego S Silva
- Sydney Health Ethics & Marie Bashir Institute for Infectious Diseases and Biosecurity, Level 1, Medical Foundation Building, The University of Sydney, Sydney, NSW, 2006, Australia.
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Nickell LA, Tracy CS, Bell SH, Upshur REG. Effect of an innovative model of complexity care on family caregiver experience: Qualitative study in family practice. Can Fam Physician 2020; 66:194-200. [PMID: 32165470 PMCID: PMC8302342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the experiences of family caregivers who participated in an innovative model of interprofessional team-based care specifically designed for elderly patients with complex care needs. DESIGN Qualitative study. SETTING Large academic family practice in Toronto, Ont. PARTICIPANTS Family caregivers of elderly patients who had attended the IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments) clinic (N = 13). METHODS Individual semistructured interviews, which were conducted face-to-face, audiorecorded, transcribed verbatim, and analyzed using the constant comparative method. MAIN FINDINGS Family caregivers who attended the IMPACT clinic believed it enhanced caregiver experience and capacity. Caregivers experienced increased validation and engagement with the treatment team. Feelings of isolation were reduced, resulting in increased confidence and greater feelings of empowerment in their caregiver role. CONCLUSION While the needs and value of caregivers are increasingly acknowledged, health care teams continue to struggle with how to relate to and engage with family caregivers-how best to support them and work with them in the context of their family members' care. Interprofessional teams who adopt the IMPACT model-providing synchronous, real-time interventions that include the caregiver-can facilitate increased caregiver capacity, confidence, and empowerment.
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Affiliation(s)
- Leslie A Nickell
- Medical Lead of Caregiver Support Services in the Sinai Health System in Toronto, Ont, Medical Director of Bridgepoint Hospital, and Associate Professor in the Department of Family and Community Medicine at the University of Toronto.
| | - C Shawn Tracy
- Scientific Associate in the Bridgepoint Collaboratory for Research and Innovation at the Lunenfeld-Tanenbaum Research Institute in the Sinai Health System
| | - Stephanie H Bell
- Family physician at the Queen Elizabeth Hospital in Charlottetown, PEI
| | - Ross E G Upshur
- Head of the Division of Clinical Public Health in the Dalla Lana School of Public Health, Professor in the Department of Family and Community Medicine at the University of Toronto, and Associate Director of the Lunenfeld-Tanenbaum Research Institute in the Sinai Health System
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Abstract
A commentary on "Ethics and Evidence in Medical Debates: The Case of Recombinant Activated Factor VII," by Narcyz Ghinea, Wendy Lipworth, Ian Kerridge, Miles Little, and Richard O. Day, in the March-April 2014 issue.
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Kuluski K, Nelson MLA, Tracy CS, Alloway CA, Shorrock C, Shearkhani S, Upshur REG. From Volumes to Valued Experiences: Measurement and the Challenge before Us. Healthc Pap 2019; 17:73-78. [PMID: 29595448 DOI: 10.12927/hcpap.2017.25406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We are grateful for the thoughtful discussion and ideas put forth in this issue on the measurement of healthcare experiences. Our colleagues, who span multiple jurisdictions across Canada and internationally, agree that we need to do a better job at engaging patients and families in their care and measuring their experiences across health services and sectors. In this response paper, we reflect on three core content areas that were identified across the eight papers in this issue: the role of context and engagement-capable environments; approaches to improve the measurement of experience and acting on results; and challenges that must be attended to in our quest to make our healthcare systems work better.
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Tracy CS, Nickell LA, Upshur REG. Canada's health care system needs to care more about caregivers. CMAJ 2019; 191:E821. [PMID: 31332054 DOI: 10.1503/cmaj.72340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- C Shawn Tracy
- Scientific associate, Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Toronto, Ont
| | - Leslie A Nickell
- Medical lead, Caregiver Support Services, Bridgepoint Hospital, Sinai Health System, University of Toronto, Toronto, Ont
| | - Ross E G Upshur
- Scientific director, Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, University of Toronto, Toronto, Ont
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Komparic A, Dawson A, Boulanger RF, Upshur REG, Silva DS. A failure in solidarity: Ethical challenges in the development and implementation of new tuberculosis technologies. Bioethics 2019; 33:557-567. [PMID: 30681168 PMCID: PMC6563531 DOI: 10.1111/bioe.12554] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/09/2018] [Accepted: 10/30/2018] [Indexed: 06/07/2023]
Abstract
Prominent tuberculosis (TB) actors are invoking solidarity to motivate and justify collective action to address TB, including through intensified development and implementation (D&I) of technologies such as drugs and diagnostics. We characterize the ethical challenges associated with D&I of new TB technologies by drawing on stakeholder perspectives from 23 key informant interviews and we articulate the ethical implications of solidarity for TB technology D&I. The fundamental ethical issue facing TB technological D&I is a failure within and beyond the TB community to stand in solidarity with persons with TB in addressing the complex sociopolitical contexts of technological D&I. The failure in solidarity relates to two further ethical challenges raised by respondents: skewed power dynamics that hinder D&I and uncertainties around weighing risks and benefits associated with new technologies. Respondents identified advocacy and participatory research practices as necessary to address such challenges and to motivate sustained collective action to accelerate toward TB elimination. We present the first empirical examination of bioethical accounts of solidarity in public and global health. Our study suggests that solidarity allows us better to understand and address the ethical challenges that arrest the D&I of new TB technologies. Solidarity lends credence to policies and practices that address the relational nature of illness and health through collective action.
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Affiliation(s)
- Ana Komparic
- Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoOntarioCanada
| | - Angus Dawson
- School of Public HealthUniversity of SydneySydneyNSWAustralia
| | | | - Ross E. G. Upshur
- University of Toronto Dalla Lana School of Public HealthTorontoOntarioCanada
| | - Diego S. Silva
- Faculty of Health SciencesSimon Fraser UniverstiyBurnabyBritish ColumbiaCanada
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Silva DS, Komparic A, Upshur REG, Gibson J, Strike C. Provider perspectives on liberty and harm in the treatment of persons with tuberculosis and mental illness. Int J Tuberc Lung Dis 2019; 23:405-411. [PMID: 31064618 DOI: 10.5588/ijtld.18.0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
<sec id="st1"> <title>OBJECTIVES</title> To examine how frontline health care workers (HCWs) and decision-makers working in tuberculosis (TB) care and mental health care conceptualise liberty, harm and the harm principle-which are often invoked in health care legislation to justify liberty restrictions-in the treatment and care of persons with TB and severe and persistent mental illness (SPMI). </sec> <sec id="st2"> <title>DESIGN</title> Qualitative study of 20 semi-structured interviews with HCWs and decision-makers working in public or mental health from three public health units and two psychiatric hospitals in the Greater Toronto Area in Ontario, Canada. Interviews were evaluated using thematic analysis. </sec> <sec id="st3"> <title>RESULTS</title> Three themes were identified: 1) the contextual nature of liberty restrictions; 2) the concept of liberty as a matter of degree; and 3) the challenges of balancing the treatment and care goals of TB and mental health for persons with both TB and SPMI. </sec> <sec id="st4"> <title>CONCLUSION</title> Harm is understood by HCWs caring for persons with TB and/or SPMI in a context-dependent manner. This is compounded in the case of persons with both TB and SPMI. Liberty restrictions to advance public health goals entail reciprocal obligations from society, including social protections and additional resources, to ease the effects and range of liberty restrictions. Attention is required to ensure that treatment and care for SPMI does not impede that of TB and vice versa. </sec>.
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Affiliation(s)
- D S Silva
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia
| | - A Komparic
- Leslie Dan Faculty of Pharmacy & Joint Centre for Bioethics, University of Toronto, Toronto, Ontario
| | - R E G Upshur
- Lunenfeld Tanenbaum Research Institute, Sinai Health System
| | - J Gibson
- Joint Centre for Bioethics & Institute of Health Policy, Management and Evaluation
| | - C Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
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Abstract
Conveying the uncertainty inherent in clinical practice has rightly become a focus of medical training. To date, much of the emphasis aims to encourage trainees to acknowledge and accept uncertainty. Intolerance of uncertainty is associated with medical student distress and a tendency in clinicians toward overtreatment. The authors argue that a deeper, philosophical understanding of the nature of uncertainty would allow students and clinicians to move beyond simple acceptance to explicating and mitigating uncertainty in practice.Uncertainty in clinical medicine can be categorized philosophically as moral, metaphysical, and epistemic uncertainty. Philosophers of medicine-in a way analogous to ethicists a half century ago-can be brought into medical education and medical practice to help students and physicians explore the epistemic and metaphysical roots of clinical uncertainty. Such an approach does not require medical students to master philosophy and should not involve adding new course work to an already-crowded medical curriculum. Rather, the goal is to provide students with the language and reasoning skills to recognize, evaluate, and mitigate uncertainty as it arises. The authors suggest ways in which philosophical concepts can be introduced in a practical fashion into a variety of currently existing educational formats. Bringing the philosophy of medicine into medical education promises not only to improve the training of physicians but, ultimately, to lead to more mindful clinical practice, to the benefit of physicians and patients alike.
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Affiliation(s)
- Mark R Tonelli
- M.R. Tonelli is professor of medicine and adjunct professor of bioethics and humanities, University of Washington, Seattle, Washington. R.E.G. Upshur is professor, Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Wei X, Zhang Z, Hicks JP, Walley JD, King R, Newell JN, Yin J, Zeng J, Guo Y, Lin M, Upshur REG, Sun Q. Long-term outcomes of an educational intervention to reduce antibiotic prescribing for childhood upper respiratory tract infections in rural China: Follow-up of a cluster-randomised controlled trial. PLoS Med 2019; 16:e1002733. [PMID: 30721234 PMCID: PMC6363140 DOI: 10.1371/journal.pmed.1002733] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/19/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing causes widespread serious health problems. To reduce prescribing of antibiotics in Chinese primary care to children with upper respiratory tract infections (URTIs), we developed an intervention comprising clinical guidelines, monthly prescribing review meetings, doctor-patient communication skills training, and education materials for caregivers. We previously evaluated our intervention using an unblinded cluster-randomised controlled trial (cRCT) in 25 primary care facilities across two rural counties. When our trial ended at the 6-month follow-up period, we found that the intervention had reduced antibiotic prescribing for childhood URTIs by 29 percentage points (pp) (95% CI -42 to -16). METHODS AND FINDINGS In this long-term follow-up study, we collected our trial outcomes from the one county (14 facilities and 1:1 cluster randomisation ratio) that had electronic records available 12 months after the trial ended, at the 18-month follow-up period. Our primary outcome was the antibiotic prescription rate (APR)-the percentage of outpatient prescriptions containing any antibiotic(s) for children aged 2 to 14 years who had a primary diagnosis of a URTI and had no other illness requiring antibiotics. We also conducted 15 in-depth interviews to understand how interventions were sustained. In intervention facilities, the APR was 84% (1,171 out of 1,400) at baseline, 37% (515 out of 1,380) at 6 months, and 54% (2,748 out of 5,084) at 18 months, and in control facilities, it was 76% (1,063 out of 1,400), 77% (1,084 out of 1,400), and 75% (2,772 out of 3,685), respectively. After adjusting for patient and prescribing doctor covariates, compared to the baseline intervention-control difference, the difference at 6 months represented a 6-month intervention-arm reduction in the APR of -49 pp (95% CI -63 to -35; P < 0.0001), and compared to the baseline difference, the difference at 18 months represented an 18-month intervention-arm reduction in the APR of -36 pp (95% CI -55 to -17; P < 0.0001). Compared to the 6-month intervention-control difference, the difference at 18 months represented no change in the APR: 13 pp (95% CI -7 to 33; P = 0.21). Factors reported to sustain reductions in antibiotic prescribing included doctors' improved knowledge and communication skills and focused prescription review meetings, whereas lack of supervision and monitoring may be associated with relapse. Key limitations were not including all clusters from the trial and not collecting returned visits or sepsis cases. CONCLUSIONS Our intervention was associated with sustained and substantial reductions in antibiotic prescribing at the end of the intervention period and 12 months later. Our intervention may be adapted to similar resource-poor settings. TRIAL REGISTRATION ISRCTN registry ISRCTN14340536.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - Joseph P. Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - John D. Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - James N. Newell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Jia Yin
- School of Health Care Management, Shandong University, Jinan, China
- Key Laboratory of Health Economics and Policy Research, National Health Commission, Jinan, China
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Yan Guo
- School of Public Health, Peking University, Beijing, China
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Ross E. G. Upshur
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Qiang Sun
- School of Health Care Management, Shandong University, Jinan, China
- Key Laboratory of Health Economics and Policy Research, National Health Commission, Jinan, China
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Smith MJ, Thompson A, Upshur REG. Is 'health equity' bad for our health? A qualitative empirical ethics study of public health policy-makers' perspectives. Can J Public Health 2018; 109:633-642. [PMID: 30465285 DOI: 10.17269/s41997-018-0128-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 08/23/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES 'Social justice' and 'health equity' are core values in public health. Yet, despite their normative character, the numerous normative accounts of social justice and equity are rarely acknowledged, meaning that these values are often unaccompanied by an explanation of what they require in practice. The objective of this study was to bridge this normative scholarship with information about how these 'core values' are integrated and interpreted by Canadian public health policy-makers. METHODS Twenty qualitative interviews with public health policy-makers recruited from public health organizations in Canada, analyzed using an 'empirical ethics' methodology that combined empirical data with normative ethical analysis involving theories of justice. FINDINGS Participants viewed health equity and social justice as distinct, where the former was perceived as 'clearer'. Health equity was conceptualized as focusing attention to 'proximal' disparities in access to services and 'materialistic' determinants of health, whereas social justice was conceptualized as focusing on structural issues that lead to disadvantage. Health equity was characterized as 'neutral' and 'comfortable', whereas social justice was characterized as 'political' and 'uncomfortable'. CONCLUSION These findings indicate that health equity dominates the discursive space wherein justice-based considerations are brought to bear on public health activities. As a result, 'uncomfortable' justice-based considerations of power imbalances and systematic disadvantage can be eschewed in practice in favour of attending to 'proximal' inequities. These findings reveal the problematic ways in which considerations of justice and equity are, and are not, being taken up in public health policy, which in turn may have negative implications for the public's health.
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Affiliation(s)
- Maxwell J Smith
- School of Health Studies, Faculty of Health Sciences, Western University, Arthur and Sonia Labatt Health Sciences Building, Room 331, 1151 Richmond Street, London, ON, N6A 5B9, Canada.
| | - Alison Thompson
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
| | - Ross E G Upshur
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5G 1L4, Canada
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Kuluski K, Peckham A, Gill A, Arneja J, Morton-Chang F, Parsons J, Wong-Cornall C, McKillop A, Upshur REG, Sheridan N. "You've got to look after yourself, to be able to look after them" a qualitative study of the unmet needs of caregivers of community based primary health care patients. BMC Geriatr 2018; 18:275. [PMID: 30419819 PMCID: PMC6233534 DOI: 10.1186/s12877-018-0962-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/24/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is growing reliance on unpaid caregivers to provide support to people with care needs. Integrated care approaches that aim to coordinate primary care with community care known as community based primary health care (CBPHC) has been a key policy initiative across health systems; however most attention has been paid to the needs of patients and not caregivers. The objective of this paper was to explore the unmet needs of caregivers of older adults with complex care needs receiving CBPHC. METHODS This qualitative descriptive study entailed one-to-one interviews with 80 caregivers from Canada and New Zealand where roles, experiences and needs were explored. Interview text related to unmet need was reviewed inductively and core themes identified. RESULTS Three themes were identified across CBPHC sites: unrecognized role; lack of personal resources; and no breaks even when services are in place. CONCLUSIONS To support caregivers, models of care such as CBPHC need to look beyond the patient to meaningfully engage caregivers, address their needs and recognize the insight they hold. This knowledge needs to be valued as a key source of evidence to inform developments in health and social care.
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Affiliation(s)
- Kerry Kuluski
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Allie Peckham
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Ashlinder Gill
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jasleen Arneja
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Frances Morton-Chang
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - John Parsons
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cecilia Wong-Cornall
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ann McKillop
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ross E. G. Upshur
- Bridgepoint Collaboratory, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, Toronto, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Nicolette Sheridan
- Centre for Nursing and Health Research, School of Nursing, College of Health Te Kura Hauora Tangata, Massey University, Albany, New Zealand
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Abstract
The evidence based medicine movement has championed the need for objective and transparent methods of clinical guideline development. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was developed for that purpose. Central to this framework is criteria for assessing the quality of evidence from clinical studies and the impact that body of evidence should have on our confidence in the clinical effectiveness of a therapy under examination. Grades of Recommendation, Assessment, Development, and Evaluation has been adopted by a number of professional medical societies and organizations as a means for orienting the development of clinical guidelines. As a result, the method of GRADE has implications on how health care is delivered and patient outcomes. In this paper, we reveal several issues with the underlying logic of GRADE that warrant further discussion. First, the definitions of the "grades of evidence" provided by GRADE, while explicit, are functionally vague. Second, the "criteria for assigning grade of evidence" is seemingly arbitrary and arguably logically incoherent. Finally, the GRADE method is unclear on how to integrate evidence grades with other important factors, such as patient preferences, and trade-offs between costs, benefits, and harms when proposing a clinical practice recommendation. Much of the GRADE method requires judgement on the part of the user, making it unclear as to how the framework reduces bias in recommendations or makes them more transparent-both goals of the programme. It is our view that the issues presented in this paper undermine GRADE's justificatory scheme, thereby limiting the usefulness of GRADE as a tool for developing clinical recommendations.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada.,Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Canada.,African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Auckland Park, South Africa
| | - Brian Baigrie
- Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Canada
| | - Ross E G Upshur
- Dalla Lana School for Public Health, University of Toronto, Toronto, Canada
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Upshur REG. Fast and frugal decision trees: How can the patient come last in a patient-centred world? J Eval Clin Pract 2018; 24:1259-1261. [PMID: 29927032 DOI: 10.1111/jep.12969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Ross E G Upshur
- Dalla Lana School of Public Health, Division of Clinical Public Health, Toronto, ON, Canada.,Bridgepoint Collaboratory for Research and Innovation, Toronto, ON, Canada.,Lunenfeld Tanenbaum Research Institute, Sinai Health Systems, Toronto, ON, Canada.,University of Toronto, Department of Family and Community Medicine and Dalla Lana School of Public Health, Toronto, ON, Canada
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Buchman DZ, Orkin AM, Strike C, Upshur REG. Overdose Education and Naloxone Distribution Programmes and the Ethics of Task Shifting. Public Health Ethics 2018. [DOI: 10.1093/phe/phy001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Abstract
North America is in the grips of an epidemic of opioid-related poisonings. Overdose education and naloxone distribution (OEND) programmes emerged as an option for structurally vulnerable populations who could not or would not access mainstream emergency medical services in the event of an overdose. These task shifting programmes utilize lay persons to deliver opioid resuscitation in the context of longstanding stigmatization and marginalization from mainstream healthcare services. OEND programmes exist at the intersection of harm reduction and emergency services. One goal of OEND programmes is to help redress the health-related inequities common among people who use drugs, which include minimizing the gap between people who use drugs and the formal healthcare system. However, if this goal is not achieved these inequities may be entrenched. In this article, we consider the ethical promises and perils associated with OEND as task shifting. We argue that public health practitioners must consider the ethical aspects of task shifting programmes that may inadvertently harm already structurally vulnerable populations. We believe that even if OEND programmes reduce opioid-related deaths, we nevertheless question if, by virtue of its existence, OEND programmes might also unintentionally disenfranchise structurally vulnerable populations from comprehensive healthcare services, including mainstream emergency care.
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Affiliation(s)
- Daniel Z Buchman
- Bioethics Program, University Health Network, University of Toronto Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto
| | - Aaron M Orkin
- Schwartz/Reisman Emergency Medicine Institute, Mt. Sinai Hospital
- Dalla Lana School of Public Health, University of Toronto
- Department of Family and Community Medicine, University of Toronto
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto
| | - Ross E G Upshur
- University of Toronto Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Lunenfeld-Tannenbaum Research Institute, Sinai Health System
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Wei X, Zhang Z, Walley JD, Hicks JP, Zeng J, Deng S, Zhou Y, Yin J, Newell JN, Sun Q, Zou G, Guo Y, Upshur REG, Lin M. Effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural China: a cluster-randomised controlled trial. Lancet Glob Health 2017; 5:e1258-e1267. [PMID: 29102353 DOI: 10.1016/s2214-109x(17)30383-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/11/2017] [Accepted: 09/15/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Inappropriate antibiotic prescribing contributes to the generation of drug resistance worldwide, and is particularly common in China. We assessed the effectiveness of an antimicrobial stewardship programme aiming to reduce inappropriate antibiotic prescribing in paediatric outpatients by targeting providers and caregivers in primary care hospitals in rural China. METHODS We did a pragmatic, cluster-randomised controlled trial with a 6-month intervention period. Clusters were primary care township hospitals in two counties of Guangxi province in China, which were randomly allocated to the intervention group or the control group (in a 1:1 ratio in Rong county and in a 5:6 ratio in Liujiang county). Randomisation was stratified by county. Eligible participants were children aged 2-14 years who attended a township hospital as an outpatient and were given a prescription following a primary diagnosis of an upper respiratory tract infection. The intervention included clinician guidelines and training on appropriate prescribing, monthly prescribing peer-review meetings, and brief caregiver education. In hospitals allocated to the control group, usual care was provided, with antibiotics prescribed at the individual clinician's discretion. Patients were masked to their allocated treatment group but doctors were not. The primary outcome was the antibiotic prescription rate in children attending the hospitals, defined as the cluster-level proportion of prescriptions for upper respiratory tract infections in 2-14-year-old outpatients, issued during the final 3 months of the 6-month intervention period (endline), that included one or more antibiotics. The outcome was based on prescription records and analysed by modified intention-to-treat. This study is registered with the ISRCTN registry, number ISRCTN14340536. FINDINGS We recruited all 25 eligible township hospitals in the two counties (14 hospitals in Rong county and 11 in Liujiang county), and randomly allocated 12 to the intervention group and 13 to the control group. We implemented the intervention in three internal pilot clusters between July 1, 2015, and Dec 31, 2015, and in the remaining nine intervention clusters between Oct 1, 2016 and March 31, 2016. Between baseline (the 3 months before implementation of the intervention) and endline (the final 3 months of the 6-month intervention period) the antibiotic prescription rate at the individual level decreased from 82% (1936/2349) to 40% (943/2351) in the intervention group, and from 75% (1922/2548) to 70% (1782/2552) in the control group. After adjusting for the baseline antibiotic prescription rate, stratum (county), and potentially confounding patient and prescribing doctor covariates, this endline difference between the groups represented an intervention effect (absolute risk reduction in antibiotic prescribing) of -29% (95% CI -42 to -16; p=0·0002). INTERPRETATION In China's primary care setting, pragmatic interventions on antimicrobial stewardship targeting providers and caregivers substantially reduced prescribing of antibiotics for childhood upper respiratory tract infections. FUNDING Department of International Development (UKAID) through Communicable Diseases Health Service Delivery.
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Affiliation(s)
- Xiaolin Wei
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Zhitong Zhang
- China Global Health Research and Development, Shenzhen, China
| | - John D Walley
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Jun Zeng
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China
| | - Simin Deng
- China Global Health Research and Development, Shenzhen, China
| | - Yu Zhou
- China Global Health Research and Development, Shenzhen, China
| | - Jia Yin
- School of Health Care Management, Shandong University, Jinan, China
| | - James N Newell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Qiang Sun
- School of Health Care Management, Shandong University, Jinan, China
| | - Guanyang Zou
- China Global Health Research and Development, Shenzhen, China
| | - Yan Guo
- Centre for Global Health, School of Public Health, Peking University, Beijing, China
| | - Ross E G Upshur
- Division of Clinical Public Health and Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mei Lin
- Guangxi Autonomous Region Centre for Disease Control and Prevention, Nanning, China.
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Aery A, Rucchetto A, Singer A, Halas G, Bloch G, Goel R, Raza D, Upshur REG, Bellaire J, Katz A, Pinto AD. Implementation and impact of an online tool used in primary care to improve access to financial benefits for patients: a study protocol. BMJ Open 2017; 7:e015947. [PMID: 29061603 PMCID: PMC5665212 DOI: 10.1136/bmjopen-2017-015947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Addressing the social determinants of health has been identified as crucial to reducing health inequities. However, few evidence-based interventions exist. This study emerges from an ongoing collaboration between physicians, researchers and a financial literacy organisation. Our study will answer the following: Is an online tool that improves access to financial benefits feasible and acceptable? Can such a tool be integrated into clinical workflow? What are patient perspectives on the tool and what is the short-term impact on access to benefits? METHODS An advisory group made up of patients living on low incomes and representatives from community agencies supports this study. We will recruit three primary care sites in Toronto, Ontario and three in Winnipeg, Manitoba that serve low-income communities. We will introduce clinicians to screening for poverty and how benefits can increase income. Health providers will be encouraged to use the tool with any patient seen. The health provider and patient will complete the online tool together, generating a tailored list of benefits and resources to assist with obtaining these benefits. A brief survey on this experience will be administered to patients after they complete the tool, as well as a request to contact them in 1 month. Those who agree to be contacted will be interviewed on whether the intervention improved access to financial benefits. We will also administer an online survey to providers and conduct focus groups at each site. ETHICS AND DISSEMINATION Key ethical concerns include that patients may feel discomfort when being asked about their financial situation, may feel obliged to complete the tool and may have their expectations falsely raised about receiving benefits. Providers will be trained to address each of these concerns. We will share our findings with providers and policy-makers interested in addressing the social determinants of health within healthcare settings. TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT02959866. Registered 7 November 2016. Retrospectively registered. Pre-results.
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Affiliation(s)
- Anjana Aery
- Wellesley Institute, Toronto, Ontario, Canada
| | - Anne Rucchetto
- The Upstream Lab, Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alexander Singer
- Department of Family Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Gayle Halas
- Department of Family Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
| | - Gary Bloch
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ritika Goel
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Central Toronto Community Health Centre, Toronto, Ontario, Canada
| | - Danyaal Raza
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ross E G Upshur
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health Systems, Toronto, Ontario, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Bellaire
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- South East Toronto Family Health Team, Toronto, Ontario, Canada
| | - Alan Katz
- Department of Family Medicine, Rady Faculty of Health Sciences, Winnipeg, Manitoba, Canada
- Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada
| | - Andrew David Pinto
- The Upstream Lab, Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Kuluski K, Nelson MLA, Tracy CS, Alloway CA, Shorrock C, Shearkhani S, Upshur REG. Experience of Care as a Critical Component of Health System Performance Measurement: Recommendations for Moving Forward. Healthc Pap 2017; 17:8-20. [PMID: 29595439 DOI: 10.12927/hcpap.2017.25415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
People's experiences can provide critical guidance on how to better meet their quality of life and care needs and deploy resources more appropriately. To maximize the utility of experience data and to advance the current debate, we present four recommendations: (1) measuring experiences outside the healthcare system can provide insight into what needs to change within the healthcare system; (2) focusing on patient experience is necessary but insufficient, (family) caregiver insights and experiences require attention and can provide insight into the needs of the patient; (3) moving from "one time/single sector" measurement of experience to iterative, ongoing measurement across sectors better reflects the true lived experience of patients (especially those with complex care needs) and their caregivers; and (4) embedding measurement within engagement-capable environments that adequately resource patients, caregivers, and providers to work together is required to move from collection to meaningful change. Applying these recommendations requires a longer-term vision, shifting from provider-centred to person-centred models of care, and a deep understanding of the structural, cultural, and normative barriers to measuring care experiences.
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Affiliation(s)
- Kerry Kuluski
- Scientist, Bridgepoint Collaboratory of the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Assistant Professor, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Michelle L A Nelson
- Scientist, Bridgepoint Collaboratory of the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Assistant Professor, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - C Shawn Tracy
- Research Associate, Sinai Health System, Toronto, ON
| | | | - Charles Shorrock
- Customer Experience Leader and Patient Experience Advisor, Ontario Patient Ombudsman's Office, Toronto, ON
| | - Sara Shearkhani
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Co-Founder, Family Caregivers Voice, Toronto, ON
| | - Ross E G Upshur
- Head, Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Scientific Director, Bridgepoint Collaboratory of the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON
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Chin-Yee B, Upshur REG. Re-evaluating concepts of biological function in clinical medicine: towards a new naturalistic theory of disease. Theor Med Bioeth 2017; 38:245-264. [PMID: 28660393 DOI: 10.1007/s11017-017-9410-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Naturalistic theories of disease appeal to concepts of biological function, and use the notion of dysfunction as the basis of their definitions. Debates in the philosophy of biology demonstrate how attributing functions in organisms and establishing the function-dysfunction distinction is by no means straightforward. This problematization of functional ascription has undermined naturalistic theories and led some authors to abandon the concept of dysfunction, favoring instead definitions based in normative criteria or phenomenological approaches. Although this work has enhanced our understanding of disease and illness, we need not necessarily abandon naturalistic concepts of function and dysfunction in the disease debate. This article attempts to move towards a new naturalistic theory of disease that overcomes the limitations of previous definitions and offers advantages in the clinical setting. Our approach involves a re-evaluation of concepts of biological function employed by naturalistic theories. Drawing on recent insights from the philosophy of biology, we develop a contextual and evaluative account of function that is better suited to clinical medicine and remains consistent with contemporary naturalism. We also show how an updated naturalistic view shares important affinities with normativist and phenomenological positions, suggesting a possibility for consilience in the disease debate.
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Affiliation(s)
- Benjamin Chin-Yee
- Department of Medicine, University of Toronto, 152 Saint Patrick St., Toronto, ON, M5T 3J9, Canada.
| | - Ross E G Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Kuluski K, Peckham A, Williams AP, Upshur REG. What Gets in the Way of Person-Centred Care for People with Multimorbidity? Lessons from Ontario, Canada. ACTA ACUST UNITED AC 2017; 19:17-23. [PMID: 27700969 DOI: 10.12927/hcq.2016.24694] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Person-centred care is becoming a key component of quality in health systems worldwide. Although the term can mean different things, it typically entails paying attention to the needs and background of health system users, involving them in decisions that affect their health, assessing their care goals and implementing a coordinated plan of care that aligns with their unique circumstances. The importance of practising a person-centred approach in care delivery dominates policy and research rhetoric worldwide, yet competing goals set by policy planners to save money, eliminate waste and sustain the healthcare system challenge the implementation of such an approach. In this commentary, we begin by exploring the concept of person-centred care and its importance among people who frequently use healthcare, such as those with multimorbidity. We then provide a brief overview of the evolution of Ontario's healthcare system and its emphasis on achieving cost savings. In doing so, we illustrate the implications for health system users, particularly people with multimorbidity, their carers and formal care providers. Finally, we reflect on examples of innovations that are striving to deliver person-centred care, despite a constrained healthcare environment. While a step in the right direction, we conclude that these "one-off" strategies are unsustainable in the absence of supporting policy levers.
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Affiliation(s)
- Kerry Kuluski
- Scientist in the Lunenfeld-Tanenbaum Research Institute, Sinai Health System and assistant professor, Institute of Health Policy, Management and Evaluation, University of Toronto, ON
| | - Allie Peckham
- Postdoctoral fellow in the Institute of Health Policy, Management and Evaluation, University of Toronto, ON
| | - A Paul Williams
- Professor of Health Policy in the Institute of Health Policy, Management and Evaluation, University of Toronto, ON
| | - Ross E G Upshur
- Professor in the Department of Family and Community Medicine and the Dalla Lana School of Public Health at the University of Toronto, assistant director of the Lunenfeld Tanenbaum Research Institute, Sinai Health System, and head of the Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, ON
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Abstract
Ten years ago, complexity was not a term often used in primary care. In the last decade, however, the population seen in primary care has shifted, posing substantial challenges for both primary care providers and health systems. In this essay, I will document the approaches that evolved in an academic family practice environment to address the challenges posed by complex patients typified by multiple concurrent chronic conditions and social determinants challenges. I will describe the research that lead to the creation, implementation and evaluation of an inter-professional model of care and associated outcomes. I will describe how this work subsequently led to the evolution of clinical models and research projects designed to reframe the discourse around complexity as well as move forward on elaborating new policy, clinical and service delivery innovations. I will conclude with some thoughts about what I see as the major challenges in the short and immediate term for research and practice, drawing on 15 years of practice and research experience with complex populations.
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Affiliation(s)
- Ross E G Upshur
- Professor in the Department of Family and Community Medicine and the Dalla Lana School of Public Health at the University of Toronto. He is also an assistant director of the Lunenfeld Tanenbaum Research Institute in the Sinai Health System and head of the Division of Clinical Public Health at the Dalla Lana School of Public Health at the University of Toronto. He can be reached by e-mail at:
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Affiliation(s)
| | - Maxwell J Smith
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Diego S Silva
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Ross E G Upshur
- Department of Family and Community Medicine, and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
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Abstract
The aim of this article is to create a space for historical thinking in medical practice. To this end, we draw on the ideas of R.G. Collingwood (1889-1943), the renowned British philosopher of history, and explore the implications of his philosophy for clinical medicine. We show how Collingwood's philosophy provides a compelling argument for the re-centring of medical practice around the patient history as a means of restoring to the clinical encounter the human meaning that is too often lost in modern medicine. Furthermore, we examine how Collingwood's historical thinking offers a patient-centred epistemology and a more pluralistic concept of evidence that includes the qualitative, narrative evidence necessary for human understanding. We suggest that clinical medicine can benefit from Collingwood's historical thinking, and, more generally, illustrates how a philosophy of medicine that draws on diverse sources from the humanities offers a richer, more empathetic clinical practice.
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Affiliation(s)
- Benjamin H Chin-Yee
- Faculty of Medicine, and Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada
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Upshur REG. Conventions or foundations? A response to Miles Little's ex nihilo nihil fit? Medicine rests on solid foundations. J Eval Clin Pract 2014; 20:988-90. [PMID: 25039939 DOI: 10.1111/jep.12208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 11/25/2022]
Abstract
In this essay, I respond to the critique of my work by Professor Miles Little.
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Affiliation(s)
- Ross E G Upshur
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Primary Care Research, University of Toronto, Toronto, Ontario, Canada; Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Clinical Research in Complexity Services, Bridgepoint Active Healthcare, University of Toronto, Toronto, Ontario, Canada
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Abstract
The evolving Ebola epidemic in West Africa is unprecedented in its size and scope, requiring the rapid mobilization of resources. It is too early to determine all of the ethical challenges associated with the outbreak, but these should be monitored closely. Two issues that can be discussed are (1) the decision to implement and evaluate unregistered agents to determine therapeutic or prophylactic safety and efficacy and (2) the justification behind this decision. In this paper, I argue that it is not compassionate use that justifies this decision and suggest three lines of reasoning to support the decision.
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Affiliation(s)
- Ross E G Upshur
- Department of Family and Community Medicine and Dalla Lana School of Public Health, Division of Clinical Public Health, University of Toronto, Toronto, ON, Canada,
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50
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Loughlin M, Bluhm R, Fuller J, Buetow S, Upshur REG, Borgerson K, Goldenberg MJ, Kingma E. Philosophy, medicine and health care - where we have come from and where we are going. J Eval Clin Pract 2014; 20:902-7. [PMID: 25644615 DOI: 10.1111/jep.12275] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2014] [Indexed: 12/21/2022]
Affiliation(s)
- Michael Loughlin
- Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK
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