Response rates and respondents' practice profile
Forty-two percent (134/317) of eligible physicians completed the survey. Five respondents were excluded, as they did not indicate their specialty. Practice profiles of the remaining 129 respondents, representing 39% (68/173) and 41% (61/147) of AMMIQ and AMSSCQ members, respectively, are described in Table .
Practice profiles of 129 specialist physicians who responded to the survey sent to all members of Quebec associations of infectious diseases and medical microbiologists and of public health and preventive medicine
A greater proportion of IDMM (91.2%) than PHPMS (65.6%) were involved in pH1N1 management. Practice profiles of IDMM involved and not involved in pH1N1 management were similar. PHPMS involved in pH1N1 management were more likely to practice in the field of infectious disease (48.7% vs. 31.7%) and in a regional public health team (87.2% vs. 75.0%) than those who were not. Other practice characteristics were similar for both subgroups.
Frequency of issues experienced during the pH1N1
Table summarizes responses to the checklist of potential issues for the 102 respondents involved in the pH1N1 episode. Overall, 85.3% (n = 87) of respondents encountered difficulties or experienced frustrations in their practice during pH1N1 and this proportion was similar for both specialties. Issues related mainly - for IDMM - to laboratories and infection prevention and control, vaccine availability, communication process (clinical practice guidelines' [CPG] dissemination, and communication routes), and with the overall management of the two pandemic waves. PHPMS reported problems mainly with the decision-making process in the prioritization and vaccination of high-risk groups. In addition, more than 50% reported issues with the top-down management process, communication processes (CPGs' dissemination and communication routes), and patient management at the public health level (expert committees, case reporting, and epidemiological investigation).
Difficulties/frustrations reported by 102 specialist physicians who were involved in the management of Quebec's 2009 pH1N1
Sixty-two of 102 (37 IDMM and 25 PHPMS) respondents (60.7%) involved in pH1N1 provided written comments. Breaking down these comments resulted in 244 distinct meaning units. Figure illustrates the hierarchy of groupings that was developed from coding these meaning units into categories, subthemes, and themes. Overall, comments could be grouped under two core themes: coordination, at all levels of implementation of the pandemic response, and availability of resources required to manage the pandemic. Open codes associated with coordination (n = 180) were more frequent than those relating to resources (n = 64). The following sections report the results for each of the two core themes and their subthemes. Representative verbatim quotations of the subthemes are provided in Table .
Figure 1 Classification of issues and suggestions mentioned by 62 specialist physicians* who were involved in the management of Quebec's 2009 A (H1N1) pandemic.* Infectious diseases specialist/medical microbiologists and public health and preventive medicine specialists. (more ...)
Representative verbatim quotations (please note: these are examples; the content of some quotations covers more than one category and thus may have appeared in multiple subthemes in our analysis)
Issues and suggested improvements with coordination comprised the following subthemes:
a Communication: A slow communication process, an overwhelming number of communication sources, and an overwhelming number of divergent messages, sometimes lacking clarity, were identified as the main problems. Respondents suggested that these issues were in part due to communication routes used to relay information. Participants mainly suggested improvements to communication management such as greater centralization and use of the Internet instead of teleconferences.
b Clinical Practice Guidelines (CPG): Respondents found that CPGs' content was inconsistent between the different pandemic management levels and advisory committees; physicians were confused as to which to follow, especially when contradictory. The changing nature and the slow dissemination of these CPGs were also perceived as problematic. CPGs were perceived as too rigid to accommodate particular regional and local situations.
c Decision-Making: Physicians expressed unhappiness with the top-down management model and speed of decision-making, which was associated by some to the large number of people involved at the top administrative level. Physicians also found that there was a lack of autonomy and transparency in the decision-making process. Suggestions were made to involve more medical specialists in the decision-making process and to increase autonomy at the regional and local levels.
d Roles and Responsibilities: Physicians complained about increased workload related to pandemic activities, such as meetings attendance that they found inefficient. Some found financial compensations inadequate for the additional workload. Respondents also mentioned that the exact role of the different actors involved in the pandemic was unclear, which generated confusion in the local management of the pandemic. Suggestions were to improve meetings' structure and to better define roles at the beginning of a healthcare emergency.
e Epidemiologic Investigation: Public health epidemiologic investigations were mentioned as an issue, in particular the changing nature of the case report form. There was also a concern with how surveillance, modelling and analysis of data were handled and with lack of timely data feedback to the local level. The main suggestion was to increase processes transparency and improve local access to data.
f Public Health Expert Advisory Committees: Respondents were mainly concerned with the lack of communication between physicians in the field and expert advisory committees. They also questioned the credentials of committees' members and their decisions. Needs of specific regions were felt as neglected. Suggestions included increasing speed of dissemination of advisory committees decisions and provision of committee members credentials, as well as increased involvement of physicians from various disciplines in committees' decision-making process.
This core theme included laboratory-related resources, patient management, and vaccination process.
a Laboratory Resources: Limited availability of diagnostic material and human resources and poor access to diagnostic tests such as nucleic acid amplification tests (e.g. PCR) were raised as issues.
b Patient Management: Many patients with influenza-like symptoms were sent to emergency rooms without prior evaluation, resulting in overburdened emergency rooms. Respondents suggested that those patients be evaluated elsewhere. Some also mentioned a lack of hospital single rooms to accommodate patients with pH1N1, as well as difficulty in transferring patients.
c Vaccination Process: Vaccines arrived late after the onset of the second wave of the pandemic and notifications of availability were last minute. Physicians expressed disagreement with high-risk group prioritization, especially in regards to school-aged children and the elderly population, who were targeted late in the vaccination campaign. Respondents proposed approaching group prioritization based on a better risk assessment. Other suggestions included earlier accessibility to the vaccine for the general public and the need for specialized clinics to serve chronically ill patients. Physicians would also have liked to receive more information on the vaccine.