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To measure primary care access on an ongoing basis, the Ontario Ministry of Health and Long-Term Care implemented the Primary Care Access Survey (PCAS) in 2006. The PCAS, a cross-sectional telephone survey, samples approximately 8,400 Ontario adults each year. It collects information on access to a family doctor, use of services, health status and socio-demographics. Analysis of the 2007—2008 PCAS (n=16,560) shows that 7.1% of Ontario's adults were without a family doctor (i.e., unattached). The attached and unattached populations differed on socio-demographic and health characteristics. Emergency department use was similar between the two groups, but walk-in clinic use was higher among the unattached. The unattached were less likely to have used care for immediate issues but accessed care in a more timely fashion than the attached. This initial exploration of the PCAS provides a better understanding of some of the differences between the attached and unattached populations in Ontario.

Background

Accounting for 36% of public spending on health care in Canada, hospitals are a major target for cost reductions through various efficiency initiatives. Some provinces are considering payment reform as a vehicle to achieve this goal. With few exceptions, Canadian provinces have generally relied on global and line-item budgets to contain hospital costs. There is growing interest amongst policy-makers for using activity based funding (ABF) as means of creating financial incentives for hospitals to increase the 'volume' of care, reduce cost, discourage unnecessary activity, and encourage competition. British Columbia (B.C.) is the first province in Canada to implement ABF for partial reimbursement of acute hospitalization. To date, there have been no formal examinations of the effects of ABF policies in Canada.

This study proposal addresses two research questions designed to determine whether ABF policies affect health system costs, access and hospital quality. The first question examines the impact of the hospital funding policy change on internal hospital activity based on expenditures and quality. The second question examines the impact of the change on non-hospital care, including readmission rates, amount of home care provided, and physician expenditures.

Methods/Design

A longitudinal study design will be used, incorporating comprehensive population-based datasets of all B.C. residents; hospital, continuing care and physician services datasets will also be used. Data will be linked across sources using anonymized linking variables. Analytic datasets will be created for the period between 2005/2006 and 2012/2013.

Discussion

With Canadian hospitals unaccustomed to detailed scrutiny of what services are provided, to whom, and with what results, the move toward ABF is significant. This proposed study will provide evidence on the impacts of ABF, including changes in the type, volume, cost, and quality of services provided. Policy- and decision-makers in B.C. and elsewhere in Canada will be able to use this evidence as a basis for policy adaptations and modifications. The significance of this proposed study derives from the fact that the change in hospital funding policy has the potential to affect health system costs, residents' access to care and care quality.

This study was designed to investigate personal and social factors associated with demand for care by women aged between 20 and 44 years, a group unlikely to suffer from chronic illness. A random sample of women was drawn from the age-sex register of a south London group practice, and information was obtained concerning their daily symptom perception, anxiety level, social and health characteristics, and their consultations for one year. Social class, family involvement, number of children in household, satisfaction with the housing, and use of other health and social services were not associated with demand for general practitioner care. Absence of basic housing amenities, difficulties in running the household, brevity of stay in the house or neighbourhood, and lack of attachment of the neighbourhood were related to a high patient-initiated consultation rate. Some of the possible interpretations of these results are discussed together with their implications for social policy planning.

Background

Ongoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. ‘Holding’, a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients.

Aim

To explore urban GPs' and patients' experiences of the management of chronic illness, with a particular focus on holding relationships.

Design and setting

A qualitative study in urban and suburban areas of north west England.

Method

Participating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results

GP responders considered holding to be a small but routine part of theirwork. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access.

Conclusion

Holding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.

Background

In response to the escalating burden of chronic illness in Australia, recent health policies have emphasised the promotion of patient self-management and better preventive care. A notable omission from these policies is the acknowledgment that patients with chronic illness tend to have co-morbid conditions. Our objectives were: to identify the common challenges co-morbidity poses to patients and carers in their experiences of self-management; to detail the views and perceptions of health professionals about these challenges; and to discuss policy options to improve health care for people with co-morbid chronic illness. The method included semi-structured interviews and focus groups with 129 purposively sampled participants. Participants were people with Type 2 diabetes, chronic obstructive pulmonary disease and/or chronic heart failure as well as carers and health care professionals. Content analysis of the interview data was conducted using NVivo7 software.

Results

Patients and their carers found co-morbidity influenced their capacity to manage chronic illness in three ways. First, co-morbidity created barriers to patients acting on risk factors; second, it complicated the process of recognising the early symptoms of deterioration of each condition, and third, it complicated their capacity to manage medication.

Conclusion

Findings highlight challenges that patients with multiple chronic conditions face in relation to preventive care and self-management. Future clinical policy initiatives need to move away from single illness orientation toward strategies that meet the needs of people with co-morbid conditions and strengthen their capacity to self-manage. These patients will benefit directly from specialised education and services that cater to the needs of people with clusters of co-morbidities.

Background

Research indicating that people increasingly prefer to die at home suggests that palliative care is likely to play a more prominent role in the future of Canada's health care system. Unfortunately, at a time when research evidence should be informing policy and service delivery, little is known about health service utilization by Canadians at the end of life. One existing mechanism that can help address this gap is provincial administrative health data. The purpose of this study was to explore the potential of administrative health data to identify characteristics of palliative care users, patterns of formal service utilization and predictors of palliative care use.

Methods

Bivariate and multivariate analyses were used to examine data from the Capital Health Region, British Columbia Linked Health Databases for the period 1992/93 to 1998/99. The databases examined include continuing care, physician claims, hospital separations, and vital statistics. As the name implies, these databases can be linked at the individual level using unique identifiers so that health services utilization can be tracked across sectors.

Results

General patterns of service use among palliative care patients suggest that general practitioner and medical specialist visits have decreased over time and the utilization of hospital beds has increased. Utilization of community-based services (i.e. home support and home nursing care) shows an overall pattern of decline. However, when compared to non-palliative care patients, palliative care patients spent fewer nights in hospital, used fewer hours of home support, and had a greater number of home nursing care visits.

Conclusions

Administrative health databases can provide valuable information for examining service utilization patterns over time. However, given that decisions surrounding the designation of palliative care include factors beyond the scope of administrative databases (such as quality of life, personal preferences, social support), these databases should only be seen as one source of information to inform service delivery and policy decision making.

OBJECTIVE

To determine the prevalence and content of existing or developing policies and guidelines of medical associations and colleges regarding after-hours care by family physicians and general practitioners, especially legal requirements.

DESIGN

Telephone survey in fall 2002, updated in fall 2004.

SETTING

Canada.

PARTICIPANTS

All national and provincial medical associations, Colleges of Family Physicians, Colleges of Physicians and Surgeons, local government offices for the north, and the Canadian Medical Protective Association (CMPA).

MAIN OUTCOME MEASURE

Response to the question: “Does your agency have a policy in place regarding after-hours health care coverage by FPs/GPs, or are there active discussions regarding such a policy?”

RESULTS

The College of Physicians and Surgeons of British Columbia was the first to institute a policy, in 1995, requiring physicians to make “specific arrangements” for after-hours care of their patients. The College of Physicians and Surgeons of Alberta adopted a similar policy in 1996 along with a guideline to aid implementation. In 2002, the College of Physicians and Surgeons of Nova Scotia approved a guideline on the Availability of Physicians After Hours. The Saskatchewan Medical Association and the College of Physicians and Surgeons of Saskatchewan formulated a joint policy on medical practice coverage that was released in 2003. Many agencies actively discussed the topic. Provincial and national Colleges of Family Physicians did not have any policies in place. The CMPA does not generate guidelines but released in an information letter in May 2000 a section entitled “Reducing your risk when you’re not available.”

CONCLUSION

There is increasing interest Canada-wide in setting policy for after-hours care. While provincial Colleges of Physicians and Surgeons have traditionally led the way, a trend toward more collaboration between associations was identified. The effect of policy implementation on physicians’ coverage of patients is unclear.

OBJECTIVES: To compare the current practice of preventive medicine in British Columbia with the recommendations of the Canadian Task Force on the Periodic Health Examination. Four common, preventable forms of cancer (cervical, breast, lung and colorectal) were used as sentinel conditions. DESIGN: Random sample mailed survey. SETTING: Private primary care practices in British Columbia. PARTICIPANTS: A sample of 300 primary care physicians in 1991; of 285 eligible physicians 185 (65%) responded. OUTCOME MEASURE: Compliance with preventive practices recommended by the task force. RESULTS: Preventive practice complied with the task force's recommendations for breast examinations, mammography, cervical smears and initial counselling against smoking; over 90% of the physicians performed these manoeuvres in all or most cases. However, less than half performed two recommended manoeuvres for all or most patients who smoke: advice to follow a diet high in beta-carotene (reported by 10%) and scheduling of follow-up visits to reinforce antismoking counselling (by 46%). Most of the physicians stated that they perform preventive manoeuvres in the context of an annual general physical examination rather than integrating them into routine patient care. CONCLUSIONS: The task force's carefully constructed recommendations are incompletely followed. Overall, there appears to be a high level of compliance with traditional and recommended manoeuvres but also widespread persistence in performing traditional manoeuvres no longer recommended and failure to adopt new recommendations.

An analysis of 98 health visitors and district nurses attached and non-attached to general practitioners in three local authority areas showed that most of them were aged over 40 and that many had entered domiciliary work because of the convenient hours or because of its intangible attractions. Adequate preparation for attachment was considered important, particularly a clear definition of the roles of the attached staff and their relationships to other workers in the practice.

Attached staff were found to be much more satisfied with the information given by the general practitioner about their patients than were unattached staff, and the former usually had access to the patients' medical records. The principal advantages of attachment were listed as access to family history; improved co-ordination within the practice and co-operation with the social services; favourable patient response; and increased mileage and work-load; the impossibility of crossing local authority boundaries; and having to deal with families registered with more than one doctor.

Background:

In May 2003, the government of British Columbia adopted income-based pharmacare, replacing an age-based drug benefits program. Stated policy goals included reducing government spending, maintaining or enhancing access to medicines and improving financial equity. The province’s experience on these policy dimensions can inform policy making in other jurisdictions and offers insight into priorities for Canada’s National Pharmaceuticals Strategy.

Method:

The research team created an anonymized database with information about drug use, private and public expenditure and household income for all residents of British Columbia from 1996 to 2004. This database was used to evaluate the impact of the policy on trends in drug expenditures, utilization and sources of payment for seniors and non-seniors of different income levels.

Results:

In the immediate term, Fair PharmaCare appears to have met many of its policy goals. Government spending was reduced. Access to medicines was maintained (though not enhanced). And the distributions of private and public expenditures were brought more closely in line with distribution of income. Long-run impacts depend largely on how a reduced role for government affects trends in costs, access and equity. Early indications suggest that a larger role for government may be needed to maintain performance on desired policy objectives over time.

Conclusion:

In the long run, there is reason for setting a new national standard for pharmacare that increases, not decreases, the share of publicly covered spending in every province. The federal government could play a key role by helping provinces increase public funding for prescription drugs and thereby facilitate cost control, maintain access to medicines and enhance financial equity.

Background

Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support.

Methods

Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience.

Results

Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician.

Conclusions

Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants’ accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery.

Objectives: To determine the effectiveness and acceptability of general practitioners’opportunistic antismoking interventions by examining detailed accounts of smokers’ experiences of these.

Design: Qualitative semistructured interview study.

Setting: South Wales.

Subjects: 42 participants in the Welsh smoking intervention study were asked about initial smoking, attempts to quit, thoughts about future smoking, past experiences with the health services, and the most appropriate way for health services to help them and other smokers.

Results: Main emerging themes were that subjects already made their own evaluations about smoking, did not believe doctors’ words could influence their smoking, believed that quitting was down to the individual, and felt that doctors who took the opportunity to talk about smoking should focus on the individual patient. Smokers anticipated that they would be given antismoking advice by doctors when attending for health care; they reacted by shrugging this off, feeling guilty, or becoming annoyed. These reactions affected the help seeking behaviour of some respondents. Smokers were categorised as “contrary,” “matter of fact,” and “self blaming,” depending on their reported reaction to antismoking advice.

Conclusions: Doctor-patient relationships can be damaged if doctors routinely advise all smokers to quit. Where doctors intervene, a patient centred approach—one that considers how individual patients view themselves as smokers and how they are likely to react to different styles of intervention—is the most acceptable.

Key messages Many patients who smoke are sceptical about the power of doctors’ words to influence smoking since most know about the dangers, make their own evaluations, and feel that quitting is down to the individual Opportunistic antismoking interventions should be sympathetic, not preaching, and centred on the patient as an individual Repeated ritualistic intervention on the part of doctors may deter patients from seeking medical help when they need it Smokers can be categorised as “contrary,” “matter of fact,” or “self blaming” in their reaction to antismoking advice Doctors can tailor their approach according to the type of patient

Background

Little is known about service providers’ knowledge, attitudes, and experiences in relation to the assessment, diagnosis, and treatment of individuals seeking care for sexually transmitted infections (STIs), and how they influence the delivery of services. The purpose of this study was to explore the perceptions of STI care providers and the ways they approached their practice.

Methods

We used a qualitative approach drawing on methods used in thematic analysis. Individual semi-structured in-depth interviews were conducted with 21 service providers delivering STI services in youth clinics, STI clinics, reproductive health clinics, and community public health units in British Columbia (BC), Canada.

Results

Service providers’ descriptions of their activities and roles were shaped by a number of themes including specialization, scarcity, and maintaining the status quo. The analysis suggests that service providers perceive, at times, the delivery of STI care to be inefficient and inadequate.

Conclusion

Findings from this study identify deficits in the delivery of STI services in BC. To understand these deficits, more research is needed to examine the larger health care structure within which service providers work, and how this structure not only informs and influences the delivery of services, but also how particular structural barriers impinge on and/or restrict practice.

Background

More than 33% of Canadians live in rural areas. The vulnerability of rural surgical patients makes them particularly sensitive to barriers to accessing health care. This study aims to describe rural patients’ experiences accessing local non-specialist, family physician–surgeon care and regional specialist surgical care when no local surgical care was available.

Methods

We conducted a qualitative pilot study of self-selected patients. Interviews were analyzed using a modified Delphi technique and NVivo qualitative software.

Results

The needs of rural surgical patients were reflective of Maslow’s hierarchy of needs: physiologic, safety and security, community belonging and self-esteem/self-actualization. Rural patients expressed a strong desire for individualized care in a familiar environment. When such care was not available, patients found it difficult to meet even basic physiologic needs. Maternity patients and marginalized populations were particularly vulnerable.

Conclusion

Rural patients seem to prefer individualized care in a familiar environment to address more of their qualitative emotional, psychological and cultural needs rather than only the physiologic needs of surgery. Larger studies are needed to delineate more clearly the qualitative aspects of surgical care.

Background

Through the 1990s, governments across Canada shifted health care funding allocation and organizational foci toward a community-based population health model. Major concerns of reform based on this model include ensuring equitable access to health and health care, and enhancing preventive and community-based resources for care. Reforms may act differentially relative to specific conditions and services, including those geared to chronic versus acute conditions. The present study therefore focuses on health service utilization, specifically cancer hospitalizations, in British Columbia during a decade of health system reform.

Methods

Data were drawn from the British Columbia Linked Health Data resource; income measures were derived from Statistics Canada 1996 Census public use enumeration area income files. Records with a discharge (separation) date between 1 January 1991 and 31 December 1998 were selected. All hospitalizations with ICD-9 codes 140 through 208 (except skin cancer, code 173) as principal diagnosis were included. Specific cancers analyzed include lung; colorectal; female breast; and prostate. Hospitalizations were examined in total (all separations), and as divided into first and all other hospitalizations attributed to any given individual. Annual trends in age-sex adjusted rates were analyzed by joinpoint regression; longitudinal multivariate analyses assessing association of residence and income with hospitalizations utilized generalised estimating equations. Results are evaluated in relation to cancer incidence trends, health policy reform and access to care.

Results

Age-sex adjusted hospitalization rates for all separations for all cancers, and lung, breast and prostate cancers, decreased significantly over the study period; colorectal cancer separations did not change significantly. Rates for first and other hospitalizations remained stationary or gradually declined over the study period. Area of residence and income were not significantly associated with first hospitalizations; effects were less consistent for all and other hospitalizations. No interactions were observed for any category of separations.

Conclusions

No discontinuities were observed with respect to total hospitalizations that could be associated temporally with health policy reform; observed changes were primarily gradual. These results do not indicate whether equity was present prior to health care reform. However, findings concur with previous reports indicating no change in access to health care across income or residence consequent on health care reform.

ABSTRACT

OBJECTIVE

To assess whether regular care from a family physician is associated with regular participation in screening mammography.

DESIGN

Secondary analysis of the 2006 Canadian Community Health Survey data.

SETTING

Canada.

PARTICIPANTS

Cross-sectional sample of 15 195 Canadian women aged 50 to 69 years.

MAIN OUTCOME MEASURES

The outcome of interest was screening mammography within the past 2 years; the key explanatory factor was active interaction with a family physician. Control factors included sociodemographic characteristics, other cancer screening behaviour, and other cancer risk habits.

RESULTS

Active interaction with a regular family doctor doubled the odds that a woman had received a recent screening mammogram. Other cancer screening and preventive measures were also strongly associated with that outcome. A woman who had had a recent Papanicolaou test was more than 3 times as likely to have had a recent mammogram; nonsmokers were much more likely to have had a recent mammogram than smokers.

CONCLUSION

Adults who receive regular care from family physicians are more likely to participate in screening mammography within the recommended time frames.

Background

The Canadian Heart Health Initiative began in 1987 as an 18-year undertaking to address the epidemic of cardiovascular disease in Canada. There is growing recognition in Canada of the need for an integrated approach to prevention that addresses common risks for many chronic diseases.

Context

Research and intervention activities of the Canadian Heart Health Initiative have shifted toward chronic disease prevention and health promotion. This study explores the contributions of the Canadian Heart Health Initiative to document how single-disease strategies can evolve into integrated chronic disease prevention efforts.

Methods

Key informant interviews were conducted with project researchers and health system stakeholders from seven Canadian Heart Health Initiative provincial projects. A review of provincial health policy documents was also performed.

Consequences

Findings indicate that the Canadian Heart Health Initiative projects contributed to public health capacity development, including coalition and partnership building, and development of health knowledge and resource infrastructure. The Canadian Heart Health Initiative projects helped put chronic disease prevention issues onto local and provincial health agendas and provided community-based models to help develop public health policies.

Interpretation

Experience with the Canadian Heart Health Initiative shows the need for integrated health programs to build on existing infrastructure. Other requirements for integrated chronic disease prevention programs include shared goals, partnerships at various policy levels and in multiple sectors, ongoing information sharing, and funding that is flexible and long-term.

Background

Providing appropriate palliative care for older people is a major task for health care systems worldwide, and up to now it has also been one of the most neglected. Focusing on the German health care system, we sought to explore the attitudes of health professionals regarding their understanding of palliative care for older patients and its implementation.

Methods

In a qualitative study design, focus groups were established consisting of general practitioners, geriatricians, palliative care physicians, palliative care nurses and general nurses (a total of 29 participants). The group discussions were recorded, transcribed, coded and analysed using the methodological approach of Qualitative Description.

Results

Deficiencies in teamwork and conflicting role definitions between doctors and nurses and between family practitioners and medical specialists were found to be central problems affecting the provision of appropriate palliative care for older people. It was emphasized that there are great advantages to family doctors playing a leading role, as they usually have the longest contacts to the patients. However, the professional qualifications of family doctors were to some extent criticized. The general practitioners for their part criticized the increasing specialization on the field of palliative care. All groups complained that the German compensation system gives insufficient consideration to the time-consuming care of older patients, and about excessive bureaucracy.

Conclusion

General practitioners are the central health professionals in the delivery of palliative care for older people. They should however be encouraged to involve specialized services such as palliative care teams where necessary. With the German health care reform of 2007, a legal framework has been created that allows for this. As far as its realization is concerned, it must be ensured that the spotlight remains on the needs of the patients and not on policy conflicts and rivalries between health care professionals. Older people might particularly benefit if "talking" medicine and time-consuming care were properly catered for, financially and organizationally, in the health care system.

The Canadian Medical Association's More Doctors, More Care campaign seeks to align physician supply targets with policy decisions elsewhere in the Organisation for Economic Co-operation and Development (OECD). Using OECD data for 19 countries to assess the relationship between physician supply and healthcare outcomes, we have determined that there is no association between avoidable mortality and overall physician supply. Similarly, there is no relationship between avoidable mortality and general practitioners and family physicians per capita, specialists per capita, nurses per capita, doctors and nurses per capita or health expenditures per capita. These findings should move us to recognize that (a) more doctors will not necessarily translate into better healthcare outcomes for Canadians and (b) it is in Canadians' better interests that we instead focus on realizing opportunities to improve access to high-quality care and to ensure that changes in physician turnover do not threaten the current generalist-to-specialist mix.

The present supplement summarizes the proceedings of the symposium “Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD”, which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients’ associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals.

This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the “Canadian Asthma and COPD Campaign”, aimed at improving care and, hence, the quality of life of those suffering from these diseases.

It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Background

Increasing attention is being paid to variations in the use of prescription drugs because their role in health care has grown to the point where their use can be considered a proxy for health system performance. Studies have shown that prescription drug use varies across regions in the US, UK, and Canada by more than would be predicted based on age and health status alone. In this paper, we explore the determinants of variations in the use of prescription drugs, drawing on health services theories of access to care.

Methods

We conducted a cross-sectional analysis using population-based administrative health care data for British Columbia (BC), Canada. We used logistic and hierarchical regressions to analyze the effects of individual- and area-level determinants of use of prescriptions overall and rates of purchase of prescriptions from five therapeutic categories representing a range of indications: antihypertensives, statins, acid reducing drugs, opioid drugs, and antidepressants. To indicate the relative scale of regional variations and the importance of individual- and area-level variables in explaining them, we computed standardized rates of utilization for 49 local health areas in BC.

Results

We found that characteristics of individuals and the areas in which they live affect likelihood of prescription drug purchase. Individual-level factors influenced prescription drug purchases in ways generally consistent with behavioral models of health services use. Contextual variables exerted influences that differed by type of drug studied. Population health, education levels, and ethnic composition of local areas were associated with significant differences in the likelihood of purchasing medications. Relatively modest regional variations remained after both individual-level and area-level determinants were taken into account.

Conclusions

The results of this study suggest that individual- and area-level factors should be considered when studying variations in the use of prescription drugs. Some sources of such variations, including individual- and area-level socioeconomic status, warrant further investigation and possible intervention to address inequities.

Background

Vitamin D deficiency during infancy may lead to rickets and possibly other poor health outcomes. The World Health Organization recommends exclusive breastfeeding for the first 6 months. Breast milk is the best food for infants but does not contain adequate vitamin D. Health Canada recommends all breastfed infants receive a daily vitamin D supplement of 400 IU; however, there appears to be limited current Canadian data as to whether parents or caregivers are following this advice. The aim of this study was to determine the rates of vitamin D supplementation among 2-month old infants in Vancouver and Richmond, British Columbia, Canada.

Methods

Mothers of all healthy infants born between April and May 2010 were approached to participate. Telephone surveys were conducted with 577 mothers (response rate 56%) when their infants turned 2 months.

Results

Over half of the infants received only breast milk in the week prior to the survey. One third received a mixture of breast milk and infant formula and 10% received only formula. About 80% of the infants were supplemented with vitamin D at 2 months. Infants who received only breast milk were most likely to be supplemented with vitamin D (91%). Over 60% of the infants had a total vitamin D intake of 300- < 500 IU/d from supplements and formula and only 5% did not receive any vitamin D. Most parents were advised to give vitamin D supplement by health professionals, such as public health nurses, midwives, and doctors.

Conclusions

About 90% of the infants received breast milk at 2 months of age. The vitamin D supplementation rate was 80%. Future studies are needed to monitor breastfeeding duration and vitamin D supplementation rates as infants get older.

Objective

To analyze the structure and composition of unattached stones in idiopathic calcium oxalate stone formers (ICSF) and compare them to attached stones from the same cohort in order to investigate whether more than one pathogenic mechanism exists for stone formation in ICSF.

Patients and methods

ICSF undergoing percutaneous nephrolithotomy or ureteroscopy for treatment of nephrolithiasis were consented for this study. All accessible renal papillae were endoscopically imaged using a digital endoscope. All stones were removed and determined by the operating surgeon to be attached or unattached to the underlying papilla. Micro-computed tomography (micro-CT), which provides three-dimensional analysis of entire stones, was used to compare the structure and composition of attached versus unattached stones.

Results

Of 115 stones collected from 9 patients (12 renal units), only 25 stones were found not to be attached to renal papillae. Of these 25 stones, 4 were lost and 12 showed definite morphological evidence of having been attached to tissue, probably having been knocked off of papillae during access. For the remaining 9 stones, micro-CT analysis revealed at least one internal region of calcium phosphate within each of these unattached calcium oxalate (CaOx) stones. That is, the internal structure of the unattached stones is consistent with their having originated attached to RP, and then having become detached but retained in the kidney, with new layers of CaOx eventually covering the original attachment site.

Conclusions

Micro CT analysis supports the hypothesis that in ICSF, both attached and unattached stones occur as a result of a common pathogenic mechanism. That is, in this type of stone former, CaOx stones—even those not showing morphology that betrays attachment—all originate attached to interstitial plaque on the renal papilla.

OBJECTIVE: To ascertain the extent to which family physicians in British Columbia agree with First Nations patients' using traditional Native medicines. DESIGN: Randomized cross-sectional survey. SETTING: Family medicine practices in British Columbia. PARTICIPANTS: A randomized volunteer sample of 79 physicians from the registry of the BC Chapter of the College of Family Physicians of Canada. Of 125 physicians contacted, 46 did not reply. MAIN OUTCOME MEASURES: Physicians' demographic variables and attitudes toward patients' use of traditional Native medicines. RESULTS: Respondents generally accepted the use of traditional Native medicines for health maintenance, palliative care, and the treatment of benign illness. More disagreement was found with its use for serious illnesses, both for outpatients and in hospital, and especially in intensive care. Many physicians had difficulty forming a definition of traditional Native medicine, and were unable to give an opinion on its health risks or benefits. A significant positive correlation appeared between agreement with the use of traditional Native medicines and physicians' current practice serving a large First Nations population, as well as with physicians' knowing more than five patients using traditional medicine. CONCLUSIONS: Cooperation between traditional Native and modern health care systems requires greater awareness of different healing strategies, governmental support, and research to determine views of Native patients and healers.

To test the popular but unproven assumption that the metaphase-anaphase transition in vertebrate somatic cells is subject to a checkpoint that monitors chromosome (i.e., kinetochore) attachment to the spindle, we filmed mitosis in 126 PtK1 cells. We found that the time from nuclear envelope breakdown to anaphase onset is linearly related (r2 = 0.85) to the duration the cell has unattached kinetochores, and that even a single unattached kinetochore delays anaphase onset. We also found that anaphase is initiated at a relatively constant 23-min average interval after the last kinetochore attaches, regardless of how long the cell possessed unattached kinetochores. From these results we conclude that vertebrate somatic cells possess a metaphase-anaphase checkpoint control that monitors sister kinetochore attachment to the spindle. We also found that some cells treated with 0.3-0.75 nM Taxol, after the last kinetochore attached to the spindle, entered anaphase and completed normal poleward chromosome motion (anaphase A) up to 3 h after the treatment--well beyond the 9-48-min range exhibited by untreated cells. The fact that spindle bipolarity and the metaphase alignment of kinetochores are maintained in these cells, and that the chromosomes move poleward during anaphase, suggests that the checkpoint monitors more than just the attachment of microtubules at sister kinetochores or the metaphase alignment of chromosomes. Our data are most consistent with the hypothesis that the checkpoint monitors an increase in tension between kinetochores and their associated microtubules as biorientation occurs.