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1.  Prevention of overweight and obesity in adult populations: a systematic review 
CMAJ Open  2014;2(4):E268-E272.
Background
The prevalence of normal-weight adults is decreasing, and the proportion in excessive weight categories (body mass index ≥ 25) is increasing. In this review, we sought to identify interventions to prevent weight gain in normal-weight adults.
Methods
We searched multiple databases from January 1980 to June 2013. We included randomized trials of primary care–relevant behavioural, complementary or alternative interventions for preventing weight gain in normal-weight adults that reported weight change at least 12 months after baseline. We included any studies reporting harms. We planned to extract and pool data for 4 weight outcomes, 6 secondary health outcomes and 5 adverse events categories.
Results
One small study provided moderate-quality evidence. The 12-month program, which used education and financial strategies and was offered more than 25 years ago in the United States, was successful in stabilizing weight and producing weight loss. More intervention participants maintained their baseline weight or lost weight than controls (82% v. 56%, p < 0.0001), and program participants maintained their weight better than controls by showing greater weight reduction by the end of the intervention (mean difference adjusted for height –0.82, 95% confidence interval –1.57 to –0.06, kg). No evidence was available for sustained effects or for any other weight outcomes, secondary outcomes or harms.
Interpretation
We were unable to determine whether behavioural interventions led to weight-gain prevention and improved health outcomes in normal-weight adults. Given the importance of primary prevention, and the difficulty of losing weight and maintaining weight loss, this paucity of evidence is surprising and leaves clinicians and public health practitioners with unclear direction. Registration: PROSPERO no. CRD42012002753
doi:10.9778/cmajo.20140019
PMCID: PMC4251511  PMID: 25485253
2.  Treatment for overweight and obesity in adult populations: a systematic review and meta-analysis 
CMAJ Open  2014;2(4):E306-E317.
Background
Obesity is a major public health issue. This review updates the evidence on the effectiveness of behavioural and pharmacologic treatments for overweight and obesity in adults.
Methods
We updated the search conducted in a previous review. Randomized trials of primary-care-relevant behavioural (diet, exercise and lifestyle) and pharmacologic (orlistat and metformin) with or without behavioural treatments in overweight and obese adults were included if 12-month, postbaseline data were provided for weight outcomes. Studies reporting harms were included regardless of design. Data were extracted and pooled wherever possible for 5 weight outcomes, 6 secondary health outcomes and 4 adverse events categories.
Results
We identified 68 studies, most consisted of short-term (≤ 12 mo) treatments using diet (n = 8), exercise (n = 4), diet and exercise (n = 10), lifestyle (n = 19), orlistat (n = 25) or metformin (n = 4). Compared with the control groups, intervention participants had a greater weight loss of −3.02 kg (95% confidence interval [CI] −3.52 to −2.52), a greater reduction in waist circumference of −2.78 cm (95% CI −3.34 to −2.22) and a greater reduction in body mass index of −1.11 kg/m2 (95% CI −1.39 to −0.84). The relative risk for loss of ≥ 5% body weight was 1.77 (95% CI 1.58–1.99, [number needed to treat 5, 95% CI 4–7]), and the relative risk for loss of ≥ 10% body weight was 1.91 (95% CI 1.69–2.16, [number needed to treat 9, 95% CI 7–12]). Incidence of type 2 diabetes was lower among pre-diabetic intervention participants (relative risk 0.62 [95% CI 0.50–0.77], number needed to treat 17 [95% CI 13–29]). With prevalence rates for type 2 diabetes on the rise, weight loss coupled with a reduction in the incidence of type 2 diabetes could potentially have a significant benefit on population health and a possible reduction in need for drug treatments for glycemic control.
Interpretation
There is moderate quality evidence that behavioural and pharmacologic plus behvioural, treatments for overweight and obesity in adults lead to clinically important reductions in weight and incidence of type 2 diabetes in pre-diabetic populations. Registration: PROSPERO no. CRD42012002753
doi:10.9778/cmajo.20140012
PMCID: PMC4251513  PMID: 25485258
3.  Linking Canadian Population Health Data: Maximizing the Potential of Cohort and Administrative Data 
Linkage of data collected by large Canadian cohort studies with provincially managed administrative health databases can offer very interesting avenues for multidisciplinary and cost-effective health research in Canada. Successfully co-analyzing cohort data and administrative health data (AHD) can lead to research results capable of improving the health and well-being of Canadians and enhancing the delivery of health care services. However, such an endeavour will require strong coordination and long-term commitment between all stakeholders involved. The challenges and opportunities of a pan-Canadian cohort-to-AHD data linkage program have been considered by cohort study investigators and data custodians from each Canadian province. Stakeholders acknowledge the important public health benefits of establishing such a program and have established an action plan to move forward.
PMCID: PMC3880355  PMID: 23823892 CAMSID: cams3806
Medical record linkage; data collection; public health
4.  Screening for depression: a systematic review and meta-analysis 
CMAJ Open  2013;1(4):E159-E167.
Background
The Canadian Task Force on Preventive Health Care has a guideline on screening for depression among adults 18 years of age or older at average or high risk for depression. To provide evidence for an update of this guideline, we evaluated the literature on the effectiveness of screening for depression in adults.
Methods
For the period 1994 to May 23, 2012, we searched the following electronic databases: MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Randomized controlled trials, observational studies and systematic reviews with evidence for the benefits or harms of screening for depression were eligible for inclusion. We performed screening for relevance, extraction of data, analysis of risk of bias and quality assessments in duplicate. We used the generic inverse variance method to conduct a meta-analysis. To determine confidence in the effect, we analyzed the results according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Results
Five quasi-experimental studies (before–after design with a nonrandomized control group) met the inclusion criteria for this review. These studies reported on the effect of community-based screening for depression, with follow-up on the risk of suicide completion, for older residents in regions of rural Japan with high suicide rates. Meta-analysis showed that the screening program had a protective effect on the overall incidence of suicide completion (ratio of rate ratios [RRR] 0.50, 95% confidence interval [CI], 0.32–0.78). When sex was considered, the RRR indicated a significantly lower rate of suicide among women (RRR 0.37, 95% CI 0.21–0.66) but not among men (RRR 0.67, 95% CI 0.35–1.27). The overall GRADE rating applied to this evidence indicated very low quality. No studies addressing the harms of screening for depression met the inclusion criteria for the review.
Interpretation
There is very limited research evidence allowing conclusions about the effectiveness of screening for depression in either average-risk or high-risk populations.
doi:10.9778/cmajo.20130030
PMCID: PMC3986010  PMID: 25077118
5.  Vitamin D, cognition, and dementia 
Neurology  2012;79(13):1397-1405.
Objective:
To examine the association between cognitive function and dementia with vitamin D concentration in adults.
Methods:
Five databases were searched for English-language studies up to August 2010, and included all study designs with a comparative group. Cognitive function or impairment was defined by tests of global or domain-specific cognitive performance and dementia was diagnosed according to recognized criteria. A vitamin D measurement was required. Two authors independently extracted data and assessed study quality using predefined criteria. The Q statistic and I2 methods were used to test for heterogeneity. We conducted meta-analyses using random effects models for the weighted mean difference (WMD) and Hedge's g.
Results:
Thirty-seven studies were included; 8 contained data allowing mean Mini-Mental State Examination (MMSE) scores to be compared between participants with vitamin D <50 nmol/L to those with values ≥50 nmol/L. There was significant heterogeneity among the studies that compared the WMD for MMSE but an overall positive effect for the higher vitamin D group (1.2, 95% confidence interval [CI] 0.5 to 1.9; I2 = 0.65; p = 0.002). The small positive effect persisted despite several sensitivity analyses. Six studies presented data comparing Alzheimer disease (AD) to controls but 2 utilized a method withdrawn from commercial use. For the remaining 4 studies the AD group had a lower vitamin D concentration compared to the control group (WMD = −6.2 nmol/L, 95% CI −10.6 to −1.8) with no heterogeneity (I2 < 0.01; p = 0.53).
Conclusion:
These results suggest that lower vitamin D concentrations are associated with poorer cognitive function and a higher risk of AD. Further studies are required to determine the significance and potential public health benefit of this association.
doi:10.1212/WNL.0b013e31826c197f
PMCID: PMC3448747  PMID: 23008220
6.  Association between caregiver quality of life and the care provided to persons with Alzheimer’s disease: protocol for a systematic review 
Systematic Reviews  2013;2:17.
Background
Primary informal caregivers provide a substantial amount of the care and support for persons with Alzheimer’s disease (AD). This review aims to investigate the association between the quality of life (QoL) of primary informal AD caregivers and the level of care that these caregivers provide to persons with AD.
Methods
Studies involving primary informal caregivers of persons with AD will be included in the review. These studies will be required to focus on the care that caregivers provide for their loved ones. The primary outcome is level or quality of care. The main independent variable is caregiver QoL. In addition to QoL, we will include studies that examine other independent variables that are considered to be important components of QoL. These variables include social support, caregiver burden, caregiver wellbeing, and caregiver depression.
We will search Medline-OVID, Embase-OVID, Cochrane Central-OVID, and PsycINFO-OVID from inception onwards. Two raters will independently screen each article using pre-established inclusion/exclusion criteria. Screening will take place at two levels: title and abstract, and full text. Conflicts will be resolved by discussion or by a third reviewer. We will assess the risk of bias of each included study using standardized quality assessment tools for specific types of designs. A narrative synthesis method will be used to describe our findings. Quantitative summary and meta-analysis will be conducted if appropriate. We will employ GRADE to evaluate the strength of the evidence in this review.
Discussion
Results of this systematic review will show whether and how caregiver QoL is related to the level of care that caregivers provide to persons with AD.
doi:10.1186/2046-4053-2-17
PMCID: PMC3610300  PMID: 23497507
Alzheimer’s disease (AD); Caregiver; Quality of life (QoL); Level of care; Quality of care; PROSPERO registration number: CRD42013003613
7.  Comparison of population-averaged and cluster-specific models for the analysis of cluster randomized trials with missing binary outcomes: a simulation study 
Abstracts
Background
The objective of this simulation study is to compare the accuracy and efficiency of population-averaged (i.e. generalized estimating equations (GEE)) and cluster-specific (i.e. random-effects logistic regression (RELR)) models for analyzing data from cluster randomized trials (CRTs) with missing binary responses.
Methods
In this simulation study, clustered responses were generated from a beta-binomial distribution. The number of clusters per trial arm, the number of subjects per cluster, intra-cluster correlation coefficient, and the percentage of missing data were allowed to vary. Under the assumption of covariate dependent missingness, missing outcomes were handled by complete case analysis, standard multiple imputation (MI) and within-cluster MI strategies. Data were analyzed using GEE and RELR. Performance of the methods was assessed using standardized bias, empirical standard error, root mean squared error (RMSE), and coverage probability.
Results
GEE performs well on all four measures — provided the downward bias of the standard error (when the number of clusters per arm is small) is adjusted appropriately — under the following scenarios: complete case analysis for CRTs with a small amount of missing data; standard MI for CRTs with variance inflation factor (VIF) <3; within-cluster MI for CRTs with VIF≥3 and cluster size>50. RELR performs well only when a small amount of data was missing, and complete case analysis was applied.
Conclusion
GEE performs well as long as appropriate missing data strategies are adopted based on the design of CRTs and the percentage of missing data. In contrast, RELR does not perform well when either standard or within-cluster MI strategy is applied prior to the analysis.
doi:10.1186/1471-2288-13-9
PMCID: PMC3560270  PMID: 23343209
Marginal model; Population-averaged model; Cluster-specific model; Multiple imputation; Cluster randomized trial; Covariate dependent missingness; Generalized estimating equations; Random-effects logistic regression
8.  Psychometric properties of a questionnaire to assess exercise-related musculoskeletal injuries in older adults attending a community-based fitness facility 
BMJ Open  2012;2(6):e001777.
Objectives
There currently exists no reliable or validated tool for the assessment of exercise-related injuries in older adults. The purpose was to develop and evaluate the psychometric properties of a questionnaire to measure exercise-related injury in older adults participating in supervised exercise programmes.
Design
The study utilised a repeated survey design.
Setting
The study took place at one community-based older-adult exercise facility.
Participants
The questionnaire was administered to 110 community-dwelling older adults (45 men, mean age 75±8 years; 65 women, mean age 71±8 years). All participants completed the survey at both time points.
Outcome measures
Test–retest reliability of the self-administered written questionnaire was determined at two-time points. The questionnaire asked participants about their exercise-related injury incurred at the facility in the 12 months. Items included the mechanism, cause and site of injury. The minimum requirement for reliability (κ coefficient) was set at 0.80.
Results
16% (n=18) reported having an injury. Test–retest reliability ranged from 0.76 to 1.00, with all but type of injury (0.76) having κ coefficients greater than 0.80. The lower extremities were the most common site of exercise-related injury. Overexertion movements were the most common cause of injury occurring during strength training exercises.
Conclusions
The present questionnaire assessing the 12-month recall in older adults is a reliable measure of exercise-related injuries and information gained indicates that older adults can safely participate in exercise activities.
doi:10.1136/bmjopen-2012-001777
PMCID: PMC3533033  PMID: 23180390
Epidemiology; Sports Medicine; Statistics & Research Methods
9.  Systematic review: conservative treatments for secondary lymphedema 
BMC Cancer  2012;12:6.
Background
Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments.
Methods
We searched MEDLINE®, EMBASE®, Cochrane Central Register of Controlled Trials®, AMED, and CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized controlled trials or observational studies (with comparison groups) that reported primary effectiveness data on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the results descriptively and discussed similarities with the English-language studies.
Results
Thirty-six English-language and eight non-English-language studies were included in the review. Most of these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's chronicity, lengths of follow-up in most studies were under 6 months. Many trial reports contained inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational studies did not control for confounding. Many studies showed that active treatments reduced the size of lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and protocols, and outcome measures, prevented us from assessing whether any one treatment was superior. This heterogeneity also precluded us from statistically pooling results. Harms were rare (< 1% incidence) and mostly minor (e.g., headache, arm pain).
Conclusions
The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. Harms are few and unlikely to cause major clinical problems.
doi:10.1186/1471-2407-12-6
PMCID: PMC3320521  PMID: 22216837
10.  How Does the Canadian General Public Rate Moderate Alzheimer's Disease? 
Journal of Aging Research  2011;2011:682470.
Objectives. The objectives of this study were to elicit health utility scores for moderate Alzheimer's disease (AD) using members of the general public. Methods. Five-hundred Canadians were chosen randomly to participate in a telephone interview. The EQ-5D was administered to estimate the health utility score for respondents' current health status (i.e., no AD) and for a hypothetical moderate AD health state. Regression analyses were conducted to explain the perceived utility decrement associated with AD. Results. The mean age of the respondents was 51 years, 60% were female, and 42% knew someone with AD. Respondents' mean EQ-5D scores for their current health status and a hypothetical moderate AD were 0.873 (SD: 0.138) and 0.638 (SD: 0.194), respectively (P < 0.001). Age, gender, and education were significant factors explaining this decrement in utility. Conclusion. Members of the general public may serve as an alternative to patients and caregivers in the elicitation of health-related quality of life in AD.
doi:10.4061/2011/682470
PMCID: PMC3250621  PMID: 22229093
11.  Effects of an evidence service on health-system policy makers' use of research evidence: A protocol for a randomised controlled trial 
Background
Health-system policy makers need timely access to synthesised research evidence to inform the policy-making process. No efforts to address this need have been evaluated using an experimental quantitative design. We developed an evidence service that draws inputs from Health Systems Evidence, which is a database of policy-relevant systematic reviews. The reviews have been (a) categorised by topic and type of review; (b) coded by the last year searches for studies were conducted and by the countries in which included studies were conducted; (c) rated for quality; and (d) linked to available user-friendly summaries, scientific abstracts, and full-text reports. Our goal is to evaluate whether a "full-serve" evidence service increases the use of synthesized research evidence by policy analysts and advisors in the Ontario Ministry of Health and Long-Term Care (MOHLTC) as compared to a "self-serve" evidence service.
Methods/design
We will conduct a two-arm randomized controlled trial (RCT), along with a follow-up qualitative process study in order to explore the findings in greater depth. For the RCT, all policy analysts and policy advisors (n = 168) in a single division of the MOHLTC will be invited to participate. Using a stratified randomized design, participants will be randomized to receive either the "full-serve" evidence service (database access, monthly e-mail alerts, and full-text article availability) or the "self-serve" evidence service (database access only). The trial duration will be ten months (two-month baseline period, six-month intervention period, and two month cross-over period). The primary outcome will be the mean number of site visits/month/user between baseline and the end of the intervention period. The secondary outcome will be participants' intention to use research evidence. For the qualitative study, 15 participants from each trial arm (n = 30) will be purposively sampled. One-on-one semi-structured interviews will be conducted by telephone on their views about and their experiences with the evidence service they received, how helpful it was in their work, why it was helpful (or not helpful), what aspects were most and least helpful and why, and recommendations for next steps.
Discussion
To our knowledge, this will be the first RCT to evaluate the effects of an evidence service specifically designed to support health-system policy makers in finding and using research evidence.
Trial registration
ClinicalTrials.gov: NCT01307228
doi:10.1186/1748-5908-6-51
PMCID: PMC3123565  PMID: 21619621
12.  Hip fracture prevention strategies in long-term care 
Canadian Family Physician  2010;56(11):e392-e397.
OBJECTIVE
To garner Canadian physicians’ opinions on strategies to reduce hip fractures in long-term care (LTC) facilities, focusing on secondary prevention.
DESIGN
A cross-sectional survey using a mailed, self-administered, written questionnaire.
SETTING
Canada.
PARTICIPANTS
Family physician members of the Ontario Long-Term Care Association (n = 165) and all actively practising geriatricians registered in the Canadian Medical Directory (n = 81).
MAIN OUTCOME MEASURES
The strength of recommendations for fracture-reduction strategies in LTC and barriers to implementing these strategies.
RESULTS
Of the 246 physicians sent the questionnaire, 25 declined study materials and were excluded. Of the 221 remaining, 120 responded for a response rate of 54%. About two-thirds of respondents were family physicians (78 of 120) and the rest were mostly geriatricians. Most respondents strongly recommended the following secondary prevention strategies for use in LTC after hip fracture: calcium, vitamin D, oral aminobisphosphonates, physical therapy, and environmental modification (such as handrails). Most respondents either did not recommend or recommended limited use of etidronate, intravenous bisphosphonates, calcitonin, raloxifene, testosterone (for hypogonadal men), and teriparatide. Postmenopausal hormone therapy was discouraged or not recommended by most respondents. Support was mixed for the use of hip protectors, B vitamins, and folate. Barriers to implementation identified by most respondents included a lack of strong evidence of hip fracture reduction (for B vitamins and folate, cyclic etidronate, and testosterone), side effects (for postmenopausal hormone therapy), poor compliance (for hip protectors), and expense (for intravenous bisphosphonates and teriparatide). Some respondents cited side effects or poor compliance as barriers to using calcium and potent oral bisphosphonates.
CONCLUSION
Canadian physicians favour the use of calcium, vitamin D, potent oral bisphosphonates, physical therapy, and evironmental modifications for LTC residents after hip fracture. Further study at the clinical and administrative levels is required to find ways to overcome the specific barriers to implementation and effectiveness of these interventions.
PMCID: PMC2980445  PMID: 21075980
13.  Support for a tax increase to provide unrestricted access to an Alzheimer's disease medication: a survey of the general public in Canada 
Background
Public drug insurance plans provide limited reimbursement for Alzheimer's disease (AD) medications in many jurisdictions, including Canada and the United Kingdom. This study was conducted to assess Canadians' level of support for an increase in annual personal income taxes to fund a public program of unrestricted access to AD medications.
Methods
A telephone survey was administered to a national sample of 500 adult Canadians. The survey contained four scenarios describing a hypothetical, new AD medication. Descriptions varied across scenarios: the medication was alternatively described as being capable of treating the symptoms of cognitive decline or of halting the progression of cognitive decline, with either no probability of adverse effects or a 30% probability of primarily gastrointestinal adverse effects. After each scenario, participants were asked whether they would support a tax increase to provide unrestricted access to the drug. Participants who responded affirmatively were asked whether they would pay an additional $75, $150, or $225 per annum in taxes. Multivariable logistic regression analysis was conducted to examine the determinants of support for a tax increase.
Results
Eighty percent of participants supported a tax increase for at least one scenario. Support was highest (67%) for the most favourable scenario (halt progression - no adverse effects) and lowest (49%) for the least favourable scenario (symptom treatment - 30% chance of adverse effects). The odds of supporting a tax increase under at least one scenario were approximately 55% less for participants who attached higher ratings to their health state under the assumption that they had moderate AD and almost five times greater if participants thought family members or friends would somewhat or strongly approve of their decision to support a tax increase. A majority of participants would pay an additional $150 per annum in taxes, regardless of scenario. Less than 50% would pay $225.
Conclusions
Four out of five persons in a sample of adult Canadians reported they would support a tax increase to fund unrestricted access to a hypothetical, new AD medication. These results signal a willingness to pay for at least some relaxation of reimbursement restrictions on AD medications.
doi:10.1186/1472-6963-9-246
PMCID: PMC2806272  PMID: 20040110
14.  Family Physician attitudes about prescribing using a drug formulary 
BMC Family Practice  2009;10:69.
Background
Drug formularies have been created by third party payers to control prescription drug usage and manage costs. Physicians try to provide the best care for their patients. This research examines family physicians' attitudes regarding prescription reimbursement criteria, prescribing and advocacy for patients experiencing reimbursement barriers.
Methods
Focus groups were used to collect qualitative data on family physicians' prescribing decisions related to drug reimbursement guidelines. Forty-eight family physicians from four Ontario cities participated. Ethics approval for this study was received from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board at McMaster University. Four clinical scenarios were used to situate and initiate focus group discussions about prescribing decisions. Open-ended questions were used to probe physicians' experiences and attitudes and responses were audio recorded. NVivo software was used to assist in data analysis.
Results
Most physicians reported that drug reimbursement guidelines complicated their prescribing process and can require lengthy interpretation and advocacy for patients who require medication that is subject to reimbursement restrictions.
Conclusion
Physicians do not generally see their role as being cost-containment monitors and observed that cumbersome reimbursement guidelines influence medication choice beyond the clinical needs of the patient, and produce unequal access to medication. They observed that frustration, discouragement, fatigue, and lack of appreciation can often contribute to family physicians' failure to advocate more for patients. Physicians argue cumbersome reimbursement regulations contribute to lower quality care and misuse of physicians' time increasing overall health care costs by adding unnecessary visits to family physicians, specialists, and emergency rooms.
doi:10.1186/1471-2296-10-69
PMCID: PMC2770461  PMID: 19835601
15.  Is There a Tension between Clinical Practice and Reimbursement Policy? The Case of Osteoarthritis Prescribing Practices in Ontario 
Healthcare Policy  2007;3(2):e128-e144.
Background:
Reimbursement policies, such as those used to manage the public drug program for senior citizens in Ontario, focus on providing access to cost-effective drug therapies. These policies may create a dilemma for physicians who want to prescribe a particular drug to a patient, but must factor reimbursement restrictions affecting patient-level access into the prescribing decision.
Methods:
Information was collected from 102 physicians about prescriptions given to osteoarthritis patients (n=2,147) aged 65 years or older. Patients' access to prescribed drugs was determined from their insurance coverage and the reimbursement criteria set out in the formulary of the public Ontario Drug Benefit Program (ODBP). Starting from the assumption that physicians would follow published consensus guidelines respecting gastroprotection when prescribing NSAIDs in these at-risk elderly patients, three groups of physicians were identified from the record of their actual prescriptions. Group A physicians (n=14) prescribed non-selective NSAIDs alone to >60% of their patients. Group B physicians (n=26) prescribed an NSAID + gastroprotective agent or a Cox-2 selective NSAID to >70% of their patients. Group C physicians (n=62) were those that fit into neither category. An open-ended question was included in the study questionnaire to elicit physicians' own interpretation of what impact drug coverage had on their prescribing behaviour.
Results:
No significant differences were found across groups with respect to years or type of practice, or to patient characteristics (LR=3.00, p>.2). Group C physicians were most likely to change their treatment choice in favour of restricted (limited use) drugs when patients met the criteria for reimbursement or had private insurance and therefore did not have to bear the additional cost out-of-pocket (LR=58.5; p<.0001).
Interpretation:
Most elderly at-risk patients are prescribed NSAIDs according to the prevailing guidelines. We found, however, that 40% of physicians have prescribing behaviour that favours non–evidence-based (Group A) or evidence-based (Group B) prescribing in this clinical setting irrespective of drug coverage. The remaining 60% of physicians appeared to be more responsive in their prescribing behaviour to financial constraints on patients' access to drugs. They also self-identified as most likely to change treatment if drug coverage had been different. These results have important implications for equity and quality of patient care. They also confirm that physicians' knowledge, values and self-efficacy are key determinants of prescribing behaviour and require further study to better understand how medical education and third-party policies and programs that govern pharmaceutical care are integrated into physicans' decision-making.
PMCID: PMC2645175  PMID: 19305773
16.  The Role of Evidence in Public Health Policy: An Example of Linkage and Exchange in the Prevention of Scald Burns 
Healthcare Policy  2007;3(2):59-66.
Is sound evidence sufficient to change public health practice and policy? In this paper, we describe a campaign to reduce scald burns among children based on compelling evidence of the effectiveness of an intervention to reduce hot tap water temperature. We provide an overview of the problem and the evidence to support our efforts, the context for addressing the scald problem and the lessons learned about why the relationship between evidence and change in practice is not straightforward.
PMCID: PMC2645177  PMID: 19305780
17.  It's all about relationships: A qualitative study of health researchers' perspectives of conducting interdisciplinary health research 
Background
Interdisciplinary research has been promoted as an optimal research paradigm in the health sciences, yet little is known about how researchers experience interdisciplinarity in practice. This study sought to determine how interdisciplinary research was conceptualized and operationalized from the researcher's perspective and to better understand how best to facilitate interdisciplinary research success.
Methods
Key informant interviews were conducted with health researchers with expertise or experience in conducting interdisciplinary research. Interviews were completed either in person or over the telephone using a semi-structured interview guide. Data collection occurred simultaneously with data analysis so that emerging themes could be explored in subsequent interviews. A content analysis approach was used.
Results
Nineteen researchers took part in this study. Interdisciplinary research was conceptualized disparately between participants, and there was modest attention towards operationalization of interdisciplinary research. There was one overriding theme, "It's all about relationships", that emerged from the data. Within this theme, there were four related subthemes: 1) Involvement in interdisciplinary research; 2) Why do I do interdisciplinary research?; 3) Managing and fostering interdisciplinary relationships; and 4) The prickly side to interdisciplinary research. Together, these themes suggest that the choice to conduct interdisciplinary research, though often driven by the research question, is highly influenced by interpersonal and relationship-related factors. In addition, researchers preferred to engage in interdisciplinary research with those that they had already established relationships and where their role in the research process was clearly articulated. A focus on relationship building was seen as a strong facilitator of interdisciplinary success.
Conclusion
Many health researchers experienced mixed reactions towards their involvement in interdisciplinary research. A well thought-out rationale for interdisciplinary research, and strategies to utilize the contribution of each researcher involved were seen as facilitators towards maximizing the benefits that could be derived from interdisciplinary research.
doi:10.1186/1472-6963-8-110
PMCID: PMC2424045  PMID: 18501005
18.  Brain type carnosinase in dementia: a pilot study 
BMC Neurology  2007;7:38.
Background
The pathological processes underlying dementia are poorly understood and so are the markers which identify them. Carnosinase is a dipeptidase found almost exclusively in brain and serum. Carnosinase and its substrate carnosine have been linked to neuropathophysiological processes.
Methods
Carnosinase activity was measured by a flourometric method in 37 patients attending a Geriatric Outpatient Clinic. There were 17 patients without dementia, 13 had Alzheimer's disease (AD) and 7 had mixed dementia (MD).
Results
The range of serum carnosinase activity for patients without dementia was 14.5 – 78.5 μmol/ml/h. There was no difference in carnosinase activity between patients without dementia (40.3 ± 15.2 μmol/ml/h) and patients with AD (44.4 ± 12.4 μmol/ml/h) or MD (26.6 ± 15 μmol/ml/h). However, levels in the MD group were significantly lower than the AD group (p = 0.01). This difference remained significant after adjusting for gender, MMSE score, exercise, but not age, one at a time and all combined. The effect of other medical conditions did not remove the significance between the AD and MD groups. The MD group, but not the AD group, demonstrated a significant trend with carnosinase activity decreasing with duration of disease (from first recorded date of diagnosis to date of blood collection) (r = -0.76, p = 0.049). There was no association with carnosinase activity and MMSE score in the AD or MD group. Both AD and MD patients on any dementia medication (donepezil, galantamine, memantine) had higher carnosinase activity compared to those not taking a dementia medication. Carnosinase activity was higher in patients who regularly exercised (n = 20) compared to those who did not exercise regularly (n = 17)(p = 0.006).
Conclusion
This exploratory study has shown altered activities of the enzyme carnosinase in patients with dementia.
doi:10.1186/1471-2377-7-38
PMCID: PMC2200655  PMID: 17983474
19.  Day of discharge and hospital readmission rates within 30 days in children: A population-based study 
Paediatrics & Child Health  2006;11(7):409-412.
BACKGROUND
Adults discharged from hospital on a Friday are more likely to be readmitted within 30 days than are adults discharged midweek. No study has examined readmission rates for children by day of discharge.
OBJECTIVE
To determine the risk of readmission within 30 days by day of discharge in the paediatric population.
METHODS
The Canadian Institute for Health Information provided data on children 29 days to 18 years of age who were discharged from hospitals in Ontario between January 1996 and December 2000. Two groups of children (those who were readmitted within 30 days and those who were not) were compared on demographic and clinical characteristics. Multivariable modelling was used to account for potential confounding variables: age, sex, length of hospital stay, number of diagnoses, in-hospital operative procedure, in-hospital complication and hospital admission in the previous six months.
RESULTS
A total of 506,035 hospitalizations (involving 334,959 children) occurred over the study period. Of these children, 3.4% were readmitted within 30 days of discharge. In total, 3.6% of children discharged on a Friday were readmitted within 30 days compared with 3.3% of children discharged on a Wednesday. After adjusting for patient and hospital factors, Friday discharge was not associated with readmission within 30 days (adjusted RR 1.07, 95% CI 0.99 to 1.15). More significant predictors of readmission included number of diagnoses, in-hospital complications and hospital admission in the six months previous to the index admission date.
CONCLUSION
Risk of readmission within 30 days is not significantly increased for children discharged on a Friday compared with children discharged midweek. Significant risk factors for hospital readmission are patient complexity and disease severity.
PMCID: PMC2528635  PMID: 19030310
Hospital; Paediatric; Patient discharge; Patient readmission; Risk factors
20.  Structural equation and log-linear modeling: a comparison of methods in the analysis of a study on caregivers' health 
Background
In this paper we compare the results in an analysis of determinants of caregivers' health derived from two approaches, a structural equation model and a log-linear model, using the same data set.
Methods
The data were collected from a cross-sectional population-based sample of 468 families in Ontario, Canada who had a child with cerebral palsy (CP). The self-completed questionnaires and the home-based interviews used in this study included scales reflecting socio-economic status, child and caregiver characteristics, and the physical and psychological well-being of the caregivers. Both analytic models were used to evaluate the relationships between child behaviour, caregiving demands, coping factors, and the well-being of primary caregivers of children with CP.
Results
The results were compared, together with an assessment of the positive and negative aspects of each approach, including their practical and conceptual implications.
Conclusion
No important differences were found in the substantive conclusions of the two analyses. The broad confirmation of the Structural Equation Modeling (SEM) results by the Log-linear Modeling (LLM) provided some reassurance that the SEM had been adequately specified, and that it broadly fitted the data.
doi:10.1186/1471-2288-6-49
PMCID: PMC1618851  PMID: 17038188
21.  Diffusion and dissemination of evidence-based dietary srategies for the prevention of cancer 
Nutrition Journal  2005;4:13.
Objective
The purpose was to determine what strategies have been evaluated to disseminate cancer control interventions that promote the uptake of adult healthy diet?
Methods
A systematic review was conducted. Studies were identified by searching MEDLINE, PREMEDLINE, Cancer LIT, EMBASE/Excerpta Medica, PsycINFO, CINAHL, the Cochrane Database of Systematic Reviews, and reference lists and by contacting technical experts. English-language primary studies were selected if they evaluated the dissemination of healthy diet interventions in individuals, healthcare providers, or institutions. Studies of children or adolescents only were excluded.
Results
One hundred one articles were retrieved for full text screening. Nine reports of seven distinct studies were included; four were randomized trials, one was a cohort design and three were descriptive studies. Six studies were rated as methodologically weak, and one was rated as moderate. Studies were not meta-analyzed because of heterogeneity, low methodological quality, and incomplete data reporting. No beneficial dissemination strategies were found except one that looks promising, the use of peer educators in the worksite, which led to a short-term increase in fruit and vegetable intake.
Conclusions and Implications
Overall, the quality of the evidence is not strong and is primarily descriptive rather than evaluative. No clear conclusions can be drawn from these data. Controlled studies are needed to evaluate dissemination strategies, and to compare dissemination and diffusion strategies with different messages and different target audiences.
doi:10.1186/1475-2891-4-13
PMCID: PMC1087879  PMID: 15819991
22.  Psychological health of family caregivers of children admitted at birth to a NICU and healthy children: a population-based cross-sectional survey 
BMC Pediatrics  2004;4:24.
Background
There is little information in the research literature on how parents of children who spend time in a neonatal intensive care unit (NICU) adapt psychologically to the demands of caregiving beyond the initial hospitalization period. Our aim was to compare parents of NICU children with parents of healthy full-term children, looking specifically at the relationship between parental psychosocial health and child characteristics, as well as the relationship between important predictor variables and psychosocial health.
Methods
A cross-sectional survey was sent to parents as their child turned 3 1/2 years of age. The setting was the province of British Columbia, Canada. The sample included all babies admitted to tertiary level neonatal intensive care units (NICU) at birth over a 16-month period, and a consecutive sample of healthy babies. The main outcome was the SF-36 mental component summary (MCS) score. Predictor variables included caregiver gender; caregiver age; marital status; parental education; annual household income; child health status; child behavior; birth-related risk factors; caregiver strain; and family function.
Results
Psychosocial health of NICU parents did not differ from parents of healthy children. Child health status and behavior for NICU and healthy children were strongly related to MCS score in bivariate analysis. In the pooled multivariate model, parental age, low family function, high caregiver strain, and child's internalizing and externalizing behavioral symptoms were independently associated with lower psychosocial health. In addition, female gender was associated with lower psychosocial health in the NICU group, whereas lower education and child's problem with quality of life indicated lower psychosocial health in the healthy baby group.
Conclusions
Overall, parental gender, family functioning and caregiver strain played influential roles in parental psychosocial health.
doi:10.1186/1471-2431-4-24
PMCID: PMC544865  PMID: 15598353
23.  Agreement between Self-reported and Routinely Collected Health-care Utilization Data among Seniors 
Health Services Research  2002;37(3):751-774.
Objective
To examine the agreement between self-reported and routinely collected administrative health-care utilization data, and the factors associated with agreement between these two data sources.
Data Sources/Study Setting
A representative sample of seniors living in an Ontario county within Canada was identified using the Ontario Ministry of Health's Registered Persons Data Base in 1992. Health professional billing information and hospitalization data were obtained from the Ontario Ministry of Health and Long-Term Care (OMH) and the Ontario Health Insurance Plan (OHIP).
Study Design
A cross-sectional survey was carried out to assess any contact and frequency of contacts with health professionals and hospital admissions. Similar information was obtained from routinely collected administrative data. The level of agreement was assessed using the proportion of absolute agreement, Cohen's kappa statistic (κ), and the intraclass correlation coefficient (ICC). Logistic and linear regressions were used to identify factors that were associated with the magnitude and direction of disagreement respectively.
Data Collection/Extraction Methods
Telephone interviews were conducted on 1,054 seniors, and complete data were available for 1,038 seniors. Each respondent's personal health number was used to electronically link survey data with health professional billing and hospitalization databases.
Principal Findings
Substantial to almost perfect agreement was found for the contact utilization measures, while agreement on volume utilization measures varied from poor to almost perfect. In surveys, seniors overreported contact with general practitioners and physiotherapists or chiropractors, and underreported contact with other medical specialists. Seniors also underreported the number of contacts with general practitioners and other medical specialists. The odds of agreement decreased if respondents were male, aged 75 years and older, had incomes of less than $25,000, had poor/fair/good self-assessed health status, or had two or more chronic conditions.
Conclusion
The findings of this study indicate that there are substantial discrepancies between self-reported and administrative data among older adults. Researchers seeking to examine health-care use among older adults need to consider these discrepancies in the interpretation of their results. Failure to recognize these discrepancies between survey and administrative data among older adults may lead to the establishment of inappropriate health-care policies.
doi:10.1111/1475-6773.00047
PMCID: PMC1434660  PMID: 12132604
Health services utilization; seniors; self-reports; agreement; billing data
24.  The relationship between sensory impairment and functional independence among elderly 
BMC Geriatrics  2004;4:3.
Background
It has been well established that increasing age is associated with decreasing functional ability in older adults. It is important to understand the specific factors that affect instrumental activities of daily living (IADL) and functional independence among older adults with sensory disabilities.
Methods
Nationally representative sample of adults aged 55 years and older with seeing or hearing disabilities were categorised into three sensory classifications: "Seeing Disabled but Hearing Abled" (SD-HA), "Hearing Disabled but Seeing Abled" (HD-SA), and both "Seeing and Hearing Disabled" (SD-HD). The additional category of "Seeing Disabled and/or Hearing Disabled" (SD and/or HD) was created to calculate the total of all individuals from the above categories who either had a seeing or hearing disability or both sensory disabilities. Respondents were asked to indicate whether they received assistance in performing seven IADL and their level of functional independence.
Results
The most common factors that affect IADL were heavy chores, grocery shopping and housework. Individuals with both seeing and hearing disabilities (SD-HD) reported having the most IADL restrictions, followed by individuals with only seeing disabilities (SD-HA) and only hearing disabilities (HD-SA). Individuals with severe sensory disabilities were generally more likely to report IADL restrictions and less likely to have decision-making control and be happy with their lives. In each sensory classification, females aged 55–64 years and 65 years and older reported more IADL restrictions than males.
Conclusion
Both seeing and hearing disabilities have a significant impact on restricting an individual's IADL.
doi:10.1186/1471-2318-4-3
PMCID: PMC425581  PMID: 15132757
25.  Caregiving process and caregiver burden: Conceptual models to guide research and practice 
BMC Pediatrics  2004;4:1.
Background
Parental care for a child with a developmental disability is an enormous responsibility, one that can far exceed that of typical parental care. While most parents adapt well to the situation of caring for a child with a disability, some do not. To understand parents' adaptations to their children's disabilities, the complex nature of stress processes must be accounted for and the constructs and factors that play a role in the caregiving must be considered.
Discussion
Evidence suggests that there is considerable variation in how caregivers adapt to their caregiving demands. Many studies have sought to qualify the association between caregiving and health outcomes of the caregivers. Contextual factors such as SES, child factors such as child behaviour problems and severity of disability, intra-psychic factors such as mastery and self-esteem, coping strategies and social supports have all been associated with psychological and/or physical outcome or parents or primary caregivers. In reviewing these issues, the literature appears to be limited by the use of traditional analytic approaches which examine the relationship between a factor and an outcome. It is clear, however, that changes to single factors, as represented in these studies, occur very rarely even in the experimental context. The literature has also been limited by lack of reliance on specific theoretical frameworks.
Summary
This conceptual paper documents the state of current knowledge and explores the current theoretical frameworks that have been used to describe the caregiving process from two diverse fields, pediatrics and geriatrics. Integration of these models into one comprehensive model suitable for this population of children with disabilities and their caregivers is proposed. This model may guide future research in this area.
doi:10.1186/1471-2431-4-1
PMCID: PMC331415  PMID: 14723791

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