Illegal drug use remains a serious threat to community health in Canada, yet there has been a remarkable discordance between scientific evidence and policy in this area, with most resources going to drug use prevention and drug law enforcement activities that have proven ineffective. Conversely, evidence-based drug treatment programs have been chronically underfunded, despite their cost-effectiveness. Similarly, various harm reduction strategies, such as needle exchange, supervised injecting programs and opioid substitution therapy, have also proven effective at reducing drug-related harm but receive limited government support. Accordingly, Canadian society would greatly benefit from reorienting its drug policies on addiction, with consideration of addiction as a health issue, rather than primarily a criminal justice issue. In this context, and in light of the simple reality that drug prohibition has not effectively reduced the availability of most illegal drugs and has instead contributed to a vast criminal enterprise and related violence, among other harms, alternatives should be prioritized for evaluation.

Background

Intravenous immune globulin (IVIG) is an expensive and sometimes scarce blood product that carries some risk. It may often be used inappropriately. We evaluated the appropriateness of IVIG use before and after the introduction of an utilization control program to reduce inappropriate use.

Methods

We used the RAND/UCLA Appropriateness Method to measure the appropriateness of IVIG use in the province of British Columbia (BC) in 2001 and 2003, before and after the introduction of a utilization control program designed to reduce inappropriate use. For comparison, we measured the appropriateness of use during the same periods in the province of Alberta, which had no control program.

Results

Of 2256 instances of IVIG use, 54.1% were deemed to be appropriate, 17.4% were of uncertain benefit, and 28.5% were deemed inappropriate. The frequency of inappropriate use in BC after the introduction of the utilization control program did not differ significantly from the frequency before the program or the frequency in Alberta.

Interpretation

Almost half of IVIG use in BC and Alberta was judged to be inappropriate or of uncertain benefit, and the frequency of inappropriate use did not decrease after implementation of a utilization control program in BC. More effective utilization controls are necessary to prevent wasted resources and unnecessary risk to patients.

Although the ongoing information explosion within medicine is indisputably beneficial, it is difficult to stay abreast of the large volume of new information being published in the peer-reviewed and grey literature. Practical strategies to organize the swelling tide of medical literature are essential for providers to recognize and incorporate new information into their practice. One strategy for managing new information is the traditional annual review, in which selected, appraised articles are presented for general consumption. Here, we present five notable articles for general internal medicine published from 1 Sept. 2010 to 31 Aug. 2011, with focused summaries of their key findings and supporting clinical vignettes to highlight their significance.

Emergency department overcrowding is a serious and ongoing issue across Canada. Short stay units (SSUs) have emerged as a potentially useful strategy for managing overcrowding in emergency departments. Members of The Ottawa Hospital senior management team contemplating the introduction of an SSU to help alleviate emergency department overcrowding approached our rapid response service to conduct a rapid review on the safety and effectiveness of SSUs. This paper presents the process for conducting this review, its findings, and the end-user report generated for the senior management team and other stakeholders.

Background

Although specialist physicians comprise nearly half of the physician workforce in Newfoundland and Labrador (NL), relatively little is known about their retention patterns. We compared 2 cohorts of physicians who were initially licensed to practise in NL between 1993 and 1997 and between 2000 and 2004, to examine whether retention had changed over time. Additionally, we examined the retention of 4 groups of physicians in each cohort: (1) fully licensed medical graduates of Memorial University, (2) fully licensed medical graduates of other Canadian universities, (3) provisionally licensed international medical graduates (IMGs) and (4) fully licensed IMGs. Provisional licences allow physicians who have not received Canadian certification to practise while obtaining credentials. We hypothesized that fully licensed physicians (largely physicians who are locally trained) would remain in NL longer than provisionally licensed physicians (largely IMGs).

Methods

Using data from the provincial medical registrar and Memorial University’s office of postgraduate medical education, we used survival analysis (Cox regression) to compare the retention of the 2 cohorts and the 4 groups of physicians within each cohort.

Results

After 48 months, roughly 60% of the physicians in the 2000–04 cohort and 45% of the physicians in the 1993–97 cohort remained in NL. Medical graduates of Memorial Universitycomprised 61/180 (33.9%) of the 2000–04 cohort and 38/211 (18.0%) of the 1993–97 cohort.Physicians in the 2000–04 cohort were 1.6 (95% confidence interval [CI] 1.23–2.08) times less likely to leave NL than physicians in the 1993–97 cohort. In the 2000–04 cohort, medical graduates of Canadian universities, provisionally licensed IMGs and fully licensed IMGs were 3.19 (95% CI 1.47–6.89), 1.85 (95% CI 1.09–3.17) and 4.39 (95% CI 1.91–10.10) times more likely to leave NL than medical graduates of Memorial University. In the 1993–97 cohort, IMGs with provisional licences were 2.16 (95% CI 1.37–3.42) times more likely to leave NL than medical graduates of Memorial University. There was no significant difference in retention between medical graduates of Memorial University and other Canadian universities or IMGs with full licences in the 1993–97 cohort.

Interpretation

The improvement in the retention of specialist physicians in NL since the 1990s may be attributable to the increase in the relative proportion of medical graduates of Memorial University. Although provisional licensing enables IMGs to begin practice in NL, it does not lead to long-term retention.

Background

Systematic reviews are recognized as the most effective means of summarizing research evidence. However, they are limited by the time and effort required to keep them up to date. Wikis present a unique opportunity to facilitate collaboration among many authors. The purpose of this study was to examine the use of a wiki as an online collaborative tool for the updating of a type of systematic review known as a scoping review.

Methods

An existing peer-reviewed scoping review on asynchronous telehealth was previously published on an open, publicly available wiki. Log file analysis, user questionnaires and content analysis were used to collect descriptive and evaluative data on the use of the site from 9 June 2009 to 10 April 2010. Blog postings from referring sites were also analyzed.

Results

During the 10-month study period, there were a total of 1222 visits to the site, 3996 page views and 875 unique visitors from around the globe. Five unique visitors (0.6% of the total number of visitors) submitted a total of 6 contributions to the site: 3 contributions were made to the article itself, and 3 to the discussion pages. None of the contributions enhanced the evidence base of the scoping review. The commentary about the project in the blogosphere was positive, tempered with some skepticism.

Interpretations

Despite the fact that wikis provide an easy-to-use, free and powerful means to edit information, fewer than 1% of visitors contributed content to the wiki. These results may be a function of limited interest in the topic area, the review methodology itself, lack of familiarity with the wiki, and the incentive structure of academic publishing. Controversial and timely topics in addition to incentives and organizational support for Web 2.0 impact metrics might motivate greater participation in online collaborative efforts to keep scientific knowledge up to date.

Objectives

Among patients undergoing noncardiac surgery, our objectives were to: (1) determine the feasibility of undertaking a large international cohort study; (2) estimate the current incidence of major perioperative vascular events; (3) compare the observed event rates to the expected event rates according to the Revised Cardiac Risk Index (RCRI); and (4) provide an estimate of the proportion of myocardial infarctions without ischemic symptoms that may go undetected without perioperative troponin monitoring.

Design

An international prospective cohort pilot study.

Participants

Patients undergoing noncardiac surgery who were > 45 years of age, receiving a general or regional anesthetic, and requiring hospital admission.

Measurements

Patients had a Roche fourth-generation Elecsys troponin T measurement collected 6 to 12 hours postoperatively and on the first, second, and third days after surgery. Our primary outcome was major vascular events (a composite of vascular death [i.e., death from vascular causes], nonfatal myocardial infarction, nonfatal cardiac arrest, and nonfatal stroke) at 30 days after surgery. Our definition for perioperative myocardial infarction included: (1) an elevated troponin T measurement with at least one of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic electrocardiogram changes, coronary artery intervention, or cardiac imaging evidence of myocardial infarction; or (2) autopsy findings of acute or healing myocardial infarction.

Results

We recruited 432 patients across 5 hospitals in Canada, China, Italy, Colombia, and Brazil. During the first 30 days after surgery, 6.3% (99% confidence interval 3.9–10.0) of the patients suffered a major vascular event (10 vascular deaths, 16 nonfatal myocardial infarctions, and 1 nonfatal stroke). The observed event rate was increased 6-fold compared with the event rate expected from the RCRI. Of the 18 patients who suffered a myocardial infarction, 12 (66.7%) had no ischemic symptoms to suggest myocardial infarction.

Conclusions

This study suggests that major perioperative vascular events are common, that the RCRI underestimates risk, and that monitoring troponins after surgery can assist physicians to avoid missing myocardial infarction. These results underscore the need for a large international prospective cohort study.

Background

Nursing homes provide long-term housing, support and nursing care to frail elders who are no longer able to function independently. Although studies conducted in the United States have demonstrated an association between for-profit ownership and inferior quality, relatively few Canadian studies have made performance comparisons with reference to type of ownership. Complaints are one proxy measure of performance in the nursing home setting. Our study goal was to determine whether there is an association between facility ownership and the frequency of nursing home complaints.

Methods

We analyzed publicly available data on complaints, regulatory measures, facility ownership and size for 604 facilities in Ontario over 1 year (2007/08) and 62 facilities in British Columbia (Fraser Health region) over 4 years (2004–2008). All analyses were carried out at the facility level. Negative binomial regression analysis was used to assess the association between type of facility ownership and frequency of complaints.

Results

The mean (standard deviation) number of verified/substantiated complaints per 100 beds per year in Ontario and Fraser Health was 0.45 (1.10) and 0.78 (1.63) respectively. Most complaints related to resident care. Complaints were more frequent in facilities with more citations, i.e., violations of the legislation or regulations governing a home, (Ontario) and inspection violations (Fraser Health). Compared with Ontario’s for-profit chain facilities, adjusted incident rate ratios and 95% confidence intervals of verified complaints were 0.56 (0.27–1.16), 0.58 (0.34–1.00), 0.43 (0.21– 0.88), and 0.50 (0.30– 0.84) for for-profit single-site, non-profit, charitable, and public facilities respectively. In Fraser Health, the adjusted incident rate ratio of substantiated complaints in non-profit facilities compared with for-profit facilities was 0.18 (0.07–0.45).

Interpretation

Compared with for-profit chain facilities, non-profit, charitable and public facilities had significantly lower rates of complaints in Ontario. Likewise, in British Columbia’s Fraser Health region, non-profit owned facilities had significantly lower rates of complaints compared with for-profit owned facilities.

Background

Health care practitioners in jurisdictions around the world are encouraged to work in groups. The extent to which they actually do so, however, is not often measured. The purpose of this paper is to demonstrate the potential for administrative data to measure how practitioners are interconnected through their care of patients. Our example examined the interconnected care provided by family physicians.

Methods

We defined a physician as being “interconnected” with another physician if these 2 physicians provided at least 1% of their clinic visits over a 2-year period to the same patients. We examined a cohort of 2945 primary care physicians in 309 Family Health Networks and Family Health Groups in Ontario, Canada, in 2005/06. In total, 9.3 million physician visits for 2.1 million patients were studied. For each group practice we calculated the number of interconnected physicians.

Results

Physicians had, on average, 2.2 interconnected physician partners (median = 1; 25th and 75th percentile: 0, 3). Physicians saw mainly their own listed patients, and 7.9% (median = 5.9%; 25th and 75th percentile: 2.4%, 11.6%) of their visits were provided to patients of their interconnected partners. The number of interconnected physicians was higher in group practices that had more physicians, but levelled to 2.5 interconnected physicians in practices with 8 or 9 physicians.

Interpretation

Routinely collected administrative data can be used to examine how health care is organized and delivered in groups or networks of practitioners. This study’s concept of interconnected care provided by primary care physicians within groups could be expanded to include other practitioners and, indeed, entire health care systems using more complex network analysis methods.

Background

The identification of health care professionals who are incompetent, impaired, uncaring or have criminal intent has received increasing attention in recent years. These individuals are often subject to disciplinary action by professional licensing authorities. To date, no national data exist for Canadian physicians disciplined for professional misconduct. We sought to describe the characteristics of physicians disciplined by Canadian professional licensing authorities.

Methods

We constructed a database of physicians disciplined by provincial licensing authorities during the years 2000 to 2009. Comparisons were made with the general population of physicians licensed in Canada. Data on demographic characteristics, type of misconduct and penalty imposed were collected for each disciplined physician.

Results

A total of 606 identifiable physicians were disciplined by their professional college during the years 2000 to 2009. The proportion of licensed physicians who were disciplined in a given year ranged from 0.06% to 0.11%. Fifty-one of the disciplined physicians committed 64 repeat offences, accounting for a total of 113 (19%) offences. Most of the disciplined physicians were independent practitioners (99%), male (92%) and trained in Canada (67%). The most common specialties of physicians subject to disciplinary action were family medicine (62%), psychiatry (14%) and surgery (9%). For disciplined physicians, the average number of years from medical school graduation to disciplinary action was 28.9 (standard deviation [SD] = 11.3). The 3 most frequent violations were sexual misconduct (20%), failure to meet a standard of care (19%) and unprofessional conduct (16%). The 3 most frequently imposed penalties were fines (27%), suspensions (19%) and formal reprimands (18%).

Interpretation

A small proportion of registered physicians in Canada were disciplined by their medical licensing authorities. Sexual misconduct was the most common disciplined offence. The standardization of provincial reporting along with the creation of a national database of physician offenders would facilitate more comparable public reporting as well as further research and educational initiatives.

Background

Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations.

Objective

To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress.

Design

Randomized controlled trial measuring efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness.

Setting

Urban tertiary care hospital.

Participants

Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians’ lounge and throughout the hospital.

Intervention

Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team.

Main outcome measure

Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200).

Results

During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change –14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change –2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change –8.5, SD 7.6; p < 0.001).

Conclusion

A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.

In April 2010, the Ontario government announced another reduction in the maximum price of generic drugs permitted under the Ontario Drug Benefit (ODB) program, demanding that generic drugs now be sold for no more than 25% of the branded product’s price. Other provinces are following Ontario in setting unprecedentedly low price-caps to reduce the cost of generic drugs. Generic product substitution legislation is vital to reducing costs to provincial drug plans, yet lower and lower price-caps may undo some of the benefits of substitution legislation if generics find it difficult to survive.

Background

Medical tourism, the intentional pursuit of elective medical treatments in foreign countries, is a rapidly growing global industry. Canadians are among those crossing international borders to seek out privately purchased medical care. Given Canada’s universally accessible, single-payer domestic health care system, important implications emerge from Canadians’ private engagement in medical tourism.

Methods

A scoping review was conducted of the popular, academic, and business literature to synthesize what is currently known about Canadian involvement in medical tourism. Of the 348 sources that were reviewed either partly or in full, 113 were ultimately included in the review.

Results

The review demonstrates that there is an extreme paucity of academic, empirical literature examining medical tourism in general or the Canadian context more specifically. Canadians are engaged with the medical tourism industry not just as patients but also as investors and business people. There have been a limited number of instances of Canadians having their medical tourism expenses reimbursed by the public medicare system. Wait times are by far the most heavily cited driver of Canadians’ involvement in medical tourism. However, despite its treatment as fact, there is no empirical research to support or contradict this point.

Discussion

Although medical tourism is often discussed in the Canadian context, a paucity of data on this practice complicates our understanding of its scope and impact.

A growing body of evidence suggests that the benefits achieved by screening for breast cancer are small, that the harm from the over-diagnosis of breast cancer arising from screening is substantial, and that, where screening is available, the observed reductions in breast cancer mortality arise largely from increased awareness and improved chemo- and hormone therapyIt is reasonable for women to choose to be screened, but only if they are completely informed about the probability of benefit versus the probability of harm. For 2000 women aged 40–49 who undergo screening for 10 years, the benefit is much smaller in terms of avoiding death from breast cancer than is the harm arising from over-diagnosis and unnecessary treatment for breast cancer, to say nothing of the increased rates of mastectomy associated with screening.These issues are not widely known to the general public.

Background

Social determinants of health (SDOH) may influence the probability of people living with HIV also being infected with hepatitis C virus (HCV). We compared the SDOH of adults co-infected with HCV/HIV with that of HIV mono-infected adults to identify factors independently associated with HCV infection.

Methods

In this cross-sectional study, face-to-face interviews were conducted with 509 HIV-infected adults affiliated with or receiving services from community-based AIDS service organizations (CBAOs). The primary outcome measure was self-reported HCV infection status. Chi-square, Student’s t tests, and Wilcoxon rank-sum tests were performed to compare SDOH of HCV/HIV co-infected participants with that of HIV mono-infected participants. Multivariable hierarchical logistic regression was used to identify factors independently associated with HCV co-infection.

Results

Data on 482 (95 HCV/HIV co-infected and 387 HIV mono-infected) adults were analyzed. Compared with participants infected with HIV only, those who were co-infected with HIV and HCV were more likely to be heterosexual, Aboriginal, less educated and unemployed. They were more likely to have a low income, to not be receiving antiretroviral treatment, to live outside the Greater Toronto Area (GTA), to use/abuse substances, experience significant depression, and utilize addiction counselling and needle-exchange services. They also were more likely to report a history of homelessness and perceived housing-related discrimination and to have moved twice or more in the previous 12 months. Factors independently associated with HCV/HIV co-infection were history of incarceration (odds ratio [OR] 8.81, 95% CI 4.43–17.54), history of homelessness (OR 3.15, 95% CI 1.59–6.26), living outside of the GTA (OR 3.13, 95% CI 1.59–6.15), and using/abusing substances in the past 12 months (OR 2.05, 95% CI 1.07–3.91).

Conclusion

Differences in SDOH exist between HIV/HCV co-infected and HIV mono-infected adults. History of incarceration, history of homelessness, substance use, and living outside the GTA were independently associated with HCV/HIV co-infection. Interventions that reduce homelessness and incarceration may help prevent HCV infection in people living with HIV.

Background

Practice pattern variations are often attributed to physician decision-making with no accounting for patient preferences.

Objective

To test whether a mass media television broadcast unrelated to health was associated with changes in the rate and characteristics of visits for acute emergency care.

Design

Time-series analysis of emergency department visits for any reason.

Subjects

Population-based sample of all patients seeking emergency care in Ontario, Canada.

Measures

The broadcast day was defined as the Olympic men’s gold medal ice hockey game final. The control days were defined as the 6 Sundays before and after the broadcast day.

Results

A total of 99 447 visits occurred over the 7 Sundays, of which 13 990 occurred on the broadcast day. Comparing the broadcast day with control days, we found no significant difference in the hourly rate of visits before the broadcast (544 vs 537, p = 0.41) or after the broadcast (647 vs 639, p = 0.55). In contrast, we observed a significant reduction in hourly rate of visits during the broadcast (647 vs 783, p < 0.001), equal to an absolute decrease of 409 patients, a relative decrease of 17% (95% confidence interval 13–21), or about 136 fewer patients per hour. The relative decrease during the broadcast was particularly large for adult men with low triage severity. The greatest reductions were for patients with abdominal, musculoskeletal or traumatic disorders.

Conclusion

Mass media television broadcasts can influence patient preferences and thereby lead to a decrease in emergency department visits.

Background

Unplanned hospital readmissions are common, expensive and often preventable. Strategies designed to reduce readmissions should target patients at high risk. The purpose of this study was to describe medical patients identified using a recently published and validated algorithm (the LACE index) as being at high risk for readmission and to examine their actual hospital readmission rates.

Methods

We used population-based administrative data to identify adult medical patients discharged alive from 6 hospitals in Toronto, Canada, during 2007. A LACE index score of 10 or higher was used to identify patients at high risk for readmission. We described patient and hospitalization characteristics among both the high-risk and low-risk groups as well as the 30-day readmission rates.

Results

Of 26 045 patients, 12.6% were readmitted to hospital within 30 days and 20.9% were readmitted within 90 days of discharge. High-risk patients (LACE ≥ 10) accounted for 34.0% of the sample but 51.7% of the patients who were readmitted within 30 days. High-risk patients were readmitted with twice the frequency as other patients, had longer lengths of stay and were more likely to die during the readmission.

Interpretation

Using a LACE index score of 10, we identified patients with a high rate of readmission who may benefit from improved post-discharge care. Our findings suggest that the LACE index is a potentially useful tool for decision-makers interested in identifying appropriate patients for post-discharge interventions.

Background

Despite experiencing a disproportionate burden of acute and chronic health issues, many homeless people face barriers to primary health care. Most studies on health care access among homeless populations have been conducted in the United States, and relatively few are available from countries such as Canada that have a system of universal health insurance. We investigated access to primary health care among a representative sample of homeless adults in Toronto, Canada.

Methods

Homeless adults were recruited from shelter and meal programs in downtown Toronto between November 2006 and February 2007. Cross-sectional data were collected on demographic characteristics, health status, health determinants and access to health care. We used multivariable logistic regression analysis to investigate the association between having a family doctor as the usual source of health care (an indicator of access to primary care) and health status, proof of health insurance, and substance use after adjustment for demographic characteristics.

Results

Of the 366 participants included in our study, 156 (43%) reported having a family doctor. After adjustment for potential confounders and covariates, we found that the odds of having a family doctor significantly decreased with every additional year spent homeless in the participant’s lifetime (adjusted odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86–0.97). Having a family doctor was significantly associated with being lesbian, gay, bisexual or transgendered (adjusted OR 2.70, 95% CI 1.04–7.00), having a health card (proof of health insurance coverage in the province of Ontario) (adjusted OR 2.80, 95% CI 1.61–4.89) and having a chronic medical condition (adjusted OR 1.91, 95% CI 1.03–3.53).

Interpretation

Less than half of the homeless people in Toronto who participated in our study reported having a family doctor. Not having a family doctor was associated with key indicators of health care access and health status, including increasing duration of homelessness, lack of proof of health insurance coverage and having a chronic medical condition. Increased efforts are needed to address the barriers to appropriate health care and good health that persist in this population despite the provision of health insurance.

Background

Evidence from the United States and Europe suggests that the use of prescription drugs may vary by ethnicity. In Canada, ethnic disparities in prescription drug use have not been as well documented as disparities in the use of medical and hospital care. We conducted a cross-sectional analysis of survey and administrative data to examine needs-adjusted rates of prescription drug use by people of different ethnic groups.

Methods

For 19 370 non-Aboriginal people living in urban areas of British Columbia, we linked data on self-identified ethnicity from the Canadian Community Health Survey with administrative data describing all filled prescriptions and use of medical services in 2005. We used sex-stratified multivariable logistic regression analysis to measure differences in the likelihood of filling prescriptions by drug class (antihypertensives, oral antibiotics, antidepressants, statins, respiratory drugs and nonsteroidal anti-inflammatory drugs [NSAIDs]). Models were adjusted for age, general health status, treatment-specific health status, socio-economic factors and recent immigration (within 10 years).

Results

We found evidence of significant needs-adjusted variation in prescription drug use by ethnicity. Compared with women and men who identified themselves as white, those who were South Asian or of mixed ethnicity were almost as likely to fill prescriptions for most types of medicines studied; moreover, South Asian men were more likely than white men to fill prescriptions for antibiotics and NSAIDs. The clearest pattern of use emerged among Chinese participants: Chinese women were significantly less likely to fill prescriptions for antihypertensives, antibiotics, antidepressants and respiratory drugs, and Chinese men for antidepressant drugs and statins.

Interpretation

We found some disparities in prescription drug use in the study population according to ethnic group. The nature of some of these variations suggest that ethnic differences in beliefs about pharmaceuticals may generate differences in prescription drug use; other variations suggest that there may be clinically important disparities in treatment use.

Abstract

The lack of systematic oversight of physician performance has led to some serious cases related to physician competence and behaviour. We are currently implementing a hospital-wide approach to improve physician oversight by incorporating it into the hospital credentialing process. Our proposed credentialing method involves four systems: (1) a system for monitoring and reporting clinical performance; (2) a system for evaluating physician behaviour; (3) a complaints management system; and (4) an administrative system for maintaining documentation. In our method, physicians are responsible for implementing an annual performance assessment program. The hospital will be responsible for the complaints management system and the system for collecting and reporting relevant health outcomes. Physicians and the hospital will share responsibility for monitoring professional behaviour. Medical leadership, effective governance, appropriate supporting information systems and adequate human resources are required for the program to be successful. Our program is proactive and will allow our hospital to enhance safety through a quality assurance framework and by complementing existing safety activities. Our program could be extended to non-hospital physicians through regional health or provider networks. Central licensing authorities could help to coordinate these programs on a province- or state-wide basis to ensure uniformity of standards and to avoid duplication of efforts.