A novel formulary: collaboration between health care professionals,seniors, private sector and government in Nova Scotia

A novel formulary has been developed in Nova Scotia with the objective of providing quality treatment with needed medications at affordable cost. Creation of the formulary has involved collaboration among health care professionals, seniors, the Department of Health and pharmaceutical companies. This is the first Canadian formulary to use the Anatomic, Therapeutic, Chemical system. Drug listing is comprehensive rather than exclusive. Colour-coded recommendations on use assist physicians with drug choice. Relative costs are indicated within each therapeutic grouping. Listings indicate drugs approved for reimbursement, interchangeable medications, maximum allowable cost, drug identification number and manufacturer code. Treatment summaries provide brief overviews of therapeutic advice. Updates on new products and new or modified treatment summaries are provided every 6 months. The formulary will be the focus of coordinated educational activities on treatment for seniors and health care professionals.     

Malaria-related health-seeking behaviour and challenges for care providers in rural Ethiopia: implications for control

A range of activities are currently underway to improve access to malaria prevention and control interventions. As disease control strategies change over time, it is crucial to understand the health-seeking behaviour and the local socio-cultural context in which the changes in interventions operate. This paper reflects on how people in an area of seasonal malaria perceive the causes and transmission of the disease, and what prevention and treatment measures they practise to cope with the disease. It also highlights some of the challenges of malaria treatment for health care providers. The study was undertaken in 2003 in Adami Tulu District in south-central Ethiopia, where malaria is a major health problem. Pre-tested structured questionnaires and focus group discussions were conducted among men and women. Malaria, locally known as busa, was perceived as the most important cause of ill health in the area. Respondent's perception and knowledge about the cause and transmission of the disease were relatively high. The newly introduced insecticide-treated nets were not popular in the area, and only 6.4% of households possessed at least one. The results showed that patients use multiple sources of health care for malaria treatment. Public health facilities, private clinics and community health workers were the main providers of malaria treatment. Despite higher treatment costs, people preferred to use private health care providers for malaria treatment due to the higher perceived quality of care they offer. In conclusion, effort in the prevention and control of malaria should be intensified through addressing not only public facilities, but also the private sector and community-based control interventions. Appropriate and relevant information on malaria should be disseminated to the local community. The authors propose the provision of effective antimalarial drugs and malaria prevention tools such as subsidized or free insecticide-treated nets.     

The health of Indians in Canadian cities: a challenge to the health care system

It is well known that Canadian native people living on reserves have high morbidity and mortality rates, but less is known about the health of those who migrated to urban centres. Several studies have shown that these people have high rates of mental health problems, specific diseases, injuries, infant death and hospital admission. In addition, there is evidence that cultural differences create barriers to their use of health care facilities. The low socioeconomic status, cultural differences and discrimination that they find in cities are identified as the primary blocks to good health and adequate health care. More epidemiologic studies need to be done to identify health problems, needs and barriers to health care. Federal, provincial and civic governments along with the appropriate departments of faculties of medicine should begin working with native organizations to improve the health of native people living in Canada''s cities.     

Ontario Maternal Serum Screening Program: practices,knowledge and opinions of health care providers

OBJECTIVE: To determine the practices, knowledge and opinions of health care providers regarding a prenatal genetic screening program in Ontario. DESIGN: Cross-sectional self-reported survey. SETTING: Ontario. PARTICIPANTS: Random sample of 2000 family physicians, all 565 obstetricians and all 62 registered midwives in the province. Among subjects who were eligible (those providing antenatal care or attending births) the response rates were 91% (778/851), 76% (273/359) and 78% (46/59) respectively. MAIN OUTCOME MEASURES: Which patients were offered maternal serum screening (MSS), how results were being communicated, knowledge of the test''s sensitivity, likes and dislikes about MSS and recommendations regarding the program. RESULTS: Most (97%) of respondents stated that they were offering MSS to the pregnant women in their practices; 88% were offering it routinely to all pregnant women (87% of the family physicians, 90% of the obstetricians and 100% of the midwives). Most (92%) of the respondents stated that they communicate positive results to their patients personally as soon as they are received; 23% did so for negative results. The respondents correctly identified the initial positive rate but underestimated the false-positive rate. About one-third did not respond to these knowledge questions. Of those who gave feedback on the screening program, 50% recommended that it not be changed, 29% suggested that it be changed, and 22% recommended that it be scrapped. CONCLUSIONS: Participation in the Ontario Maternal Serum Screening Program by health care providers has been good, although knowledge about MSS is far from ideal. Many providers have reservations about the program. In light of concerns raised about the high false-positive rate and the anxiety such results generate in pregnant women, there is a need for more education of providers and patients and a better understanding of women''s experiences with genetic screening.     

Identification by families of pediatric adverse events and near misses overlooked by health care providers

Background:

Identifying adverse events and near misses is essential to improving safety in the health care system. Patients are capable of reliably identifying and reporting adverse events. The effect of a patient safety reporting system used by families of pediatric inpatients on reporting of adverse events by health care providers has not previously been investigated.

Methods:

Between Nov. 1, 2008, and Nov. 30, 2009, families of children discharged from a single ward of British Columbia’s Children’s Hospital were asked to respond to a questionnaire about adverse events and near misses during the hospital stay. Rates of reporting by health care providers for this period were compared with rates for the previous year. Family reports for specific incidents were matched with reports by health care providers to determine overlap.

Results:

A total of 544 familes responded to the questionnaire. The estimated absolute increase in reports by health care providers per 100 admissions was 0.5% (95% confidence interval −1.8% to 2.7%). A total of 321 events were identified in 201 of the 544 family reports. Of these, 153 (48%) were determined to represent legitimate patient safety concerns. Only 8 (2.5%) of the adverse events reported by families were also reported by health care providers.

Interpretation:

The introduction of a family-based system for reporting adverse events involving pediatric inpatients, administered at the time of discharge, did not change rates of reporting of adverse events and near misses by health care providers. Most reports submitted by families were not duplicated in the reporting system for health care providers, which suggests that families and staff members view safety-related events differently. However, almost half of the family reports represented legitimate patient safety concerns. Families appeared capable of providing valuable information for improving the safety of pediatric inpatients.It has been estimated that adverse events occur in about 1% of children treated in hospital and that, on average, 60% of these events are preventable.¹ To increase institutional awareness of adverse events, hospitals have implemented systems to encourage health care providers to report adverse events.² The reporting of adverse events can be improved by making electronic systems for reporting readily accessible³ and by ensuring a “just culture,” which includes nonpunitive reporting policies.⁴ However, adverse events reported by health care providers account for only a small fraction of total adverse events as determined by chart review.⁵ Time pressures to treat patients, fear of punishment, lack of belief in the benefit of reporting and differing opinions of what defines a reportable event contribute to low reporting rates.⁶ However, patients and their families are readily available, keen and motivated observers who may not be subject to these reporting barriers. Family members are capable of observing and reporting adverse events in a variety of clinical settings.⁷ It is known that the interpretation of safety events and the threshold for reporting differ among health care disciplines and individual health care providers.⁶ However, it is not clear how families of pediatric patients interpret safety-related events or what their threshold would be for reporting events.The purpose of this study was to test whether the introduction of an adverse event reporting system for use by families of pediatric patients at the time of discharge from a surgical ward would significantly change the rate of reporting of adverse events by health care providers. We also evaluated the types of events that families reported, the relevance of these events with respect to patient safety, families’ desires for anonymous reporting and families’ assessments of institutional responses to reported events. We anticipated that health care providers’ reporting rates would rise with the introduction of the family reporting system, on the assumption that greater attention would be paid to reporting safety-related events on the ward. We also anticipated that families would provide useful information about safety-related events, at least some of the time. In particular, we thought that facilitating communication from the patient’s family directly to the study institution’s Quality, Safety and Outcome Improvement Department would allow more opportunities to improve safety through changes in practice.     

Rationing health care: its impact and implications for hematology-oncology.

Rationing of health care in the United States currently exists via the covert mechanism of restricting significant segments of medical care for many of those who cannot afford it. Provision of universal health care would necessitate explicit rationing of certain interventions and technologies, even though an individual could afford them. The British and Canadian experiences provide lessons from which America can profit, and the Oregon health plan is an experiment in this direction. The progressive "graying" of America has raised the question of the need for intergenerational charity as a form of rationing. The implications of these rationing plans would result in a major restructuring of the practice of hematology-oncology.     

Underprivileged areas and health care planning: implications of use of Jarman indicators of urban deprivation.

OBJECTIVE--To analyse critically the use of the Jarman underprivileged area index in health care planning and distribution of resources. DESIGN--The original derivation of the score was examined and evidence to support criticisms of the use of underprivileged area scores examined. MAIN OUTCOME MEASURES--Discrepancies between areas classified as deprived according to the index and areas known to require government funding; the extent of the bias towards family practitioner areas in London; and how the results of using the Jarman index compared with those when another deprivation index based on different indicators was used. RESULTS--The use of electroal wards as geographical areas for which deprivation payments are made is unsatisfactory as the wards vary considerably in size. Of the 20 district health authorities with the highest underprivileged area scores in England, 12 were in London, and four of the six family practitioner committee areas with the highest scores were in London. No health authority or family practitioner committee area in the Northern region had one of the top 20 or 10 scores respectively. When an alternative deprivation index was used to determine the allocation of resources to doctors there was considerable variation compared with the Jarman index. CONCLUSION--The Jarman index underprivileged area score is an inappropriate measure to use for health care planning and distribution of resources. There is a need for a revised measure for allocating deprivation payments to general practitioners.     

The effectiveness of evidence summaries on health policymakers and health system managers use of evidence from systematic reviews: a systematic review

Background

Systematic reviews are important for decision makers. They offer many potential benefits but are often written in technical language, are too long, and do not contain contextual details which make them hard to use for decision-making. There are many organizations that develop and disseminate derivative products, such as evidence summaries, from systematic reviews for different populations or subsets of decision makers. This systematic review aimed to (1) assess the effectiveness of evidence summaries on policymakers’ use of the evidence and (2) identify the most effective summary components for increasing policymakers’ use of the evidence. We present an overview of the available evidence on systematic review derivative products.

Methods

We included studies of policymakers at all levels as well as health system managers. We included studies examining any type of “evidence summary,” “policy brief,” or other products derived from systematic reviews that presented evidence in a summarized form. The primary outcomes were the (1) use of systematic review summaries in decision-making (e.g., self-reported use of the evidence in policymaking and decision-making) and (2) policymakers’ understanding, knowledge, and/or beliefs (e.g., changes in knowledge scores about the topic included in the summary). We also assessed perceived relevance, credibility, usefulness, understandability, and desirability (e.g., format) of the summaries.

Results

Our database search combined with our gray literature search yielded 10,113 references after removal of duplicates. From these, 54 were reviewed in full text, and we included six studies (reported in seven papers) as well as protocols from two ongoing studies. Two studies assessed the use of evidence summaries in decision-making and found little to no difference in effect. There was also little to no difference in effect for knowledge, understanding or beliefs (four studies), and perceived usefulness or usability (three studies). Summary of findings tables and graded entry summaries were perceived as slightly easier to understand compared to complete systematic reviews. Two studies assessed formatting changes and found that for summary of findings tables, certain elements, such as reporting study event rates and absolute differences, were preferred as well as avoiding the use of footnotes.

Conclusions

Evidence summaries are likely easier to understand than complete systematic reviews. However, their ability to increase the use of systematic review evidence in policymaking is unclear.

Trial registration

The protocol was published in the journal Systematic Reviews (2015;4:122)

     

Appropriateness in health care delivery: definitions,measurement and policy implications.

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

The effect of awareness on the outcome of oral health performed by home care service providers

Objectives: The purpose of this study was to investigate the correlations amongst factors, such as knowledge, attitude, practice and oral health behaviour, in caregiver managers so as to improve the oral health of the dependent elderly. Methods: Data were collected from a sample of 102 caregiver managers from home care service providers using a questionnaire. The respondents were divided into two groups: the group who were aware of effective oral care (A group) and the group who were unaware of effective oral care (U group). The evaluations were frequency distribution tables followed by chi‐squared tests of independence and Fisher’s exact test. Results: Ninety percent of the respondents thought that dependent elderly needed to be provided with oral care and 77% had been trained in oral care. However, only 44% thought that they could provide appropriate oral care and only 52% had experienced its effect on oral health and general health. There was a significant difference in training by dental hygienists between the A group (36%) and the U group (11%). There was also a significant difference in learning of oral care skills. Conclusion: The results suggested a high oral care awareness amongst caregiver managers and an inadequate oral care training system. To improve oral health of the dependent elderly, theoretical teaching alone is not sufficient when providing oral health education and a positive contact with the dental team, especially dental hygienists, is an important factor which supports oral care provided by caregivers.     

Bridging the gaps between research,policy and practice in low- and middle-income countries: a survey of health care providers

Background

Gaps continue to exist between research-based evidence and clinical practice. We surveyed health care providers in 10 low- and middle-income countries about their use of research-based evidence and examined factors that may facilitate or impede such use.

Methods

We surveyed 1499 health care providers practising in one of four areas relevant to the Millennium Development Goals (prevention of malaria, care of women seeking contraception, care of children with diarrhea and care of patients with tuberculosis) in each of China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania.

Results

The proportion of respondents who reported that research was likely to change their clinical practice if performed and published in their own country (84.6% and 86.0% respectively) was higher than the proportion who reported the same about research and publications from their region (66.4% and 63.1%) or from high-income countries (55.8% and 55.5%). Respondents who were most likely to report that the use of research-based evidence led to changes in their practice included those who reported using clinical practice guidelines in paper format (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.03–2.28), using scientific journals from their own country in paper format (OR 1.70, 95% CI 1.26–2.28), viewing the quality of research performed in their country as above average or excellent (OR 1.93, 95% CI 1.16–3.22); trusting systematic reviews of randomized controlled trials (OR 1.59, 95% CI 1.08–2.35); and having easy access to the Internet (OR 1.90, 95% CI 1.19–3.02).

Interpretation

Locally conducted or published research has played an important role in changing the professional practice of health care providers surveyed in low- and middle-income countries. Increased investments in local research, or at least in locally adapted publications of research-based evidence from other settings, are therefore needed. Although access to the Internet was viewed as a significant factor in whether research-based evidence led to concrete changes in practice, few respondents reported having easy access to the Internet. Therefore, efforts to improve Internet access in clinical settings need to be accelerated.Gaps continue to exist between evidence generated by clinical research and practice.¹ Efforts to improve access to health information in low- and middle-income countries² and a greater knowledge of how to support the use of research evidence in clinical practice have made little difference. The health consequences of these gaps can be particularly profound when highly effective interventions exist. For example, in the 42 countries in which 90% of the deaths involving children worldwide occurred in 2000, nearly 2.2 million deaths among those under five years of age could have been prevented through the universal use of oral rehydration therapy in those with diarrhea and the use of insecticide-treated materials to prevent malaria.³We conducted this study to examine the use of research-based evidence in defined clinical areas in a sample of health care providers in 10 low- and middle-income countries. We also examined factors that may facilitate or impede such use.