Predictors of home care expenditures and death at home for cancer patients in an integrated comprehensive palliative home care pilot program.

PURPOSE: Empirical understanding of predictors for home care service use and death at home is important for healthcare planning. Few studies have examined these predictors in the context of the publicly funded Canadian home care system. This study examined predictors for home care use and home death in the context of a "gold standard" comprehensive palliative home care program pilot in Ontario where patients had equal access to home care services. METHODS: Secondary clinical and administrative data sources were linked using a unique identifier to examine multivariate factors (predisposing, enabling, need) on total home care expenditures and home death for a cohort of cancer patients enrolled in the HPCNet pilot. RESULTS: SUBJECTS WITH GASTROINTESTINAL SYMPTOMS (OR: 1.64; p=0.03) and those with higher income had increased odds of dying at home (OR: 1.14; p<0.001), whereas age, number of GP visits, gastrointestinal symptoms (i.e., nausea, vomiting, bowel obstruction) and eating problems (i.e., anorexia/cachexia) predicted home care expenditures. CONCLUSIONS: Predictors of home death found in earlier studies appeared less important in this comprehensive palliative home care pilot. An income effect for home death observed in this study requires examination in future controlled studies. RELEVANCE: Access to palliative home care that is adequately resourced and organized to address the multiple domains of issues that patients/families experience at the end of life has the potential to enable home death and shift care appropriately from limited acute care resources.

Mapping health on the internet: a new tool for environmental justice and public health research.

This paper examines the prospects for integrating Internet platform GIS or 'web-GIS' into environmental justice and related public health research. Specifically, we document the development of a web-GIS created for investigating relationships between health, air quality and socioeconomic factors in Hamilton, Canada. After development of the web-GIS site, we assembled a focus group of public health professionals to test functionality and render opinions about the potential of the site and geographic information in their program implementation. Results show overwhelming support for the further integration of GIS into public health practice. The results also underscore the potential of web-GIS to alleviate concerns of cost and data availability that often limit the use of GIS in community debates centred on environmental justice issues.

Inequalities in neighbourhood socioeconomic characteristics: potential evidence-base for neighbourhood health planning.

BACKGROUND: Population health planning aims to improve the health of the entire population and to reduce health inequities among population groups. Socioeconomic factors are increasingly being recognized as major determinants of many aspects of health and causes of health inequities. Knowledge of socioeconomic characteristics of neighbourhoods is necessary to identify their unique health needs and enhance identification of socioeconomically disadvantaged populations. Careful integration of this knowledge into health planning activities is necessary to ensure that health planning and service provision are tailored to unique neighbourhood population health needs. In this study, we identify unique neighbourhood socioeconomic characteristics and classify the neighbourhoods based on these characteristics. Principal components analysis (PCA) of 18 socioeconomic variables was used to identify the principal components explaining most of the variation in socioeconomic characteristics across the neighbourhoods. Cluster analysis was used to classify neighbourhoods based on their socioeconomic characteristics. RESULTS: Results of the PCA and cluster analysis were similar but the latter were more objective and easier to interpret. Five neighbourhood types with distinguishing socioeconomic and demographic characteristics were identified. The methodology provides a more complete picture of the neighbourhood socioeconomic characteristics than when a single variable (e.g. income) is used to classify neighbourhoods. CONCLUSION: Cluster analysis is useful for generating neighbourhood population socioeconomic and demographic characteristics that can be useful in guiding neighbourhood health planning and service provision. This study is the first of a series of studies designed to investigate health inequalities at the neighbourhood level with a view to providing evidence-base for health planners, service providers and policy makers to help address health inequity issues at the neighbourhood level. Subsequent studies will investigate inequalities in health outcomes both within and across the neighbourhood types identified in the current study.

Hospitalization and emergency department visits among seniors receiving homecare: a pilot study.

BACKGROUND: Despite the recent growth in home health services, data on clinical outcomes and acute health care utilization among older adults receiving homecare services are sparse. Obtaining such data is particularly relevant in Ontario where an increasing number of frail seniors receiving homecare are awaiting placement in long-term care facilities. In order to determine the feasibility of a large-scale study, we conducted a pilot study to assess utilization of acute health care services among seniors receiving homecare to determine associated clinical outcomes. METHODS: This prospective cohort study followed forty-seven seniors admitted to homecare by two homecare agencies in Hamilton, Ontario over a 12-month period. Demographic information and medical history were collected at baseline, and patients were followed until either termination of homecare services, death, or end of study. The primary outcome was hospitalization. Secondary outcomes included emergency department visits that did not result in hospitalization and death. Rates of hospitalization and emergency department visits without admission were calculated, and univariate analyses were performed to test for potential risk factors. Survival curves for accumulative rates of hospitalization and emergency department visits were created. RESULTS: 312 seniors were eligible for the study, of which 123 (39%) agreed to participate initially. After communicating with the research nurse, of the 123 who agreed to participate initially, 47 (38%) were enrolled in the study. Eleven seniors were hospitalized during 3,660 days of follow-up for a rate of 3.0 incident hospitalizations per 1,000 homecare-days. Eleven seniors had emergency department visits that did not result in hospitalization, for a rate of 3.3 incident emergency department visits per 1,000 homecare-days. There were no factors significantly associated with hospitalization or emergency department visits when adjustment was made for multiple comparisons. CONCLUSION: The incidence of hospitalization and visits to the emergency department among seniors receiving homecare services is high. Getting satisfactory levels of enrollment will be a major challenge for larger prospective studies.

Service preferences among family caregivers of the terminally ill.

OBJECTIVE: The ability of families to assume caregiving responsibilities is contingent on material, social, and professional support. Inadequate or inappropriate support to the terminally ill and their family caregivers can result in the misuse of resources and add burden to the family. In this report, we describe service preferences among informal caregivers of the terminally ill. DESIGN: Three hundred seventy-three caregivers participated in telephone interviews at two points in time: when the terminally ill person was designated as palliative and 5 months subsequent to the first interview. In the case that the care recipient died during the study period, the caregiver participated in the interview three months after the death. MEASURES: After reviewing possible services received by the care recipients and caregivers, caregivers were asked to identify the five services they found most valuable and which services they would have liked to have had or received more of when caregiving. RESULTS: The five services caregivers reported as most valuable included: in-home nursing care, (90.7%); family physicians, (45.6%); medical specialists, (46.4%); housekeeping, (23.6%); and, religious support, (11.3%). The five most frequently reported services that family caregivers would have liked to have received or had more available included: housekeeping, (13.1%); caregiver respite, (10.2%); in-home nursing care, (8.0%); personal support workers, (4.6%); and, self-help/support groups, (3.8%). Analyses revealed that most (64.8%) perceived service needs were of a supportive nature for caregivers. Caregiver perceptions of the value and perceived need of services were consistent over time and into bereavement. Logistic regression analyses suggested that younger caregivers who were not employed, reported higher levels of burden and cared for someone with a diagnosis of cancer had greater perceived service needs. CONCLUSIONS: The findings reported in this paper provide important insights into caregiver perceptions of valued services when caring for a terminally ill family member. These finding also highlight the stability of caregiver service perceptions over time and into bereavement.

Evaluation of a HACCP pilot program for the food service industry.

OBJECTIVE: To evaluate the efficacy and applicability of a HACCP-based program for use in restaurants. PARTICIPANTS: A randomly selected sample of 16 intervention and 42 control full service, "stand-alone" restaurants with a minimum of 3 full-time food handling staff on duty per shift. SETTING: Six communities in Central West Ontario. INTERVENTION: The Critical Approach, a HACCP-based program for use in restaurants, was designed in consultation with health inspectors and restaurant operators. It focusses on generic risk factors (Critical Control Points, CCPs) for food handlers rather than assessing specific menu items or foods; offers appropriate training of both management and staff; and encourages self-monitoring of CCPs by operators without extensive record keeping or retention. OUTCOMES: Outcome indicators measured changes in three areas: the environment, knowledge, and behaviour. CONCLUSION: Results suggest that among a subpopulation of restaurants, the program is acceptable to operators and capable of producing tangible results. Principles and methods of the program (i.e., an initial assessment of the site, working with the operator to identify and suggest improvements, and return visits to monitor compliance) may be transferable to other types of food service operations.

Angina and socio-economic status in Ontario: how do characteristics of the county you live in influence your chance of developing heart disease?

OBJECTIVE: To assist in the development of community heart health programming and policy development, the Central West Health Planning Information Network (CWHPIN) was asked by its partners to collaborate in obtaining information that might clarify the relationships between socio-economic status (SES) and heart disease among residents of Ontario, Canada. The purpose of this component of the project was to explore, at the county level, how much of the variation in angina pectoris (angina) could be explained by SES variables. STUDY DESIGN: Linear regression modeling was used to identify key predictors of angina hospitalization rates in counties Ontario-wide. RESULTS: Results of the linear regression modeling showed that SES variables (most notably education and occupation) were key predictors of angina, even when traditional risk factors (i.e., smoking, etc.) were included in the analysis. CONCLUSION: This study demonstrates that, at the county level, socio-economic variables such as education and occupation have a significant relationship with rates of heart disease at the population level, even when including the traditional risk factors in the analysis.