Seasonal congestive heart failure mortality and hospitalisation trends, Quebec 1990-1998.

STUDY OBJECTIVE: To describe seasonal congestive heart failure (CHF) mortality and hospitalisations in Quebec, Canada between 1990-1998 and compare trends in CHF mortality and morbidity with those in France. DESIGN: Population cohort study. SETTING: Province of Quebec, Canada. PATIENTS: Mortality data were obtained from the Quebec Death Certificate Registry and hospitalisation from the Quebec Med-Echo hospital discharge database. Cases with primary ICD-9 code 428 were considered cases of CHF. RESULTS: Monthly CHF mortality was higher in January, declined until September and then rose steadily (p<0.05). Hospital admissions for CHF declined from May until September (moving averages analysis p<0.0001). Seasonal mortality patterns observed in Quebec were similar to those observed in France. CONCLUSION: CHF mortality in Quebec is highest during the winter and declines in the summer, similar to observations in France and Scotland. This suggests that absolute temperatures may not necessarily be that important but increased CHF mortality is observed once environmental temperatures fall below a certain "threshold" temperature. Alternatively better internal heating and warmer clothing required for survival in Quebec may ameliorate mortality patterns despite colder external environments.

The St-Louis du Parc Heart Health Project: a critical analysis of the reverse effects on smoking.

OBJECTIVES: Although some school based smoking prevention programmes have shown positive impacts, others have had only short term effects, no effects, and in some cases reverse effects. The St-Louis du Parc Heart Health Project was a five year heart health promotion programme targeting children in eight elementary schools aged 9-12 years in disadvantaged multiethnic neighbourhoods in Montreal. In a controlled, longitudinal evaluation, the programme produced reverse effects on smoking--children exposed to the programme were more likely to initiate and to continue smoking than control children. This article explores hypotheses to explain the reverse effects. DESIGN: Following work by an in-house committee, a consensus workshop with international experts was conducted to develop hypotheses to explain the reverse effects. This was complemented by an analysis of the programme's concordance with the standard guidelines on the school based prevention of tobacco use, and discussions with experts at the Centers for Disease Control and Prevention. RESULTS: The programme respected most standard guidelines for smoking prevention programmes with respect to content and mode of delivery. Hypotheses to explain the reverse effects include: an unfavourable environment characterised by strong pro-smoking models and resistance to environmental interventions; heightened sensitivity to smoking among children most exposed to the programme; defence mechanisms among children stimulated by cognitive dissonance or anxiety; unanticipated effects associated with the health educator who delivered the programme; inadequate attention in programme development to the diverse cultural origins of the population targeted; and intervention content inappropriately targeted to children's stages of cognitive development. CONCLUSION: Elementary school based interventions should aim to develop a clear and coherent social norm about the non-use of tobacco, as a precursor to or in close conjunction with having children as their primary target. Programme design should take key student characteristics into consideration and ensure that the modes of communication are adapted to the targeted group's characteristics. Neighbourhood level interventions should be orchestrated to complement regional, provincial, and national programmes.

Changing trends in mortality and admissions to hospital for elderly patients with congestive heart failure in Montreal.

BACKGROUND: Congestive heart failure (CHF) is a common disease requiring admission to hospital among elderly people and is associated with a high mortality rate. The objective of this study was to examine trends in CHF mortality and admissions to hospital in Montreal between 1990 and 1997 for individuals aged 65 years or more. METHODS: We obtained information about deaths from the Quebec Death Certificate Registry database and information about admissions to hospital from the Quebec Med-Echo database. Patients with a primary diagnosis that was classified as ICD-9 code 428 were considered cases of CHF. RESULTS: Although age-adjusted rates of mortality from CHF did not change significantly between 1990 and 1997, the annual rate of admission to hospital for CHF increased from 92 per 10,000 population in 1990/91 to 124 per 10,000 population in 1997/98 (p < 0.01). Deaths due to CHF, expressed as a proportion of all cardiovascular deaths, increased among women from 5.6% in 1990 to 6.2% in 1997 (p = 0.01). The rate of readmission for all causes following a first admission for CHF during that year rose over the study period from 16.6% to 22.0% within one month (p < 0.001) and from 46.7% to 49.4% within 6 months (p = 0.03). Conversely, mean annual length of stay per admission decreased from 16.4 days in 1990/91 to 12.2 days in 1997/98. INTERPRETATION: The increase in rates of admission to hospital for CHF and the stable rates of CHF mortality suggest that the management of CHF and its antecedents has improved in recent years.

Smoking cessation counseling practices of general practitioners in Montreal.

BACKGROUND: Despite the cost-effectiveness of physician smoking cessation counseling, many physicians do not adhere to current clinical practice guidelines. METHODS: A cross-sectional mail survey was conducted in a random sample of general practitioners in Montreal to document cessation-counseling practices and identify correlates of these activities. RESULTS: Of 440 eligible general practitioners, 337 (77%) completed the questionnaire. Despite favorable beliefs/attitudes about cessation counseling, only 10.5% of general practitioners provided "thorough" counseling. While high proportions of general practitioners ascertained smoking status and encouraged patients to quit, relatively few offered adjunct support (i.e., for patients preparing to quit, 49.8% offered follow-up visits; 42.5% offered educational material; 20% referred patients to community resources). Correlates of counseling completeness included high self-efficacy to provide counseling (odds ratio (OR) = 2.0, 95% confidence interval (1.1-3.6)) and favorable beliefs/attitudes about counseling (OR = 3.6 (2.0-6.4)). Correlates of ascertaining smoking status included female gender (OR = 2.3 (1.5-3.5)), high self-efficacy (OR = 3.5 (2.0-5.9)), and favorable beliefs/attitudes (OR = 2.7 (1.6-4.5)). Correlates of offering adjunct support included female gender (OR = 1.9 (1.1-3.2)), awareness of stages of change (OR = 2.4 (1.3-4.4)), and knowledge of community resources to help patients quit (OR = 2.3 (1.3-3.9)). CONCLUSION: Support, training, and intervention programs to overcome lack of awareness and knowledge, unfavorable beliefs/attitudes, and low self-efficacy could increase and enhance cessation counseling practices among general practitioners.

The role of community pharmacists in health education and disease prevention: a survey of their interests and needs in relation to cardiovascular disease.

BACKGROUND: Recently there has been increased interest in broadening the role of community pharmacists to include more health education and disease prevention activities such as patient counseling for risk management and interventions to improve compliance. However, to date, there is little information on interest in prevention among community pharmacists or on their current prevention practices. METHOD: Data on current health education and disease prevention practices, as well as interest in expanding their role in prevention, were collected in a cross-sectional mail survey of a random representative sample of community pharmacists currently practicing in the province of Quebec. RESULTS: Among 597 eligible subjects, 455 (76.2%) completed the questionnaire. Few pharmacists practice prevention routinely. Independent correlates of engaging in prevention included working in a smaller pharmacy (odds ratio (OR) 3. 2 (95% confidence interval 2.0-5.3)), owning the pharmacy (OR 1.9 (1. 2-3.0)), moderate/high job satisfaction (OR 2.1 (1.4-4.3)), and history of prevention activities in the pharmacy (OR 2.2 (1.4-3.6)). Over 90% of respondents reported that integrating prevention into their practices was important. Independent correlates of high perceived importance included working as a salaried pharmacist (OR 2. 3 (1.4-3.8)), high job satisfaction (OR 4.1 (1.7-9.7)), and currently practicing prevention (OR 2.0 (1.2-3.2)). The most important perceived barriers to integrating prevention included lack of time and lack of skills/instrumentation for practicing prevention. CONCLUSIONS: There is considerable interest among community pharmacists in expanding their role to include more prevention, but there are many barriers to actualizing this role. Further work should focus on ways to overcome these barriers because pharmacists are particularly well-situated to make an important contribution to prevention.

Hypertension follow-up survey Laval, Quebec, 1988.

In 1988, a follow-up study of a group of hypertensives (n = 278), identified two years earlier in a prevalence survey (1986), was conducted. Blood pressure (BP) levels, treatment and control status and medical follow-up were assessed. Subjects were classified as either known hypertensives or newly identified hypertensives. There was a moderate increase in blood pressure control over the two-year period in known hypertensives. Approximately half of newly identified hypertensives remained untreated, uncontrolled; half became ex-hypertensives. One third of the ex-hypertensives, however, still had high-normal diastolic readings (85-89 mm Hg). Newly identified hypertensives reported less frequent medical visits and fewer non-pharmacological recommendations from their physicians than known hypertensives. The study suggests that follow-up and counselling on modifiable risk factors in borderline and mild hypertensives might not be up to recent Canadian and American guidelines.