Advocating for Policy Change: Examples Emerging From a Medical-Legal Partnership in Primary Care.

Medical-legal partnerships bring legal services directly into clinical settings. Policy advocacy is often opportunistic and varies across partnerships. Our objective was to study policy advocacy that emerged from a medical-legal partnership in Toronto over a four-year period. This study consisted of a document review and thematic analysis, triangulated with data from interviews with legal team members and health providers. We defined policy advocacy as actions associated with attempts to change policy or legislation. The medical-legal partnership engaged in seven distinct cases of policy advocacy: disability support form requirements, changing workplace review, challenging barriers to citizenship, housing, publicly funded medication program (pharma care), safe injection sites, and the need for increased social assistance. Actions taken included presentations at conferences and submissions of briefs to government. We found that a medical-legal partnership resulted in policy advocacy with issues arising from both the health and the legal team with impacts likely greater than if each group had acted alone.

Association Between Clinic-Reported Third Next Available Appointment and Patient-Reported Access to Primary Care.

This cross-sectional study examines the association of the third next available appointment with patient-reported measures of access in primary care settings.

An Electronic Clinical Decision-Making Tool for Patients with Suspected Colorectal Cancer-Preliminary Evaluation in Patients Presenting with Rectal Bleeding.

BACKGROUND AND OBJECTIVES: The CarePath-CRC electronic clinical decision-making application was designed to assist physicians with evaluation of patients with suspected colorectal cancer (CRC). The physician completes an interactive checklist of evidence-based clinical parameters, and a recommended referral urgency is generated based on the post-test probability of CRC. This study aimed toward validation of the tool in symptomatic patients presenting with rectal bleeding. METHODS: The medical records of a sample of patients with histologically confirmed CRC from 2010 to 2014 were reviewed. The CarePath-CRC tool was applied retrospectively to all patients who initially presented with rectal bleeding, to determine its sensitivity for detecting CRC in this population. A generated recommendation of 'immediate referral' (referral ≤24 hours, expected endoscopy ≤2 weeks) or 'urgent referral' (expected consultation and endoscopy ≤4 and ≤8 weeks) was considered a positive test result. An a priori sensitivity of 90% was deemed adequate, based on test characteristics of the tool's individual clinical criteria. RESULTS: The tool was applied to 281 patients. A total of 69 (24.6%) and 211 (75.1%) patients met criteria for immediate and urgent referral, respectively. The remaining patient (0.4%) met criteria for 'possible priority referral', while none met criteria for 'no specific action recommended'. This resulted in a calculated sensitivity of 99.6% (95% confidence interval 98.0 to 99.9%). CONCLUSIONS: The CarePath-CRC tool is sensitive in the prediction of CRC in patients presenting with rectal bleeding. A prospective cohort study is being designed to allow for acquisition of comprehensive test performance characteristics and full validation of the instrument.

Management of major bleeds in patients with immune thrombocytopenia.

BACKGROUND: A standard approach to the recognition and management of major bleeding in immune thrombocytopenia (ITP) is lacking. METHODS: Retrospective cohort study of ITP patients presenting to the emergency department (ED) with severe thrombocytopenia (platelet count <20 × 109 /L) and bleeding in four academic hospitals from 2008 to 2016. We defined a major ITP bleed as a bleed at a critical site or causing hemodynamic instability. RESULTS: We identified 112 ITP patients (n = 141 visits) who presented to the ED with platelets <20 × 109 /L and bleeding. Twenty--nine patients (26%) had 32 ED visits with major bleeds. Risk factors for major bleeds were older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.06), male sex (OR 3.25, 95% CI 1.22-9.32), and more prior ITP therapies (OR 1.42, 95% CI 1.10-1.87). Acute treatment of major bleeds required a median of three treatments (interquartile range [IQR] 2--4), which included intravenous immune globulin (91% of visits), corticosteroids (78% of visits), and platelet transfusions (75% of visits). Three patients (10%) died, nine (31%) developed recurrent bleeds, one (3%) developed arterial thrombosis, and one (3%) had permanent neurological disability. Six patients presented with minor bleeding and subsequently developed a major bleed after a median of 2 days (IQR 1-3). All six patients had oral purpura and four of six had gross hematuria preceding the major bleed. CONCLUSIONS: Major ITP bleeds are associated with significant morbidity and mortality. Oral purpura and hematuria often preceded major bleeds. Further research is needed to refine the definition of a major ITP bleed and develop evidence-based treatment strategies.

System Performance Indicators for Adolescent and Young Adult Cancer Care and Control: A Scoping Review.

Adolescents and young adults (AYAs) with cancer represent a unique group with unmet needs. Metrics and quality indicators are important for evaluating AYA cancer care. The purpose of this study is to describe the quality indicators in a Canadian context that are used for AYA (15-39 years of age) cancer care and control. The Arksey and O'Malley methodological framework was applied to undertake a scoping review of the peer-reviewed and gray literature for indicators related to AYA cancer care and control. OVID Medline was searched from January 1995 until April 2018 for English language articles. Inquiries were made to AYA cancer organizations and a Google search conducted to identify unpublished material. Articles were included if they incorporated AYAs and contained cancer care indicators. Data were summarized at the article and indicator level. A total of 610 abstracts were reviewed. Eighty-nine full-text articles and reports were assessed for eligibility, with 19 included in analyses which identified 146 indicators or indicator concepts. Most of the indicators were specific to the AYA age group (65.8%) and dealt with the active care theme (57.5%), almost half focusing on guideline adherence and treatment (26.4%) and multidisciplinary/specialized care (20.7%). Notable deficits in indicators were in fertility, psychosocial care, and prevention. Important progress has been made internationally and within Canada on developing indicators for AYA cancer care and control. However, there is a lack of well-defined AYA-specific cancer care indicators developed through a consensus process.