An international study of the quality of national-level guidelines on driving with medical illness.

BACKGROUND: Medical illnesses are associated with a modest increase in crash risk, although many individuals with acute or chronic conditions may remain safe to drive, or pose only temporary risks. Despite the extensive use of national guidelines about driving with medical illness, the quality of these guidelines has not been formally appraised. AIM: To systematically evaluate the quality of selected national guidelines about driving with medical illness. DESIGN: A literature search of bibliographic databases and Internet resources was conducted to identify the guidelines, each of which was formally appraised. METHODS: Eighteen physicians or researchers from Canada, Australia, Ireland, USA and UK appraised nine national guidelines, applying the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. RESULTS: Relative strengths were found in AGREE II scores for the domains of scope and purpose, stakeholder involvement and clarity of presentation. However, all guidelines were given low ratings on rigour of development, applicability and documentation of editorial independence. Overall quality ratings ranged from 2.25 to 5.00 out of 7.00, with modifications recommended for 7 of the guidelines. Intra-class coefficients demonstrated fair to excellent appraiser agreement (0.57-0.79). CONCLUSIONS: This study represents the first systematic evaluation of national-level guidelines for determining medical fitness to drive. There is substantive variability in the quality of these guidelines, and rigour of development was a relative weakness. There is a need for rigorous, empirically derived guidance for physicians and licensing authorities when assessing driving in the medically ill.

Defining quality criteria for online continuing medical education modules using modified nominal group technique.

INTRODUCTION: The rapid increase in the use of the Internet for continuing education by physicians suggests the need to define quality criteria for accredited online modules. METHODS: Continuing medical education (CME) directors from Canadian medical schools and academic researchers participated in a consensus process, Modified Nominal Group Technique, to develop agreement on the most important quality criteria to guide module development. Rankings were compared to responses to a survey of a subset of Canadian Medical Association (CMA) members. RESULTS: A list of 17 items was developed, of which 10 were deemed by experts to be important and 7 were considered secondary. A quality module would: be needs-based; presented in a clinical format; utilize evidence-based information; permit interaction with content and experts; facilitate and attempt to document practice change; be accessible for later review; and include a robust course evaluation. There was less agreement among CMA members on criteria ranking, with consensus on ranking reached on only 12 of 17 items. In contrast to experts, members agreed that the need to assess performance change as a result of an educational experience was not important. DISCUSSION: This project identified 10 quality criteria for accredited online CME modules that representatives of Canadian organizations involved in continuing education believe should be taken into account when developing learning products. The lack of practitioner support for documentation of change in clinical behavior may suggest that they favor traditional attendance- or completion-based CME; this finding requires further research.

Physician experiences providing primary care to people with disabilities.

The 2003 Statistics Canada Health Services Access Survey found that 12% of Canadians polled did not have a family doctor, and 18% reported access problems such as long waiting times and difficulty contacting the doctor. Research has repeatedly shown that where a problem with access exists in the general population, it is considerably more severe in subsets of the population that are most disadvantaged. Statistics at both the national and local levels confirm that although people with disabilities have greater need for health services, including both institutional and community services, they also experience significant disadvantages in attempting to access service. The question explored in this study is how physicians' perceptions of disabled patients and behaviour towards them might affect access to primary care for adults with disabilities. The study used a qualitative interpretive approach to uncover physicians' perspectives on working with people with disabilities. Semi-structured interviews were conducted with a sample of 34 physicians in Eastern Ontario. Physicians were asked: How are disabled patients similar to/different from non-disabled patients? How are you as a physician different with disabled patients? Physicians' perceptions, as revealed by their responses to these questions, were interpreted in terms of four types of barriers to access to primary care for disabled adults: physical, attitudinal, expertise-related and systemic. These barriers were examined for their impact on finding a doctor, getting an appointment, getting into the office and receiving a reasonable standard of care.

Delivering primary care to homeless persons: a policy analysis approach to evaluating the options.

Homeless persons are numerous, carry a significant burden of illness and face challenges in accessing care. A search of the literature revealed insufficient empirical sources to permit the use of standard systematic review methodology to determine the most effective way to deliver point-of-first-contact healthcare to homeless people. Instead, we used a policy analysis approach. We found that the dominant model of primary care in Canada performs poorly when assessed on 13 evaluation criteria. While there is variable performance on individual measures, the three alternative models - targeted standard facility/clinic site, fixed outreach site and mobile outreach service - all perform well. Our findings suggest that some factor other than performance on the specified measures, such as costs, feasibility, geographical fit or local preferences, should be used to choose a specific model. Our analysis clearly indicates that the status quo model of primary care is inadequate to meet the needs of homeless people.

Making sense of social capital, health and policy.

This paper summarizes current knowledge about social capital and its application to health policy. There is a consensus that social capital is a characteristic of social groups, rather than individuals, and is born of shared experience which fosters mutual trust and reciprocity. It is a collective resource that may accumulate over time and facilitates the accomplishment of objectives that would otherwise be unlikely. The theoretical articulation of social capital remains under-theorized, and its measurement is subject to considerable debate. Health researchers, searching for a pathway to explain the adverse health outcomes associated with income inequality, as well as to understand the results of multi-level analyses that demonstrate an independent etiological role for community of residence, may find social capital an attractive notion. Despite professions of interest, the utility of social capital for health policy formation remains problematic; however, as a theoretical paradigm for policy it may have particular appeal to exponents of the "Third Way".

The impact of hospital restructuring on home care nursing.

BACKGROUND: Health reform in many industrialized countries has prompted the shift from institutional to community care. In Ontario, this approach was instigated through the Health Services Restructuring Commission. OBJECTIVES: The purpose of this study was to determine whether changes in the hospital sector between 1996 and 2000 resulted in changes in the provision of home-care services by nurses and practical nurses. METHODS: This study was a retrospective trend analysis of linked hospitalization and home-care utilization data for Kingston for 1996 to 2000. The measures include the rate of home care and the volume and intensity of home-care services. RESULTS: Between 1996 and 2000 there was a net 4% increase in the age-gender standardized rate of admission to home-care nursing services, with a 10% rate rise between 1996 and 1997. The total volume of home-care services increased during the study, as did the average intensity of home-care service delivery over the first month post-hospitalization during the first four years. This article will give readers their first look at the changes in home-care nursing following hospital restructuring in Kingston.

Alternative funding for academic medicine: experience at a Canadian Health Sciences Center.

In 1994 the School of Medicine of Queen's University in Kingston, Ontario, its clinical teachers, and the three principal teaching hospitals initiated a new approach to funding, the Alternative Funding Plan, a pragmatic response to the inability of fee-for-service billing by clinical faculty to subsidize the academic mission of the health sciences center. The center was funded to provide a package of service and academic deliverables (outputs), rather than on the basis of payment for physician clinical activity (inputs). The new plan required a new governance structure representing stakeholders and raised a number of important issues: how to reconcile the preservation of physician professional autonomy with corporate responsibilities; how to gather requisite information so as to equitably allocate resources; and how to report to the Ontario Ministry of Health and Long-term Care in order to demonstrate accountability. In subsequent iterations of the agreement it was necessary to address issues of flexibility resulting from locked-in funding levels and to devise meaningful performance measures for departments and the center as a whole. The authors conclude that the Alternative Funding Plan represents a successful innovation in funding for an academic health sciences center in that it has created financial stability, as well as modest positive effects for education and research. The Ontario government hopes to replicate the model at the province's other four health sciences centers, and it may have applicability in any jurisdiction in which the costs of medical education outstrip the capacity of faculty clinical earnings.

Toward an accountability framework for Canadian healthcare.

State-funded healthcare systems increasingly recognize accountability as an important public policy issue. This article explores significant aspects of current theory and practice in order to describe an accountability framework for the Canadian health system. Stakeholders include governments, institutions, providers and patients. Their relationships may be framed in constitutional, political, financial, managerial, clinical or ethical terms. The specific processes and instruments to operationalize accountability depend on the terms by which it is framed.

The Mazankowski Report: radical solutions in innocuous wrapping?

On the surface, the Mazankowski Report appears highly conventional. The flaws in the current health system that it identifies - lack of service integration, inadequate human resource planning, insufficient information to manage the system appropriately - and the solutions proposed will be familiar to aficionados of health commission reports from the last decade. However, the report does depart from the current Canadian consensus in two important respects: first, it views ensuring access to some types of health services as explicitly an individual, rather than a collective, responsibility; second, it recommends funding access to such services through mechanisms that will likely create financial barriers to care for less healthy or affluent Canadians.

Access to elective vascular surgery within the recommended time according to emergency referrals.

BACKGROUND: Referral pattern is a potential confounding factor when waiting-list performance is reported across hospitals or periods. A common concern is the ability to accurately estimate proportions of patients undergoing surgery in the recommended time without considering emergency caseload. In this study, the relation between emergency referrals and the rate of elective admissions to hospital within the recommended time was estimated. DESIGN: A prospective cohort study. SETTING: An acute care hospital in Kingston, Ont. PATIENTS: Between 1994 and 1999, 1,173 consecutive patients accepted for elective vascular surgery. MAIN OUTCOME MEASURES: The proportion of patients who underwent surgery within the recommended time, and time to surgery. STUDY VARIABLES: The weekly number of emergency cases, enrolment periods, urgency and type of surgery. RESULTS: Overall, the proportion of patients who underwent surgery within recommended time was 0.45, (95% confidence interval [CI], 0.42-0.48). Adjusted for enrolment period, urgency and type of surgery, the estimated proportion was 0.57, (95% CI, 0.49-0.64). Compared with surgery for peripheral vascular disease, the odds of the procedure being done within the recommended time were 34% lower for aortic abdominal aneurysm repair and 41% lower for carotid endarterectomy. After adjustment for the case-mix and access attributes, the rate of elective admission within recommended time was on average 30% lower for weeks in which there were 1 to 2 emergency cases (rate ratio [RR] = 0.70, [95% CI, 0.53- 0.93]), and 39% lower for weeks with 3 or more emergency cases (RR = 0.61 [95% CI, 0.53-0.83]), relative to weeks with no emergency cases. CONCLUSIONS: When there is an increase in the number of emergency cases, a lower proportion of patients undergo elective surgery within the recommended time. Thus, when performance of surgical servces is evaluated, the probability of patients undergoing elective surgery on time should be adjusted relative to the number of emergency referrals.

Dying in Canada: is it an institutionalized, technologically supported experience?

Although preliminary evidence shows that people generally prefer to die at home, very little is known about where Canadians die. Understanding the epidemiology of dying in Canada may illuminate opportunities to improve quality of end-of-life care and related health policy. We conducted a cross-sectional analysis of death records in Canada to determine the proportions of deaths occurring in hospitals and special care units. Our analysis found that deaths in Canada occur in hospitals with provincial and territorial proportions ranging from 87% in Quebec to 52% in the Northwest Territories. In hospitals recording deaths in special care units, 18.64% of all deaths occurred in special care units. The proportion of deaths in special care units ranged from 25% in Manitoba to 7% in the Northwest Territories. The proportion of deaths in special care units varied by size and nature (teaching vs. non-teaching) of hospitals. It increased with the size of the hospital from 8% in hospitals with 1-49 beds, to 23% for hospitals with 400 or more beds. In teaching hospitals, 27% of deaths occurred in special care units, and in non-teaching hospitals the proportion was 15%. In conclusion, the majority of deaths in Canada occur in hospitals and a substantial proportion occur in special care units, raising questions about the appropriateness and quality of current end-of-life care practices in Canada.

An assessment of the in vitro toxicology of Clostridium perfringens type D epsilon-toxin in human and animal cells.

The epithelial Madin Darby canine kidney (MDCK) cell line and 17 human cell lines were examined for sensitivity to Clostridium perfringens type D epsilon-toxin. MDCK cells were confirmed as being sensitive to the toxin. In addition, the Caucasian renal leiomyoblastoma (G-402) human cell line was identified as being epsilon-toxin sensitive. Using the MTS/PMS assay system the concentration of toxin reducing cell culture viability by 50% (LC50) was found to be 2 microg/ml in MDCK cells. The LC50 for G-402 cells was 280 microg/ml. Epsilon-Toxin was found to be rapid acting in MDCK cells exposed to a maximum lethal dose of the toxin (40% loss of viability after a 0.5 h exposure), but slower acting in G-402 cells (40% loss of viability after 1.7 h exposure). Photomicrography of toxin exposed cultures indicated necrotic cell death on exposure to epsilon-toxin. Investigations using an antibody probe indicated that epsilon-toxin could bind to many cell surface proteins in both MDCK, G-402 and a toxin insensitive human cell line (CAKI-2). It has previously been found that the toxin may bind to the cell surface via glycosylated moieties. However, exposing MDCK and G-402 cells to epsilon-toxin in the presence of sialic acid and several different sugars did not reduce the lethal effects of the toxin.