What matters to patients following total knee arthroplasty? A grounded theory of adapting to a knee replacement.

BACKGROUND: Globally the volume of total knee arthroplasty (TKA) is on the rise, reflecting aging populations, an associated increase in treatment of osteoarthritis, and a desire for improved quality of life. There is evidence that as high as 15 to 20% of patients are not satisfied with their TKA results and efforts need to be made to improve these rates. This study set out to identify what patients consider important when reflecting on TKA satisfaction, to pave the way to identifying service transformation opportunities that will enhance patient-centred care and satisfaction with this procedure. METHODS: Twenty-seven TKA recipients were recruited in the province of British Columbia, Canada. Semi-structured interviews were conducted about participants' experience and satisfaction with TKA, three to four years post-surgery. Grounded theory was employed to analyze participants' stories about what was front of mind when they reflected on satisfaction with their new knee. RESULTS: Participants described their post-TKA knee in terms its adequacy: how it felt and worked, and how it matched their pre-surgical expectations. The central element of their stories was the process of adapting, which gave rise to their perceptions of adequacy. Adapting comprises the patient experience of physically integrating and cognitively accepting their new knee. Patterns of adapting reflect the level of the new knee's achieved adequacy and the straightforwardness of the adapting process. DISCUSSION: The conceptualization of adequacy and the process of adapting allow a patient-centred understanding of what patients experience following TKA. For participants who did not readily achieve the adequacy they had anticipated, the challenges they experienced during adapting dominated their stories. Participants' adapting stories afford key insights into how the health care system could adjust to better support TKA patients, and improve rates of satisfaction with this procedure. CONCLUSIONS: The process of adapting lends itself to system intervention in support of enhanced post-TKA outcomes and satisfaction. These interventions could include the development of a care model including long-term clinical support for patients whose knees do not achieve desired results on schedule, and collaborating with patients to set and manage reasonable expectations about how their post-TKA knee will feel and function.

Patient-reported confidence in primary healthcare: are there disparities by ethnicity or language?

OBJECTIVE: To examine whether confidence in primary healthcare (PHC) differs among ethnic-linguistic groups and which PHC experiences are associated with confidence. DESIGN: A cross-sectional study where patient surveys were administered using random digit dialling. Regression models identify whether ethnic-linguistic group remains significantly associated with confidence in PHC. SETTING: British Columbia, Canada. MAIN OUTCOME MEASURES: Confidence in PHC measured using a 0-10 scale, where a higher score indicates increased confidence in the ability to get needed PHC services. PARTICIPANTS: Community-dwelling adults in the following ethnic-linguistic groups: English-speaking Chinese, Chinese-speaking Chinese, English-speaking South Asians, Punjabi-speaking South Asians and English-speakers of presumed European descent. FINDINGS: Based on a sample of 1211 respondents, confidence in PHC differed by ethnicity and the ability to speak English. Most of the differences in confidence by ethnic-linguistic group can be explained by various aspects of care experience. Patient experiences associated with lower confidence in PHC were: if care was received outside Canada, having to wait months to see their regular doctor and rating the quality of healthcare as good or fair/poor. Better patient experiences of their doctor being concerned about their feelings and being respectful and if they found wait times acceptable were associated with higher levels of confidence in PHC. The final regression model explained 30% of the variance. CONCLUSIONS: Improving the delivery of PHC services through positive interactions between patients and their usual provider and acceptability of wait times are examples of how the PHC system can be strengthened.

Patient activation in primary healthcare: a comparison between healthier individuals and those with a chronic illness.

BACKGROUND AND OBJECTIVE: Current policy directions place increasing expectations on patients to actively engage in their care, especially in chronic disease management. We examined relationships between patient activation and multiple dimensions of primary healthcare (PHC), including access, utilization, responsiveness, interpersonal communication, and satisfaction for patients with and without chronic illness. RESEARCH DESIGN: Cross-sectional, random digit dial survey conducted in British Columbia (BC), Canada. SUBJECTS: Stratified sample of adults (n=504), aged 19 to 90 years, who had visited their regular provider within the past 24 months. All data were weighted to represent residents living in BC. MEASURES: Patient activation and PHC experiences include accessibility, continuity, whole-person care, interpersonal communication, responsiveness, chronic disease management, and satisfaction. RESULTS: The multivariate models provide evidence that both quantity of time and quality of interactions with one's regular provider are associated with higher patient activation. Those with no chronic illness had higher activation scores when they spent more time talking with their regular provider, experienced less hurried communication, or if their test results were explained. The more time people with chronic illness are able to spend with their physician, the more activated they were. Chronic illness respondents also had higher activation scores if they reported higher whole-person care or if they were more satisfied. CONCLUSIONS: Positive interactions between the patient and the provider can influence the patient's abilities to engage in and be confident in maintaining/improving his/her health. Supporting patients in becoming actively engaged, in ways that work for them, is essential to providing high quality care, especially among those with a chronic condition.

Registration for public drug benefits across areas of differing ethnic composition in British Columbia, Canada.

BACKGROUND: In 2003, the government of British Columbia, Canada introduced a universal drug benefit plan to cover drug costs that are high relative to household income. Residents were required to register in order to be eligible for the income-based benefits. Given past research suggesting that registration processes may pose an access barrier to certain subpopulations, we aimed to determine whether registration rates varied across small geographic areas that differed in ethnic composition. METHODS: Using linked population-based administrative databases and census data, we conducted multivariate logistic regression analyses to determine whether the probability of registration for the public drug plan varied across areas of differing ethnic composition, controlling for household-level predisposing, enabling and needs factors. RESULTS: The adjusted odds of registration did not differ across regions characterized by high concentrations (greater than 30%) of residents identifying as North American, British, French or other European. Households located in areas with concentrations of residents identifying as an Asian ethnicity had the highest odds of program registration: Chinese (OR = 1.21, CI: 1.19-1.23) and South Asian (OR = 1.19, CI: 1.16-1.22). Despite this positive finding, households residing in areas with relatively high concentrations of recent immigrants had slightly lower adjusted odds of registering for the program (OR = 0.97, CI: 0.95-0.98). CONCLUSIONS: This study identified ethnic variation in registration for a new public drug benefit program in British Columbia. However, unlike previous studies, the variation observed did not indicate that areas with high concentrations of certain ethnicities experienced disadvantages. Potential explanations are discussed.

Is Canadian women's breast cancer screening behaviour associated with having a family doctor?

OBJECTIVE: To assess whether regular care from a family physician is associated with regular participation in screening mammography. DESIGN: Secondary analysis of the 2006 Canadian Community Health Survey data. SETTING: Canada. PARTICIPANTS: Cross-sectional sample of 15 195 Canadian women aged 50 to 69 years. MAIN OUTCOME MEASURES: The outcome of interest was screening mammography within the past 2 years; the key explanatory factor was active interaction with a family physician. Control factors included sociodemographic characteristics, other cancer screening behaviour, and other cancer risk habits. RESULTS: Active interaction with a regular family doctor doubled the odds that a woman had received a recent screening mammogram. Other cancer screening and preventive measures were also strongly associated with that outcome. A woman who had had a recent Papanicolaou test was more than 3 times as likely to have had a recent mammogram; nonsmokers were much more likely to have had a recent mammogram than smokers. CONCLUSION: Adults who receive regular care from family physicians are more likely to participate in screening mammography within the recommended time frames.

Measuring the performance of primary healthcare: existing capacity and potential information to support population-based analyses.

WHAT DID WE DO?: We reviewed the degree to which existing population-based data in Canada can be used to describe and report on primary healthcare (PHC) performance. We identified gaps in current data sources and made recommendations on how these gaps might be addressed to support quality improvement and public reporting for PHC. WHAT DID WE LEARN?: Population-based survey and administrative data are available to describe population characteristics and other contextual factors for PHC, as well as some aspects of the material, financial and human resources inputs, and selected activities and decisions at the policy, management and clinical levels. Existing data can also be used to describe some volumes and types of PHC outputs. However, we currently have limited population-based data to assess selected qualities of PHC services (e.g., coordination and interpersonal effectiveness) and most immediate outcomes of PHC. The ability to link data to assess outcomes and attribute changes in outcomes to PHC is limited. A full report describing more than 130 indicators from existing data sources and gaps in current data is available at www.chspr.ubc.ca. WHAT ARE THE IMPLICATIONS?: As we look to the future, there is a clear need to build on existing data sources to expand PHC data capacity in Canada. Data are needed to inform an understanding of PHC outputs, outcomes and the linkages among PHC dimensions. Commitment to a comprehensive PHC data collection strategy and information system is needed across Canadian provinces and territories to inform policy development and planning, to evaluate PHC redesign initiatives and to meet the accountability expectations of Canadians.

Developing and maintaining a population research registry to support primary healthcare research.

WHAT DID WE DO?: This paper describes the creation of a population research registry as part of an information system to support primary healthcare (PHC) research in British Columbia. The population registry includes all residents of the province who were either eligible to use or actually used healthcare services, together with demographic, geographic, health status, registration and service use data. The PHC population research registry is built using administrative data inputs, and data are anonymized to comply with privacy and confidentiality standards. WHAT DID WE LEARN?: The registry provides data to undertake research into PHC needs and service utilization. It facilitates both population-based research as well as research on population subgroups. Combined with anonymous physician and utilization data, the information system can be used to study service utilization rates for population-based analyses. Over the longer term, the information will contribute to our understanding of PHC qualities and outcomes. WHAT ARE THE IMPLICATIONS?: Continued completeness of the population research registry depends upon full administrative source data. Planning to ensure complete data capture is critical both for the research registry and our ability to undertake population-based PHC research.

The research collective: a model for developing timely, contextually relevant and dynamic approaches to research synthesis?

In this issue, Pineault and colleagues (2006) report on a Quebec-based research collective, a process aimed at rapidly synthesizing results from ongoing or recently completed research and releasing them to decision-makers. The process outlined differs markedly from Cochrane-based formal systematic reviews, and the authors claim a number of benefits that make the results more relevant to decision-makers, including enhanced timeliness of results, increased triangulation among emerging research findings, and more in-depth understanding of the impact of contextual environments on research results. This approach may offer opportunities to both advance and enrich existing synthesis tools. The research community should learn more from this process.

Income-Based Drug Coverage in British Columbia: Lessons for BC and the Rest of Canada.

BACKGROUND: In May 2003, the government of British Columbia adopted income-based pharmacare, replacing an age-based drug benefits program. Stated policy goals included reducing government spending, maintaining or enhancing access to medicines and improving financial equity. The province's experience on these policy dimensions can inform policy making in other jurisdictions and offers insight into priorities for Canada's National Pharmaceuticals Strategy. METHOD: The research team created an anonymized database with information about drug use, private and public expenditure and household income for all residents of British Columbia from 1996 to 2004. This database was used to evaluate the impact of the policy on trends in drug expenditures, utilization and sources of payment for seniors and non-seniors of different income levels. RESULTS: In the immediate term, Fair PharmaCare appears to have met many of its policy goals. Government spending was reduced. Access to medicines was maintained (though not enhanced). And the distributions of private and public expenditures were brought more closely in line with distribution of income. Long-run impacts depend largely on how a reduced role for government affects trends in costs, access and equity. Early indications suggest that a larger role for government may be needed to maintain performance on desired policy objectives over time. CONCLUSION: In the long run, there is reason for setting a new national standard for pharmacare that increases, not decreases, the share of publicly covered spending in every province. The federal government could play a key role by helping provinces increase public funding for prescription drugs and thereby facilitate cost control, maintain access to medicines and enhance financial equity.

Discharge outcomes in seniors hospitalized for more than 30 days.

Hospitalization is a sentinel event that leads to loss of independence for many seniors. This study of long-stay hospitalizations (more than 30 days) in seniors was undertaken to identify risk factors for not going home, to characterize patients with risk factors who did go home and to describe 1-year outcomes following home discharge. Using Manitoba's health care databases, the likelihood of death in hospital, discharge to a nursing home, and transfer to another hospital was determined for a set of risk factors in seniors with long-stay hospitalizations in Winnipeg's acute hospitals. Of the 17,984 long-stay hospitalizations during 1993-2000, 45 per cent were discharged home, 20 per cent died, and 30 per cent were discharged to a nursing home or another hospital. Seniors who received home care prior to hospitalization were more likely to be discharged to a nursing home or die in hospital than to go home. Stroke and cognitive impairment increased the likelihood of discharge to a nursing home. Seniors with neoplasms, multiple co-morbidities, and length-of-stay more than 120 days were more likely to die in hospital. Long-stay patients with risk factors who did go home had few co-morbidities. Within 1 year of home discharge, 20 per cent of seniors died, 5-15 per cent were admitted to a nursing home or long-term care institution, and 26-35 per cent of persons were re-hospitalized from home. A full 37 per cent experienced none of these outcomes. Our findings point to opportunities to improve discharge outcomes and plan support services for seniors.

The impact of influenza-associated respiratory illnesses on hospitalizations, physician visits, emergency room visits, and mortality.

OBJECTIVES: Although the increased risk of hospitalization and mortality during influenza seasons has been documented extensively, there is a relative paucity of research on the impact of influenza-related illnesses on other health care use indicators, such as physician use. The purpose of this study was to examine the impact of influenza-associated respiratory illnesses on the Winnipeg health care system, including hospitalizations, physician visits and emergency room visits. Their impact on mortality was also examined. METHODS: Administrative data were used to track health care use and mortality over four influenza seasons (1995-96 to 1998-99). Excess health care use and deaths were calculated by subtracting rates during influenza seasons from those during weeks when influenza viruses were not circulating. RESULTS: Significant excess hospitalization, physician visit, and emergency room visit rates emerged for influenza and pneumonia, acute respiratory diseases, and chronic lung disease, especially among children and adults aged 65 and over. Considerable excess mortality due to influenza and pneumonia and chronic lung disease among individuals aged 65 and over also emerged, particularly among nursing home residents. DISCUSSION: Influenza-associated respiratory illnesses have a substantial impact on the health care system. Given the burden of illness among children during influenza seasons, the study further suggests that influenza vaccination might be considered for this age group.

Assessing population health care need using a claims-based ACG morbidity measure: a validation analysis in the Province of Manitoba.

OBJECTIVES: To assess the ability of an Adjusted Clinical Group (ACG)-based morbidity measure to assess the overall health service needs of populations. Data Sources/Study Setting. Three population-based secondary data sources: registration and health service utilization data from fiscal year 1995-1996; mortality data from vital statistics reports from 1996-1999; and Canadian census data. The study included all continuously enrolled residents in the universal health care plan in Manitoba. STUDY DESIGN: Using 60 small geographic areas as the units of analysis, we compared a population-based "ACG morbidity index," derived from individual ACG assignments in fiscal year 1995-1996, with the standardized mortality ratio (ages < 75 years) for 1996-1999. Key variables included a population-based socioeconomic status measure and age- and sex-standardized physician utilization ratios. DATA EXTRACTION METHODS: The ACGs were assigned based on the complement of diagnoses assigned to persons on physician claims and hospital separation abstracts. The ACG index was created by weighting the ACGs using average health care expenditures. PRINCIPAL FINDINGS: The ACG morbidity index had a strong positive linear relationship with the subsequent rate of premature death in the small areas of Manitoba. The ACG index was able to explain the majority of the relationships between mortality and both socioeconomic status and physician utilization. CONCLUSIONS: In Manitoba, ACGs are closely related to premature mortality, commonly accepted as the best single indicator for health service need in populations. Issues in applying ACGs in settings where needs adjustment is a primary objective are discussed.

Epinephrine dispensing patterns for an out-of-hospital population: a novel approach to studying the epidemiology of anaphylaxis.

BACKGROUND: The underlying rate of occurrence of anaphylaxis from all potential triggers in the general population is unknown. OBJECTIVE: We sought to obtain a perspective on the epidemiology of anaphylaxis in a defined general population by studying epinephrine dispensing patterns in an out-of-hospital setting. METHODS: Using an administrative claims pharmaceutical database, we analyzed dispensing data for all epinephrine formulations prescribed for out-of-hospital treatment over 5 consecutive fiscal years in a population of 1.15 million persons in the province of Manitoba, Canada. We identified the number and percentage of individuals in the general population for whom epinephrine was dispensed on one or more occasions, their age and sex, and the type of formulation dispensed. In addition to performing these analyses for the entire population of children, adults, and elderly individuals, we also performed analyses by 5-year age groupings; furthermore, for individuals younger than 5 years of age, we performed a detailed analysis by 6-month age groupings. RESULTS: During the 5-year period, 0.95% of this defined general population had injectable epinephrine dispensed for out-of-hospital treatment. There were substantial variations in epinephrine dispensing rates across subsets of the population, ranging from 1.44% for individuals younger than 17 years of age, to 0.9% for individuals 17 to 64 years of age (inclusive), to 0.32% for those age 65 years or older. In infancy, childhood, and early adolescence boys were more likely to have epinephrine dispensed than girls. Beginning at age 15 years and continuing into adulthood, girls and women were more likely to have epinephrine dispensed than boys and men. In the elderly there were no differences in dispensing patterns between the sexes. The highest epinephrine dispensing rate (5.3%) was found for boys age 12 to 17 months. CONCLUSIONS: Epinephrine dispensing data provide a novel and practical approach for studying and monitoring the epidemiology of anaphylaxis in a community. Using this approach, we provide evidence that anaphylaxis from all triggers peaks in early childhood and then gradually declines into old age.

Assessing the performance of rural hospitals.

This study developed population-based and hospital-based indicators to examine the performance of Manitoba's 68 rural hospitals. Analyses of the indicators revealed considerable differences in the populations served and their use of rural hospital services. Hospital type was also an important factor for performance. The rural hospital indicators would be useful to hospital planners and regional policy makers for comparison purposes and for highlighting issues that need to be addressed.