Helpful and unhelpful responses after suicide: Experiences of bereaved family members.

Individuals who are bereaved by suicide and other traumatic natured deaths are thought to be at greater risk of psychological complications, than people bereaved by other means. While it is recognized that interventions can influence the bereavement process, there remains limited communications about both helpful responses and those that may adversely influence the grieving process for the suicide bereaved. This paper presents findings from a narrative study, which sought the experiences of family members after the loss of a loved one as a result of suicide. The study findings demonstrated that responses by agencies are often insensitive and not aligned with the needs of those bereaved. We argue that training is paramount for all services to increase awareness of the needs of people bereaved by suicide and available support services. Changes to organizational policies in relation to finance support would greatly support the bereaved during their time of grief and heightened distress.

The Relationship Between Reticular Macular Disease and Choroidal Thickness.

PURPOSE: Subretinal drusenoid deposits (SDD) are the main structural lesion of reticular macular disease (RMD), a phenotype of age-related macular degeneration (AMD). We aim to demonstrate spatiotemporal relationships between SDD and choroidal thickness (CTh) alterations in RMD+ and RMD- eyes. METHODS: Thirty-three eyes (26 subjects) with early AMD/no SDD (RMD-) and 18 eyes (16 subjects) with early AMD/SDD (RMD+) underwent enhanced depth imaging spectral domain optical coherence tomography (SD-OCT) for CTh measurements at 11 points per scan, in 5 horizontal B scans, creating a grid of 55 points/eye. The 55 points were treated as a cluster, controlling within-subject correlation. Marginal generalized estimating equation modeling was used to estimate the association between CTh and RMD status. All eyes were divided by their median age (≤82 and >82 years) for stratified analyses. RESULTS: CTh was not significantly reduced in RMD+ eyes compared with RMD- eyes (mean difference [MD] -16.84 µm, P = 0.24). Among younger subjects, mean CTh was significantly reduced in RMD+ versus RMD- eyes (MD -53.72 µm, P = 0.01). Conversely, among older subjects, there was no significant difference in CTh between RMD+ and RMD-. CONCLUSIONS: In RMD, the association of SDD and CTh alterations varies with age but not by macular region. Among younger subjects (<82 years old), CTh was significantly thinner in RMD+ versus RMD- eyes.

'People look down on you when you tell them how he died': Qualitative insights into stigma as experienced by suicide survivors.

This paper aims to present findings that convey how people felt stigmatized after the loss of a loved one to suicide. A qualitative design was used for the purpose of this study. Data were collected using in-depth, face-to-face interviews. Audio-recordings of the interviews were transcribed and thematically analyzed. Ten people bereaved by suicide participated in the study. Four themes emerged from the data namely: Feeling blamed, shamed and judged; Feeling isolated/rejected by friends and community; Feeling silenced and Feeling the burden of others' discomfort. Findings show that stigmatization of the bereaved by suicide had detrimental effects on their relationships and their help seeking behaviours. Further, due to stigma imposed on them by others, participants were denied the opportunity to tell their stories which further complicated their grieving process. Further education and training is required for health professionals to enhance understanding of the specific needs of those bereaved by suicide.

Risk Factors for Developing Staphylococcus aureus Nasal Colonization in Spine and Arthroplasty Surgery.

Staphylococcus aureus nasal colonization is a risk factor for surgical site infection. We conducted a retrospective case-control study of 1,708 consecutively enrolled patients to identify criteria that places orthopaedic surgery patients undergoing spine and total joint arthroplasty surgery at risk for nasal colonization by MRSA and MSSA. Multivariate analysis showed obesity and asthma as significant risk factors for MRSA colonization. The identification of these two risk factors for MRSA colonization may help decolonization programs target patients with these factors for treatment prior to surgery, which could potentially lead to reductions in the rates of surgical site infections.

The Lifekeeper Memory Quilt: evaluation of a suicide postvention program.

The Lifekeeper Memory Quilt Project, implemented by the Salvation Army (Suicide Prevention-Bereavement Support Services) in Australia in 2008, aimed to provide support for those bereaved by suicide and to create greater public awareness of suicide. To evaluate participants' satisfaction with this project, 82 bereaved individuals completed surveys and 30 completed an interview. Results indicated that the Quilt was helpful in assisting participants in their bereavement. The Quilt project gave participants an opportunity to reflect on the life of their loved one and provided a space for them to grieve without fear of negative social reactions.

Aetiology of schizophrenia and implications for nursing practice: a literature review.

Schizophrenia is recognised as a major mental illness and is prevalent in approximately 1% of the global population. This paper reviewed literature published between 2001 and 2013 to explore the aetiology of schizophrenia and discuss implications for mental health nursing practice. Although the causes of schizophrenia are largely unknown, there is a strong correlation between identified physiological and environmental markers and the development of the disease. With this knowledge, mental health nurses can potentially contribute to the development of strategies and approaches to complement current treatments, and therefore ensure improved outcomes for mental health clients.

Physical health inequities in people with severe mental illness: identifying initiatives for practice change.

People with severe mental illness have a higher prevalence of co-morbid physical diseases and a significantly reduced life expectancy when compared with people in the general population. This article explores the literature published between 2002 and 2012 in order to identify causes of poor physical health in those with severe mental illness and discusses interventions that may be implemented to enhance health outcomes for this group. The causes of poor physical health in those with severe mental illness are difficult to address. However, existing literature does identify some interventions that can potentially provide the basis for practice change.

Racial and ethnic disparities in the use of antipsychotic medication: a systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of published evidence on ethnic or racial disparities in the outpatient use versus non-use of antipsychotics and in the outpatient use of newer versus older antipsychotics. METHOD: Electronic databases were searched for potentially relevant studies. Two independent reviewers conducted the review in three stages: title review, abstract review and full-text review. Included studies were those that: (a) report measures of disparity in the outpatient use of antipsychotic drugs in clearly defined racial or ethnic groups (b) have a primary focus on ethnic or racial disparities, and (c) have adjusted for factors known to influence medicine use. Odds ratios were pooled following the inverse-variance method of weighting effect sizes. I (2) statistics were calculated to quantify the amount of variation that is likely due to heterogeneity between studies. Funnel plots were produced and Egger's statistic was calculated to assess potential publication bias. RESULTS: No significant differences were found in the odds of using any antipsychotics among African Americans (OR = 1.01, CI = 0.99-1.02) compared with non-African Americans and among Latinos (OR = 0.98, CI = 0.86-1.13) compared with non-Latinos. Small to moderate but statistically non-significant disparities were also noted in other ethnic groups: Asians (OR = 1.10, CI = 0.88-1.36), Maoris (OR = 0.78, CI = 0.53-1.13) and Pacific Islanders (OR = 0.97, CI = 0.84-1.11). Among those who received antipsychotic medication, African Americans (OR = 0.62, CI = 0.50-0.78) and Latinos (OR = 0.77, CI = 0.73-0.81) appeared to have lower odds of receiving newer antipsychotics compared with non-African Americans and non-Latinos. CONCLUSION: No significant ethnic disparities in the use versus non-use of any antipsychotics were observed, but, among those who received antipsychotic treatment, ethnic minorities were consistently less likely than non-ethnic minorities to be treated with newer antipsychotics.

Information behaviour of Canadian pharmaceutical policy makers.

OBJECTIVES: Understanding the information behaviour of policy makers targeted by knowledge translation efforts is key to improving policy research impact. This study explores the reported information behaviour of pharmaceutical policy decision-makers in Canada, a country highly associated with evidence-based practice yet still facing substantial barriers to evidence-informed health policy. METHODS: We conducted semi-structured telephone interviews with a purposive sample of 15 Canadian pharmaceutical policy decision-makers. Results of the descriptive, qualitative analysis were compared with the General Model of Information Seeking of Professionals (GMISP) proposed by Leckie, Pettigrew and Sylvain in 1996. RESULTS: Characteristics of information needs included topic, depth/breadth of questions and time sensitivity. Approaches to information seeking were variously scattershot, systematic and delegated, depending on the characteristics as well as respondent resources. Major source types were human experts, electronic sources and trusted organisations. Affective (emotion-related) outcomes were common, including frustration and desire for better information systems and sources. CONCLUSIONS: The GMISP model may be adapted to model information behaviour of Canadian pharmaceutical policy makers. In the absence of a dedicated, independent source for rapid-response policy research, these policy makers will likely continue to satisfice (make do) with available resources, and barriers to evidence-informed policy will persist.

Ethnic disparities in antipsychotic drug use in British Columbia: a cross-sectional retrospective study.

OBJECTIVE: This study examined ethnic disparities in antipsychotic therapy in a population with significant Asian representation. METHODS: Using a cross-sectional retrospective study design, self-reported ethnicity data pooled from three cycles of the Canadian Community Health Survey were linked to 2005 administrative data on physician, hospital, and pharmaceutical use in British Columbia, Canada. Logistic regression was used to model the association between ethnicity and the likelihood of filling one or more prescriptions for any antipsychotic, with controls for sex, age, residence, immigrant status, income, health status, and diagnoses of schizophrenia, bipolar disorder, depression, and dementia. RESULTS: Of the 27,658 individuals in the sample, 2.2% filled at least one antipsychotic prescription. The proportion varied across ethnic groups: Chinese, 1.0%; other Asians, 1.2%; whites, 2.3%; nonwhite non-Asians, 2.8%; and mixed ethnicity, 4.3%. After adjustment for patient characteristics and diagnoses of schizophrenia and bipolar disorder, the likelihood of filling a prescription was found to be lower among Chinese (odds ratio [OR] = .47, 95% confidence interval [CI] = .24-.90) and higher among persons of mixed ethnicity (OR = 3.19, CI = 1.49-6.83). Further adjustment for depression and dementia diagnoses did not significantly change the ORs for the Chinese (OR = .49, CI = .25-.98) and the mixed ethnic groups (OR = 2.97, CI = 1.30-6.80). CONCLUSIONS: Consistent with the existing literature on ethnic disparities in antipsychotic therapy, the study found evidence of persistent disparities in a population that has a significant number of Asians. Further studies should be done to identify possible causes of these disparities and to identify potential interventions that may reduce or eliminate them.

Ethnic differences in the use of prescription drugs: a cross-sectional analysis of linked survey and administrative data.

BACKGROUND: Evidence from the United States and Europe suggests that the use of prescription drugs may vary by ethnicity. In Canada, ethnic disparities in prescription drug use have not been as well documented as disparities in the use of medical and hospital care. We conducted a cross-sectional analysis of survey and administrative data to examine needs-adjusted rates of prescription drug use by people of different ethnic groups. METHODS: For 19 370 non-Aboriginal people living in urban areas of British Columbia, we linked data on self-identified ethnicity from the Canadian Community Health Survey with administrative data describing all filled prescriptions and use of medical services in 2005. We used sex-stratified multivariable logistic regression analysis to measure differences in the likelihood of filling prescriptions by drug class (antihypertensives, oral antibiotics, antidepressants, statins, respiratory drugs and nonsteroidal anti-inflammatory drugs [NSAIDs]). Models were adjusted for age, general health status, treatment-specific health status, socio-economic factors and recent immigration (within 10 years). RESULTS: We found evidence of significant needs-adjusted variation in prescription drug use by ethnicity. Compared with women and men who identified themselves as white, those who were South Asian or of mixed ethnicity were almost as likely to fill prescriptions for most types of medicines studied; moreover, South Asian men were more likely than white men to fill prescriptions for antibiotics and NSAIDs. The clearest pattern of use emerged among Chinese participants: Chinese women were significantly less likely to fill prescriptions for antihypertensives, antibiotics, antidepressants and respiratory drugs, and Chinese men for antidepressant drugs and statins. INTERPRETATION: We found some disparities in prescription drug use in the study population according to ethnic group. The nature of some of these variations suggest that ethnic differences in beliefs about pharmaceuticals may generate differences in prescription drug use; other variations suggest that there may be clinically important disparities in treatment use.

Income inequities in end-of-life health care spending in British Columbia, Canada: A cross-sectional analysis, 2004-2006.

BACKGROUND: This study aimed to measure the income-related inequalities and inequities - the inequalities that remain after accounting for differences in health need - in expenditure on fully publicly covered (hospital and ambulatory) and partially publicly covered (prescription drugs) services for those in their last year of life in the province of British Columbia (B.C.), Canada. We focused on a decedent population for three reasons: to minimize unmeasured need differences among our cohort and therefore isolate income effects; to explore inequities for a high-spending window of health care use; and, because previous studies have found conflicting relationships between income and decedent health care spending, to further quantify this relationship. METHODS: We used linked administrative databases to describe spending on health services by income for all 58,820 deaths of B.C. residents 65 and older from 2004 to 2006. Regression analyses examined the association between income and health care spending, adjusting for age, sex, health status, cause of death, and other relevant factors. We then used concentration indexes to measure both inequalities and inequities separately for three key types of services. Analyses were also run separately for men and women. RESULTS: On average, per capita expenditure on acute health care in the last year of life was $20,705 (CDN2006). In need-adjusted regression analyses, we found decedents in the highest income quintile had 11% lower hospital expenditures, 15% higher specialist expenditures and 23% higher prescription drug expenditures than decedents in the lowest income quintile. Concentration index analysis suggested that spending for all types of care was concentrated among those with higher income before adjusting for need. Need-adjusted equity results mirrored regression findings and suggested patterns of inequities that were more pronounced among male decedents than females. CONCLUSIONS: Despite the universal health care system in B.C., we found patterns of inequity in spending by income in the last year of life, even for fully publicly covered services. These results, parallel to relationships between income and spending from previous studies of the B.C. population, suggest persistent income-related inequities in the health care Canadians receive throughout their lives.

The cost of drug development: a systematic review.

OBJECTIVES: We aimed to systematically review and assess published estimates of the cost of developing new drugs. METHODS: We sought English language research articles containing original estimates of the cost of drug development that were published from 1980 to 2009, inclusive. We searched seven databases and used citation tracing and expert referral to identify studies. We abstracted qualifying studies for information about methods, data sources, study samples, and key results. RESULTS: Thirteen articles were found to meet our inclusion criteria. Estimates of the cost of drug development ranged more than 9-fold, from USD$92 million cash (USD$161 million capitalized) to USD$883.6 million cash (USD$1.8 billion capitalized). Differences in methods, data sources, and time periods explain some of the variation in estimates. Lack of transparency limits many studies. Confidential information provided by unnamed companies about unspecified products forms all or part of the data underlying 10 of the 13 studies. CONCLUSIONS: Despite three decades of research in this area, no published estimate of the cost of developing a drug can be considered a gold standard. Studies on this topic should be subjected to reasonable audit and disclosure of - at the very least - the drugs which authors purport to provide development cost estimates for.

Population aging and the determinants of healthcare expenditures: the case of hospital, medical and pharmaceutical care in british columbia, 1996 to 2006.

THERE IS A GAP BETWEEN RHETORIC AND REALITY CONCERNING HEALTHCARE EXPENDITURES AND POPULATION AGING: although decades-old research suggests otherwise, there is widespread belief that the sustainability of the healthcare system is under serious threat owing to population aging. To shed new empirical light on this old debate, we used population-based administrative data to quantify recent trends and determinants of expenditure on hospital, medical and pharmaceutical care in British Columbia. We modelled changes in inflation-adjusted expenditure per capita between 1996 and 2006 as a function of two demographic factors (population aging and changes in age-specific mortality rates) and three non-demographic factors (age-specific rates of use of care, quantities of care per user and inflation-adjusted costs per unit of care). We found that population aging contributed less than 1% per year to spending on medical, hospital and pharmaceutical care. Moreover, changes in age-specific mortality rates actually reduced hospital expenditure by -0.3% per year. Based on forecasts through 2036, we found that the future effects of population aging on healthcare spending will continue to be small. We therefore conclude that population aging has exerted, and will continue to exert, only modest pressures on medical, hospital and pharmaceutical costs in Canada. As indicated by the specific non-demographic cost drivers computed in our study, the critical determinants of expenditure on healthcare stem from non-demographic factors over which practitioners, policy makers and patients have discretion.

Patterns in the use of benzodiazepines in British Columbia: examining the impact of increasing research and guideline cautions against long-term use.

OBJECTIVE: We examined changes in patterns of benzodiazepine use in British Columbia over a period of increasing evidence of harms associated with long-term use. METHODS: Using linked administrative databases for the years 1996 and 2006, we performed logistic regression to examine how socio-economic and health factors affect the likelihood of benzodiazepine use and long-term use, and to test for changes in rates of use and long-term use over time. RESULTS: In 2006, 8.4% of British Columbians used benzodiazepines, 3.5% long-term. Use was positively related with being female, lower income, older, and of poorer health status. Long-term use was positively associated with being in the lowest income quintile, of poorest health, and over the age of 65. While the rate of long-term use decreased from 1996 to 2006 for those over age 70, it increased in middle-aged populations. CONCLUSIONS: Our results suggest, despite increased awareness of and cautions regarding risks associated with long-term use of benzodiazepines, rates of potentially inappropriate use have changed very little over a decade. Given that early use of benzodiazepines is positively associated with later long-term use, policies targeting populations younger than conventionally studied (i.e. those under age 65) may be needed to decrease rates of long-term use.

Individual and contextual determinants of regional variation in prescription drug use: an analysis of administrative data from British Columbia.

BACKGROUND: Increasing attention is being paid to variations in the use of prescription drugs because their role in health care has grown to the point where their use can be considered a proxy for health system performance. Studies have shown that prescription drug use varies across regions in the US, UK, and Canada by more than would be predicted based on age and health status alone. In this paper, we explore the determinants of variations in the use of prescription drugs, drawing on health services theories of access to care. METHODS: We conducted a cross-sectional analysis using population-based administrative health care data for British Columbia (BC), Canada. We used logistic and hierarchical regressions to analyze the effects of individual- and area-level determinants of use of prescriptions overall and rates of purchase of prescriptions from five therapeutic categories representing a range of indications: antihypertensives, statins, acid reducing drugs, opioid drugs, and antidepressants. To indicate the relative scale of regional variations and the importance of individual- and area-level variables in explaining them, we computed standardized rates of utilization for 49 local health areas in BC. RESULTS: We found that characteristics of individuals and the areas in which they live affect likelihood of prescription drug purchase. Individual-level factors influenced prescription drug purchases in ways generally consistent with behavioral models of health services use. Contextual variables exerted influences that differed by type of drug studied. Population health, education levels, and ethnic composition of local areas were associated with significant differences in the likelihood of purchasing medications. Relatively modest regional variations remained after both individual-level and area-level determinants were taken into account. CONCLUSIONS: The results of this study suggest that individual- and area-level factors should be considered when studying variations in the use of prescription drugs. Some sources of such variations, including individual- and area-level socioeconomic status, warrant further investigation and possible intervention to address inequities.

Listening for prescriptions: a national consultation on pharmaceutical policy issues.

OBJECTIVES AND METHODS: Pharmaceutical policy is an increasingly costly, essential and challenging component of health system management. We sought to identify priority pharmaceutical policy issues in Canada and to translate them into research priorities using key informant interviews, stakeholder surveys and a deliberative workshop. RESULTS: WE FOUND CONSENSUS ON OVERARCHING POLICY GOALS: to provide all Canadians with equitable and sustainable access to necessary medicines. We also found widespread frustration that many key pharmaceutical policy issues in Canada - including improving prescription drug financing and pricing - have been persistent challenges owing to a lack of policy coordination. The coverage of extraordinarily costly medicines for serious conditions was identified as a rapidly emerging policy issue. CONCLUSION: Targeted research and knowledge translation activities can help address key policy issues and, importantly, challenges of policy coordination in Canada and thereby reduce inequity and inefficiency in policy approaches and outcomes.

The effect of evidence-based drug coverage policies on pharmaceutical r&d: a case study from british columbia.

BACKGROUND: To manage public expenditures in the mid-1990s, British Columbia implemented evidence-based drug coverage policies, including "reference pricing." Industry lobbied against the province's policy, arguing that reference pricing harms patients and that it is inconsistent with federal and provincial legislation. Researchers and the courts have studied and rejected industry's claims. However, industry also threatened to halt R&D investment in British Columbia and continues to so threaten other provinces contemplating evidence-based drug coverage policies. The purpose of this study is to review evidence regarding these threats. METHODS: Provincial-level R&D data for 1988-2006 were used to analyze the impact of BC PharmaCare's policies on pharmaceutical R&D in British Columbia. We used statistical analyses to determine whether the province's policies affected BC-based R&D as expressed in two ways: (1) as inflation-adjusted expenditure per capita in British Columbia and (2) as the ratio of expenditure per capita in the province to expenditure per capita in the rest of Canada. RESULTS: Evidence-based drug coverage policies had no statistically significant negative effects on BC-based pharmaceutical R&D. BC R&D was slightly above expected trends in 1997 and slightly below expected trends in 1998 and 1999 (though not statistically significantly in either case). From 2001 to 2003, BC R&D was (statistically significantly) above expected trends. CONCLUSIONS: While they are part of the politics of the pharmaceutical sector, claims and threats regarding connections between coverage policy and location of R&D investment are not borne out in British Columbia's experience. This is likely because, as suggested by business and economic literature, firms locate R&D based on the expected cost-to-firm and productivity of the R&D investment itself. Prudent policy would therefore manage pharmaceutical expenditures using evidence-based policies and pursue scientific and economic development goals through direct and strategic government investment in local scientific capacity.