Evaluation of a pilot immunization curriculum to meet competency training needs of medical residents.

BACKGROUND: Vaccination is the most cost-effective medical intervention known to prevent morbidity and mortality. However, data are limited on the effectiveness of residency programs in delivering immunization knowledge and skills to trainees. The authors sought to describe the immunization competency needs of medical residents at the University of Toronto (UT), and to develop and evaluate a pilot immunization curriculum. METHODS: Residents at the University of Toronto across nine specialties were recruited to attend a pilot immunization workshop in November 2018. Participants completed a questionnaire before and after the workshop to assess immunization knowledge and compare baseline change. Feedback was also surveyed on the workshop content and process. Descriptive statistics were performed on the knowledge questionnaire and feedback survey. A paired sample T-test compared questionnaire answers before and after the workshop. Descriptive coding was used to identify themes from the feedback survey. RESULTS: Twenty residents from at least six residencies completed the pre-workshop knowledge questionnaire, seventeen attended the workshop, and thirteen completed the post-workshop questionnaire. Ninety-five percent (19/20) strongly agreed that vaccine knowledge was important to their career, and they preferred case-based teaching. The proportion of the thirty-four knowledge questions answered correctly increased from 49% before the workshop to 67% afterwards, with a mean of 2.24 (CI: 1.43, 3.04) more correct answers (P < 0.001). Sixteen residents completed the post-workshop feedback survey. Three themes emerged: first, they found the content specific and practical; second, they wanted more case-based learning and for the workshop to be longer; and third, they felt the content and presenters were of high quality. CONCLUSIONS: Findings from this study suggest current immunization training of UT residents does not meet their training competency requirements. The study's workshop improved participants' immunization knowledge. The information from this study could be used to develop residency immunization curriculum at UT and beyond.

Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents.

OBJECTIVE: To provide primary care physicians with clinical guidance for addressing parental vaccine hesitancy. SOURCES OF INFORMATION: The PubMed database was searched for English-language articles published in the 10 years before January 1, 2018. Search terms included vaccine hesitancy or confidence or acceptance, parents or children, and communication, counseling, or clinical practice. References of identified articles were assessed for additional relevant articles. A separate gray literature search was conducted using Google to find best-practice guidelines from public health and health care organizations, knowledge translation materials for health care providers, and resources that could be used in discussions with parents about vaccines. MAIN MESSAGE: Practical tips for addressing parental vaccine hesitancy in primary care include starting early, presenting vaccination as the default approach, building trust, being honest about side effects, providing reassurance on a robust vaccine safety system, focusing on protection of the child and community, telling stories, and addressing pain. Also provided are statements that providers could use in vaccination-related conversations; answers to commonly asked questions on benefits, safety, and immunologic aspects of vaccines; and links to a number of online resources for physicians and parents. CONCLUSION: Vaccine-hesitant parents who are on the fence far outnumber vaccine refusers; therefore, counseling this group might be more effective. Reasons behind vaccine hesitancy are complex and encompass more than just a knowledge deficit. As a trusted source of information on vaccines, family physicians play a key role in driving vaccine acceptance.

Répondre à l'hésitation face à la vaccination: Conseils cliniques à l'intention des médecins de première ligne qui travaillent avec les parents.

OBJECTIF: Conseiller aux médecins de première ligne une approche clinique pour parler de l'hésitation face à la vaccination avec les parents. SOURCES DE L'INFORMATION: On a recherché sur PubMed des articles publiés en anglais dans les 10 années ayant précédé le 1er janvier 2018. Les mots-clés anglais étaient vaccine hesitancy ou confidence ou acceptance, parents ou children, et communication, counseling ou clinical practice. On a épluché les références des articles relevés, à la recherche d'autres articles pertinents. Une recherche distincte de la littérature parallèle a été effectuée sur Google pour trouver les lignes directrices de pratique clinique publiées par les organisations de santé publique et de soins de santé, le matériel de transfert des connaissances à l'intention des professionnels de la santé et les ressources pouvant être utilisées durant les conversations avec les parents sur les vaccins. MESSAGE PRINCIPAL: Les conseils pratiques pour répondre à l'hésitation des parents face à la vaccination dans les soins de première ligne consistent à commencer tôt, à présenter la vaccination comme l'approche par défaut, à établir une relation de confiance, à être honnête quant aux effets secondaires, à rassurer les parents en leur disant que le système d'innocuité vaccinale est solide, à s'attarder sur la protection de l'enfant et de la collectivité, à raconter des histoires et à parler de la douleur. Nous fournissons aussi des énoncés que les professionnels de la santé peuvent utiliser durant les conversations sur les vaccins; des réponses aux questions souvent posées sur les bienfaits, l'innocuité et l'aspect immunologique des vaccins; et des liens vers un certain nombre de ressources en ligne à l'intention des médecins et des parents. CONCLUSION: Les parents qui n'ont pas pris position quant aux vaccins pour leurs enfants sont beaucoup plus nombreux que les parents qui refusent les vaccins; il serait ainsi plus efficace de conseiller ce groupe de parents. Les raisons qui incitent à la réticence chez les parents sont complexes et comprennent plus qu'un simple manque d'information. À titre de sources fiables d'information sur les vaccins, les médecins de famille jouent un rôle de premier plan pour stimuler l'acceptation des vaccins.

Сокращение несправедливости в отношении здоровья на всех этапах жизни: пожилой возраст и здоровое старение

Здоровое старение - процесс развития и поддержания функциональной способности, обеспечивающий благополучие в пожилом возрасте. Ставшие системными неравенства в получении услуг здравоохранения, несправедливые и предотвратимые различия в состоянии здоровья или в распределении ресурсов здравоохранения накапливаются с течением времени и меняют траектории здоровья на разных этапах жизни. Соответствующая оценка и постоянный мониторинг несправедливости в отношении здоровья и детерминант ложатся в основу конкретных мер, направленных на снижение несправедливости к пожилым людям. Успешные действия неуклонно улучшают или выравнивают различия в состоянии здоровья на всех этапах жизни. В данном докладе обсуждаются различные детерминанты здоровья людей старшего возраста: услуги здравоохранения, способности человека и сообщества, условия жизни, трудовая занятость и условия работы, доходы и социальная защита. В нем приведены варианты политики и конкретные примеры мер в системах здравоохранения и разных секторах по сокращению несправедливости в отношении здоровья пожилых людей и потенциальные показатели измерения прогресса.

Reducing inequities in health across the life-course: later life and healthy ageing

Healthy ageing is the process of developing and maintaining functional ability that enables well-being in older age. Health inequities, which are systematic, unfair and avoidable differences in health status or in the distribution of health resources, accumulate over time and alter health trajectories across the life-course. Appropriate measurement and ongoing monitoring of health inequities and determinants can support policy actions that aim to reduce inequities among older people. Successful actions progressively raise or flatten the health gradient across the life-course. This paper discusses multiple determinants of health among older people: health services; personal and community capabilities; living conditions; employment and working conditions; and income and social protection. It outlines policy options and concrete examples of what can be done in health systems and across multiple sectors to reduce health inequities among older people, and potential indicators for measuring progress.

Predictors of non-adherence to colorectal cancer screening among immigrants to Ontario, Canada: a population-based study.

Though colorectal cancer (CRC) screening rates have increased over time in Ontario, Canada, immigrants continue to have lower rates of screening. This study examines the association between non-adherence to CRC screening and immigration, socio-demographic, healthcare utilization, and primary care physician characteristics among immigrants to Ontario. This is a population-based retrospective cross-sectional study that uses healthcare administrative databases housed at the Institute for Clinical Evaluative Sciences. Our cohort comprised immigrants aged 60 to 74 years who lived in Ontario on March 31, 2015 and who had been eligible for the Ontario Health Insurance Plan for at least 10 years. The outcome was lack of adherence to CRC screening with any modality (fecal occult blood test, flexible sigmoidoscopy, colonoscopy) on March 31, 2015. Our cohort contained 182,949 immigrants. Overall 70,134 (38%) individuals were not adherent to screening. Risk of non-adherence to CRC screening was higher among immigrants who were from low (adjusted relative risk [ARR] 1.35, 95%CI 1.28-1.42) or low-middle (ARR 1.27, 95%CI 1.24-1.30, population-attributable risk [PAR] 9.8%) income countries and refugees (ARR 1.09, 95%CI 1.06-1.11). Compared to those from the United States, Australia, and New Zealand, immigrants from most other world regions, particularly Eastern Europe and Central Asia (ARR 1.28, 95%CI 1.21-1.37), had higher risks of non-adherence. Non-immigration factors such as low healthcare use and lack of primary care enrolment also increased the risk of non-adherence to screening. These findings can be used to inform future efforts to improve uptake of CRC screening among immigrant groups.

Hand-arm vibration syndrome: What family physicians should know.

OBJECTIVE: To provide family physicians with an understanding of the epidemiology, pathogenesis, symptoms, diagnosis, and management of hand-arm vibration syndrome (HAVS), an important and common occupational disease in Canada. SOURCES OF INFORMATION: A MEDLINE search was conducted for research and review articles on HAVS. A Google search was conducted to obtain gray literature relevant to the Canadian context. Additional references were obtained from the articles identified. MAIN MESSAGE: Hand-arm vibration syndrome is a prevalent occupational disease affecting workers in multiple industries in which vibrating tools are used. However, it is underdiagnosed in Canada. It has 3 components-vascular, in the form of secondary Raynaud phenomenon; sensorineural; and musculoskeletal. Hand-arm vibration syndrome in its more advanced stages contributes to substantial disability and poor quality of life. Its diagnosis requires careful history taking, in particular occupational history, physical examination, laboratory tests to rule out alternative diagnoses, and referral to an occupational medicine specialist for additional investigations. Management involves reduction of vibration exposure, avoidance of cold conditions, smoking cessation, and medication. CONCLUSION: To ensure timely diagnosis of HAVS and improve prognosis and quality of life, family physicians should be aware of this common occupational disease and be able to elicit the relevant occupational history, refer patients to occupational medicine clinics, and appropriately initiate compensation claims.

Maladie des vibrations: Ce que tout médecin de famille devrait savoir.

OBJECTIF: Permettre aux médecins de famille de comprendre l'épidémiologie, la pathogenèse, les symptômes, le diagnostic et la prise en charge de la maladie des vibrations, une maladie professionnelle importante et courante au Canada. SOURCES D'INFORMATION: Une recherche a été effectuée sur MEDLINE afin de relever les recherches et comptes rendus portant sur la maladie des vibrations. Une recherche a été effectuée sur Google dans le but d'obtenir la littérature grise qui convient au contexte canadien. D'autres références ont été tirées des articles relevés. MESSAGE PRINCIPAL: La maladie des vibrations est une maladie professionnelle répandue touchant les travailleurs de diverses industries qui utilisent des outils vibrants. La maladie est cependant sous-diagnostiquée au Canada. Elle compte 3 éléments : vasculaire, sous la forme d'un phénomène de Raynaud secondaire; neurosensoriel; et musculosquelettique. Aux stades les plus avancés, la maladie des vibrations entraîne une invalidité importante et une piètre qualité de vie. Son diagnostic exige une anamnèse minutieuse, en particulier des antécédents professionnels, un examen physique, des analyses de laboratoire afin d'éliminer les autres diagnostics, et la recommandation en médecine du travail aux fins d'investigations plus poussées. La prise en charge consiste à réduire l'exposition aux vibrations, éviter les températures froides, abandonner le tabac et administrer des médicaments. CONCLUSION: Pour assurer un diagnostic rapide de la maladie des vibrations et améliorer le pronostic et la qualité de vie, les médecins de famille devraient connaître cette maladie professionnelle courante, et pouvoir obtenir les détails pertinents durant l'anamnèse, recommander les patients aux cliniques de médecine du travail et débuter les demandes d'indemnisation de manière appropriée.

A Decade of Research on the Quality of Systemic Cancer Therapy in Routine Care: What Aspects of Quality Are We Measuring?

PURPOSE: To systematically review population-based studies that evaluated the quality of care related to delivery of systemic cancer therapy (ST) in routine practice, summarize the literature, and define knowledge gaps across five quality domains: access, treatment delivery, toxicity, safety, and outcome. METHODS: We searched MEDLINE using terms pertaining to ST and keywords related to health care quality for articles published in English from January 1, 2000, to December 31, 2010. Articles were included if they were original studies that examined quality of care of ST among adult patients with cancer from a population perspective. RESULTS: Our search identified 179 articles. The number of studies published each year increased over time. Most studies (58%) were conducted in the United States in either colorectal (31%) or breast cancers (27%), and focused on adjuvant intent cytotoxic chemotherapy (73%). The majority of the studies (92%) retrospectively identified patients from cancer registries (83%) and used either billing data (36%) or information in the registry itself (27%) for identification of ST. No study examined safety from a population perspective. Access was the most frequently evaluated domain (77%), whereas treatment delivery was the least examined (12%). Among studies that assessed the outcome of ST, most evaluated patient-specific outcomes such as survival (89%), although a few (11%) examined system-level outcomes such as cost. CONCLUSION: The majority of studies evaluating quality of ST have focused on access to cytotoxic chemotherapy in early stage disease. Further studies focusing on other aspects of quality and in different clinical settings are needed.

Seasonal influenza vaccine effectiveness in pre- and full-term children aged 6-23 months over multiple seasons.

INTRODUCTION: This study aimed to determine the effectiveness of seasonal influenza vaccine in pre- and full-term children aged 6-23 months. METHODS: We examined a cohort of 683,354 young children (7.7% preterm) over five influenza seasons (2004-2005 to 2008-2009) in Ontario, Canada. Vaccine effectiveness was estimated using influenza-coded ambulatory visits during virologically-confirmed influenza season periods as the outcome and multivariable Cox proportional hazards modeling. RESULTS: Full vaccination was associated with a 19% reduction in influenza-coded ambulatory visits (HR=0.81; 95% CI, 0.68-0.97) in all children, and an 18% reduction in full-term children (HR=0.82; 95% CI, 0.68-0.99). We did not find significant vaccine effectiveness for preterm children. No benefit was found for partial vaccination. CONCLUSIONS: In children younger than two years, only full influenza vaccination is associated with reduced influenza-coded ambulatory visits. Since the effectiveness of influenza vaccination in preterm children remains uncertain, further study of this highly vulnerable population is warranted.

The air quality health index and asthma morbidity: a population-based study.

BACKGROUND: Exposure to air pollution has been linked to the exacerbation of respiratory diseases. The Air Quality Health Index (AQHI), developed in Canada, is a new health risk scale for reporting air quality and advising risk reduction actions. OBJECTIVE: We used the AQHI to estimate the impact of air quality on asthma morbidity, adjusting for potential confounders. METHODS: Daily air pollutant measures were obtained from 14 regional monitoring stations in Ontario. Daily counts of asthma-attributed hospitalizations, emergency department (ED) visits, and outpatient visits were obtained from a provincial registry of 1.5 million patients with asthma. Poisson regression was used to estimate health services rate ratios (RRs) as a measure of association between the AQHI or individual pollutants and health services use. We adjusted for age, sex, season, year, and region of residence. RESULTS: The AQHI values were significantly associated with increased use of asthma health services on the same day and on the 2 following days, depending on the specific outcome assessed. A 1-unit increase in the AQHI was associated with a 5.6% increase in asthma outpatient visits (RR = 1.056; 95% CI: 1.053, 1.058) and a 2.1% increase in the rate of hospitalization (RR = 1.021; 95% CI: 1.014, 1.028) on the same day and with a 1.3% increase in the rate of ED visits (RR = 1.013; 95% CI: 1.010, 1.017) after a 2-day lag. CONCLUSIONS: The AQHI values were significantly associated with the use of asthma-related health services. Timely AQHI health risk advisories with integrated risk reduction messages may reduce morbidity associated with air pollution in patients with asthma.