Quels liens entre les caractéristiques des médecins et leur cadre de pratique dans le contexte canadien : une étude de la portée

Background: Physician characteristics such as education and sociodemographic attributes are associated with particular practice patterns, such as practice in rural settings. Understanding the Canadian context of such associations can inform medical school recruitment and health workforce decision-making. Objective: The objective of this scoping review was to report the nature and extent of the literature on associations between characteristics of physicians in Canada and physicians’ practice patterns. Eligibility criteria: We included studies reporting associations between 1) the education or sociodemographic attributes of practicing physicians or residents in Canada and 2) practice patterns, including career choice, practice setting, and populations served. Methods: We searched five electronic databases (MEDLINE (R) ALL, Embase, ERIC, Education Source and Scopus) for quantitative primary studies and reviewed reference lists of included studies for additional studies. Data were extracted using a standardized data charting form. Results: Our search yielded 80 studies. Sixty-two examined education, evenly divided between undergraduate and postgraduate. Fifty-eight examined physicians’ attributes, most focusing on sex/gender. The majority of studies focused on the outcome of practice setting. We found no studies examining race/ethnicity or socioeconomic status. Conclusion: Many studies in our review found positive associations between (i) rural training or rural background and rural practice setting and (ii) location of training or physicians’ origin and practice in that location, consistent with previous literature. Associations for sex/gender were mixed, suggesting it may be a less useful target for workforce planning or recruitment aiming to address gaps in health care provision. More research is needed on the association of characteristics, particularly race/ethnicity and socioeconomic status, with career choice and populations served.Contexte : Il existe un lien entre les caractéristiques des médecins, comme leur formation et leur profil sociodémographique, et des cadres de pratique particuliers, comme la pratique en milieu rural. La compréhension de ces liens dans le contexte canadien peut éclairer les stratégies d’admission dans les facultés de médecine et la planification de la main-d’œuvre dans le secteur de la santé. Objectif : L’objectif de cette étude de la portée était de faire état de la nature et de l’étendue de la littérature sur les liens entre les caractéristiques des médecins au Canada et leurs cadres de pratique. Critères de sélection : Nous avons inclus les études établissant des liens entre 1) la formation ou le profil sociodémographique des médecins ou des résidents en exercice au Canada et 2) les cadres de pratique, y compris le choix de carrière, le milieu de pratique et les populations desservies. Méthodes : Nous avons effectué des recherches dans cinq bases de données électroniques (MEDLINE (R) ALL, Embase, ERIC, Education Source et Scopus) pour trouver des études quantitatives primaires et avons examiné les listes de références bibliographiques des articles inclus pour repérer d’autres études. Les données ont été extraites à l’aide d’un formulaire normalisé. Résultats : Notre recherche a permis de recenser 80 études. Soixante-deux d’entre elles portaient sur l’éducation, réparties de manière égale entre le premier cycle et le cycle de spécialisation. Cinquante-huit examinaient les caractéristiques des médecins, la plupart portant sur le sexe/genre. La majorité des études étaient focalisées sur le résultat lié au milieu de pratique. Nous n’avons trouvé aucune étude portant sur la race/ethnicité ou le statut socio-économique. Conclusion : Conformément à la littérature antérieure, de nombreuses études de notre revue trouvent des associations positives entre (i) la formation en milieu rural ou l’origine rurale et le cadre de pratique rurale et entre (ii) le lieu de formation ou l’origine des médecins et la pratique dans ce lieu. Les associations relatives au sexe/genre étaient mitigées, ce qui suggère qu’il s’agit peut-être d’une cible moins utile pour la planification ou le recrutement de la main-d’œuvre visant à combler les lacunes dans la prestation des soins de santé. Des recherches supplémentaires sont nécessaires sur les liens entre le profil des médecins, en particulier la race/ethnie, et le statut socio-économique, et leur choix de carrière et les populations desservies

Interhospital variation in the RATPAC trial (Randomised Assessment of Treatment using Panel Assay of Cardiac markers)

Background: The RATPAC trial showed that using a point-of-care panel of CK-MB(mass), myoglobin and troponin at baseline and 90 min increased the proportion of patients successfully discharged home, leading to reduced median length of initial hospital stay. However, it did not change mean hospital stay and may have increased mean costs per patient. The aim of this study was to explore variation in outcome and costs between participating hospitals. Methods: RATPAC was a pragmatic multicentre randomised controlled trial (N=2243) and economic analysis comparing diagnostic assessment using the panel to standard care for patients with acute chest pain due to suspected myocardial infarction at six hospitals. The difference in the proportion of patients successfully discharged (primary outcome) and mean costs per patient between the participating hospitals was compared. Results: Point-of-care assessment led to a higher proportion of successful discharges in four hospitals, a lower proportion in one and was equivocal in another. The OR (95% CI) for the primary outcome varied from 0.12 (0.01 to 1.03) to 11.07 (6.23 to 19.66) with significant heterogeneity between the centres (

Characteristics of Canadian physicians and their associations with practice patterns: a scoping review

Background: Physician characteristics such as education and sociodemographic attributes are associated with particular practice patterns, such as practice in rural settings. Understanding the Canadian context of such associations can inform medical school recruitment and health workforce decision-making. Objective: The objective of this scoping review was to report the nature and extent of the literature on associations between characteristics of physicians in Canada and physicians’ practice patterns. Eligibility criteria: We included studies reporting associations between 1) the education or sociodemographic attributes of practicing physicians or residents in Canada and 2) practice patterns, including career choice, practice setting, and populations served. Methods: We searched five electronic databases (MEDLINE (R) ALL, Embase, ERIC, Education Source and Scopus) for quantitative primary studies and reviewed reference lists of included studies for additional studies. Data were extracted using a standardized data charting form. Results: Our search yielded 80 studies. Sixty-two examined education, evenly divided between undergraduate and postgraduate. Fifty-eight examined physicians’ attributes, most focusing on sex/gender. The majority of studies focused on the outcome of practice setting. We found no studies examining race/ethnicity or socioeconomic status. Conclusion: Many studies in our review found positive associations between (i) rural training or rural background and rural practice setting and (ii) location of training or physicians’ origin and practice in that location, consistent with previous literature. Associations for sex/gender were mixed, suggesting it may be a less useful target for workforce planning or recruitment aiming to address gaps in health care provision. More research is needed on the association of characteristics, particularly race/ethnicity and socioeconomic status, with career choice and populations served

"It's Like the Pieces of a Puzzle That You Know": Research Interviews With People Who Inject Drugs Using the VidaviewTM Life Story Board

Bei dem Life Story Board (LSB) handelt es sich um ein visuelles Tool, das in therapeutischen Kontexten zum Einsatz kommt, um die Lebenswelt zu ko-konsturieren, die die persönlichen, relationalen und zeitlichen Aspekte individueller gelebter Erfahrung umfasst. In unserer Studie zu Drogennutzung und Schadensreduzierung interviewten wir Menschen, die Drogen injizieren unter Einsatz des LSB, um herauszufinden, ob sich hieraus Potenziale für eine verbesserte qualitative Forschung ergeben könnten. In unserem Forschungsteam arbeiteten neben Akademiker*innen auch frühere oder aktuelle Drogenkonsument*innen mit. Interviews wurden von jeweils zwei Personen geführt: eine agierte als Interviewer*in, die andere war für das LSB zuständig.Entlang der Ergebnisse war nachvollziehbar, dass Interviewende und Interviewte in unterschiedlicher Weise mit dem LSB interagierten: Während die Interviewer*innen es nutzten, um sich im Leitfaden zu orientieren, half es den Befragten, die eigene Lebensgeschichte mittels einer Vielzahl an emotionalen und kognitiven Äußerungen zu validieren oder zu unterstreichen. Das LSB erlaubte, sich an spezifische Situationen oder Vorfälle zu erinnern, Perspektiven hinzuzugewinnen und der eigenen Geschichte zusätzlichen Sinn zu verleihen. Insoweit arbeiteten Interviewte und Interviewende unter jeweils unterschiedlichen Vorzeichen mittels des LSB gemeinsam an einer (Re-)Präsentation der jeweiligen Lebensgeschichte.The Life Story Board (LSB) is a visual tool used in therapeutic circumstances to co-construct a lifescape that represents the personal, relational and temporal aspects of a person's lived experiences. We conducted a study of the drug use and harm reduction experiences of people who inject drugs through research interviews using the LSB to determine whether it has the potential to enhance qualitative research. Our team included community researchers who were current or former drug users and academic researchers. Interviews were conducted by two community researchers: an interviewer and a storyboarder who populated the LSB.Results showed that interviewers and participants interacted with the LSB in different ways. The board functioned to situate the interviewers in the interview schedule, whereas participants often used the board as a way to validate or reinforce their life story. Participants expressed a variety of emotional and cognitive responses to the board. Overall, the LSB helped participants focus on their life story to recall specific occasions or incidents and enabled them to gain perspective and make greater sense of their lives. Both participants and interviewers engaged with the LSB in nuanced ways that enabled them to work together to represent the participant's life story

Engaging the public in healthcare decision making: Results from a citizens’ jury on emergency care services

Background: Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed. Objective: This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care. Methods: A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury. Results: The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient. Conclusions: These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding

A search for diffuse bands in the circumstellar envelopes of post-AGB stars

In this work we present the results of a systematic search for diffuse bands (DBs, hereafter) in the circumstellar envelopes of a carefully selected sample of post-AGB stars. We concentrated on the analysis of 9 of the DBs most commonly found in the interstellar medium. The strength of these features is determined using high resolution optical spectroscopy and the results obtained are compared with literature data on field stars affected only by interstellar reddening. Based on the weak features observed in the subsample of post-AGB stars dominated by circumstellar reddening we conclude that the carrier(s) of these DBs must not be present in the circumstellar environment of these sources, or at least not under the excitation conditions in which DBs are formed. The conclusion is applicable to all the post-AGB stars studied, irrespective of the dominant chemistry or the spectral type of the star considered. A detailed radial velocity analysis of the features observed in individual sources confirms this result, as the Doppler shifts measured are found to be consistent with an interstellar origin.Comment: Accepted for A&

Lignin biomarkers as tracers of mercury sources in lakes water column

This study presents the role of specific terrigenous organic compounds as important vectors of mercury (Hg) transported from watersheds to lakes of the Canadian boreal forest. In order to differentiate the autochthonous from the allochthonous organic matter (OM), lignin derived biomarker signatures [Lambda, S/V, C/V, P/(V ? S), 3,5-Bd/V and (Ad/Al)v] were used. Since lignin is exclusively produced by terrigenous plants, this approach can give a non equivocal picture of the watershed inputs to the lakes. Moreover, it allows a characterization of the source of OM and its state of degradation. The water column of six lakes from the Canadian Shield was sampled monthly between June and September 2005. Lake total dissolved Hg concentrations and Lambda were positively correlated, meaning that Hg and ligneous inputs are linked (dissolved OM r2 = 0.62, p\0.0001; particulate OM r2 = 0.76, p\0.0001). Ratios of P/(V ? S) and 3,5-Bd/V from both dissolved OM and particulate OM of the water column suggest an inverse relationship between the progressive state of pedogenesis and maturation of the OM in soil before entering the lake, and the Hg concentrations in the water column. No relation was found between Hg levels in the lakes and the watershed flora composition—angiosperm versus gymnosperm or woody versus non-woody compounds. This study has significant implications for watershed management of ecosystems since limiting fresh terrestrial OM inputs should reduce Hg inputs to the aquatic systems. This is particularly the case for largescale land-use impacts, such as deforestation, agriculture and urbanization, associated to large quantities of soil OM being transferred to aquatic systems

Multitrait genetic association analysis identifies 50 new risk loci for gastro-oesophageal reflux, seven new loci for Barrett’s oesophagus and provides insights into clinical heterogeneity in reflux diagnosis

Objective: Gastro-oesophageal reflux disease (GERD) has heterogeneous aetiology primarily attributable to its symptom-based definitions. GERD genome-wide association studies (GWASs) have shown strong genetic overlaps with established risk factors such as obesity and depression. We hypothesised that the shared genetic architecture between GERD and these risk factors can be leveraged to (1) identify new GERD and Barrett's oesophagus (BE) risk loci and (2) explore potentially heterogeneous pathways leading to GERD and oesophageal complications. Design: We applied multitrait GWAS models combining GERD (78 707 cases; 288 734 controls) and genetically correlated traits including education attainment, depression and body mass index. We also used multitrait analysis to identify BE risk loci. Top hits were replicated in 23andMe (462 753 GERD cases, 24 099 BE cases, 1 484 025 controls). We additionally dissected the GERD loci into obesity-driven and depression-driven subgroups. These subgroups were investigated to determine how they relate to tissue-specific gene expression and to risk of serious oesophageal disease (BE and/or oesophageal adenocarcinoma, EA). Results: We identified 88 loci associated with GERD, with 59 replicating in 23andMe after multiple testing corrections. Our BE analysis identified seven novel loci. Additionally we showed that only the obesity-driven GERD loci (but not the depression-driven loci) were associated with genes enriched in oesophageal tissues and successfully predicted BE/EA. Conclusion: Our multitrait model identified many novel risk loci for GERD and BE. We present strong evidence for a genetic underpinning of disease heterogeneity in GERD and show that GERD loci associated with depressive symptoms are not strong predictors of BE/EA relative to obesity-driven GERD loci

Assessment of Health Care Cost for Complex Surgical Patients: Review of Cost, Re-Imbursement and Revenue Involved in Pancreatic Surgery at a High-Volume Academic Medical Centre

AbstractBackgroundPancreatic surgery is complex with the potential for costly hospitalization.MethodsA retrospective review of patients undergoing a pancreatic resection was performed.ResultsThe median age of the study population was 64 years. Half of the cohort was female (51%), and the majority were white (62%). Most patients underwent a pancreaticoduodenectomy (PD) (69%). The pre-operative age-adjusted Charlson comorbidity index was zero for 36% (n = 50), 1 for 31% (n = 43) and ≥2 for 33% (n = 45). The Clavien–Dindo grading system for post-operative complication was grade I in 17% (n = 24), whereas 45% (n = 62) were higher grades. The medians direct fixed, direct variable, fixed indirect and total costs were $2476,$15 397, $13 207 and$31 631, respectively. There was a positive contribution margin of $7108, whereas the net margin was a loss of$6790. On univariate analyses, age, type of operation and complication grade were associated with total cost (P ≤ 0.05), whereas operation type and complication grade were associated with a net margin (P = 0.01). These findings remained significant on multivariate analysis (P < 0.05).ConclusionsIncreased cost, reimbursement and revenue were associated with type of operation and post-operative complications

An embedded longitudinal multi-faceted qualitative evaluation of a complex cluster randomized controlled trial aiming to reduce clinically important errors in medicines management in general practice

<p>Abstract</p> <p>Background</p> <p>There is a need to shed light on the pathways through which complex interventions mediate their effects in order to enable critical reflection on their transferability. We sought to explore and understand key stakeholder accounts of the acceptability, likely impact and strategies for optimizing and rolling-out a successful pharmacist-led information technology-enabled (PINCER) intervention, which substantially reduced the risk of clinically important errors in medicines management in primary care.</p> <p>Methods</p> <p>Data were collected at two geographical locations in central England through a combination of one-to-one longitudinal semi-structured telephone interviews (one at the beginning of the trial and another when the trial was well underway), relevant documents, and focus group discussions following delivery of the PINCER intervention. Participants included PINCER pharmacists, general practice staff, researchers involved in the running of the trial, and primary care trust staff. PINCER pharmacists were interviewed at three different time-points during the delivery of the PINCER intervention. Analysis was thematic with diffusion of innovation theory providing a theoretical framework.</p> <p>Results</p> <p>We conducted 52 semi-structured telephone interviews and six focus group discussions with 30 additional participants. In addition, documentary data were collected from six pharmacist diaries, along with notes from four meetings of the PINCER pharmacists and feedback meetings from 34 practices. Key findings that helped to explain the success of the PINCER intervention included the perceived importance of focusing on prescribing errors to all stakeholders, and the credibility and appropriateness of a pharmacist-led intervention to address these shortcomings. Central to this was the face-to-face contact and relationship building between pharmacists and a range of practice staff, and pharmacists’ explicitly designated role as a change agent. However, important concerns were identified about the likely sustainability of this new model of delivering care, in the absence of an appropriate support network for pharmacists and career development pathways.</p> <p>Conclusions</p> <p>This embedded qualitative inquiry has helped to understand the complex organizational and social environment in which the trial was undertaken and the PINCER intervention was delivered. The longitudinal element has given insight into the dynamic changes and developments over time. Medication errors and ways to address these are high on stakeholders’ agendas. Our results further indicate that pharmacists were, because of their professional standing and skill-set, able to engage with the complex general practice environment and able to identify and manage many clinically important errors in medicines management. The transferability of the PINCER intervention approach, both in relation to other prescribing errors and to other practices, is likely to be high.</p