The Impact of the Patient-Centered Medical Home on Health Disparities in Adults: A Systematic Review of the Evidence

Introduction: The objective of this study was to review the empirical evidence on Patient-Centered Medical Home (PCMH) impact on health disparities in adults. Methods: We searched PubMed, Scopus, and Google Scholar to identify studies on PCMH/health homes and health disparities published in English between January 1, 2009 and December 31, 2014. Articles met inclusion criteria if they investigated at least one component of PCMH or health homes in vulnerable populations, defined by PROGRESS-PLUS criteria, and reported differences in one of five clinical quality measures. Results: 964 articles were identified through database searching and subsequent snowballing. 60 articles underwent full text screening. Further review eliminated 56 studies. In the final 4 studies, PCMH interventions showed small improvements in health disparities. Discussion: The PCMH has been suggested as a model for improving health disparities. Given rapid implementation in underserved settings, stakeholders should better understand the impact of the PCMH on health disparities

Back to the basics: Identifying and addressing underlying challenges in achieving high quality and relevant health statistics for indigenous populations in Canada

Abstract. Canada is known internationally for excellence in both the quality and public policy relevance of its health and social statistics. There is a double standard however with respect to the relevance and quality of statistics for Indigenous populations in Canada. Indigenous specific health and social statistics gathering is informed by unique ethical, rights-based, policy and practice imperatives regarding the need for Indigenous participation and leadership in Indigenous data processes throughout the spectrum of indicator development, data collection, management, analysis and use. We demonstrate how current Indigenous data quality challenges including misclassification errors and non-response bias systematically contribute to a significant underestimate of inequities in health determinants, health status, and health care access between Indigenous and non-Indigenous people in Canada. The major quality challenge underlying these errors and biases is the lack of Indigenous specific identifiers that are consistent and relevant in major health and social data sources. The recent removal of an Indigenous identity question from the Canadian census has resulted in further deterioration of an already suboptimal system. A revision of core health data sources to include relevant, consistent, and inclusive Indigenous self-identification is urgently required. These changes need to be carried out in partnership with Indigenous peoples and their representative and governing organizations

International Group for Indigenous Health Measurement: Recommendations for best practice for estimation of Indigenous mortality

AIM: To provide a best practice guide on Indigenous mortality reporting based on recommendations from the International Group for Indigenous Health Measurement. METHOD: A workshop of the International Group for Indigenous Health Measurement was held in Montreal in 2013 during which best practices in determining Indigenous mortality were discussed. A subsequent discussion paper and draft recommendations were further refined at a meeting in Vancouver in 2014. A working group finalized this best practice guide in follow-up to the two meetings. OUTCOME: Ten final recommendations are made regarding identification, community engagement and ownership, data linkage, uncertainty in official statistics and a timeline for implementation. In this paper we review and discuss these recommendations drawing on examples of best practice in Australia, Canada, New Zealand and the United States of America and highlighting some shortcomings in the current practices of official statistical agencies

Décomposer la vulnérabilité : vers un langage qui favorise la compréhension et la résolution des iniquités sociales en santé publique

Our attention was drawn to an important recent paper published in the journal Critical Public Health, which discusses the use (and misuse) of the word “vulnerable” in public health research and practice (Katz, Hardy, Firestone, Lofters, & Morton-Ninomiya, 2019). We commend these authors for contributing a timely paper that calls attention to the role of language in what we regard as the longstanding challenge of downstream drift in public health research (e.g., Baum & Fisher, 2014; Baum & Sanders, 2011; Carey, Malbon, Crammond, Pescud, & Baker, 2016). The paper caught our eye, in part, because the authors went about their task by identifying and analyzing recent articles published in the Canadian Journal of Public Health (CJPH), as well as the American Journal of Public Health, that had used the word “vulnerable” in a way that was “vaguely, inconsistently or undefined at least once.”

The Indigenous Determinants of Health as Predictors for Diabetes and Unmet Health Needs Among Urban Indigenous People: A Respondent-Driven Sampling Study in Toronto, Ontario

National statistics commonly present Indigenous peoples as a falsely homogenous group of people experiencing disproportionate ill health when compared to non-Indigenous peoples. There are significant gaps in statistical information regarding the health services access barriers experienced by Indigenous people that disrupts the quality of care they receive or prevents them from accessing care altogether. Our Health Counts Toronto is a community-based study that employed respondent-driven sampling (RDS) methodologies to sample 917 urban Indigenous adults. Prevalence estimates and prevalence ratios were calculated using RDS-II weights and adjusting for clustering by shared recruiter in SAS 9.4 and SAS-callable SUDAAN 11.0 software. This study estimated that 14.85% (95% CI: 9.56, 20.14) of the study population had a self-reported diabetes diagnosis and 27.68% (95% CI: 20.56, 34.81) reported an unmet health need. Regional-level health assessment data is essential to tackle the health inequities endured by Indigenous peoples in Canada and system-level changes are necessary to decrease barriers to health care for Indigenous people

Examining the Association Between Traditional and Mainstream Medicine and the Prevalence of Arthritis in the Urban Indigenous Population Living in Toronto

Background: In the Indigenous community, the prevalence of arthritis is 1.3 to 1.6 times higher than their non-Indigenous counterparts. Moreover, minimal population health information on urban Indigenous peoples is available. Objective: To explore the relationship between the use of traditional and mainstream medicine and the prevalence of arthritis in the Indigenous population living in Toronto. Methods: The Our Health Counts Toronto study surveyed 918 self-identified Indigenous adults using Respondent-Driven Sampling. Survey logistic regression and generalized linear mixed models were used to investigate the multivariable relationships between medication use and arthritis, including adjustments for known confounders. Results: Compared to using neither types of medicine, use of both mainstream and traditional medicines (OR: 8.69, 95% CI: 4.06-18.59), mainstream medicine use only (6.08 2.41-15.36) and traditional medicine use only (3.86 2.63-5.67) are associated with arthritis. Conclusion: Indigenous community members with arthritis are likely to use both traditional and mainstream medicine to manage this condition

Does Consideration and Assessment of Effects on Health Equity Affect the Conclusions of Systematic Reviews? A Methodology Study

INTRODUCTION: Tackling health inequities both within and between countries remains high on the agenda of international organizations including the World Health Organization and local, regional and national governments. Systematic reviews can be a useful tool to assess effects on equity in health status because they include studies conducted in a variety of settings and populations. This study aims to describe the extent to which the impacts of health interventions on equity in health status are considered in systematic reviews, describe methods used, and assess the implications of their equity related findings for policy, practice and research. METHODS: We conducted a methodology study of equity assessment in systematic reviews. Two independent reviewers extracted information on the reporting and analysis of impacts of health interventions on equity in health status in a group of 300 systematic reviews collected from all systematic reviews indexed in one month of MEDLINE, using a pre-tested data collection form. Any differences in data extraction were resolved by discussion. RESULTS: Of the 300 systematic reviews, 224 assessed the effectiveness of interventions on health outcomes. Of these 224 reviews, 29 systematic reviews assessed effects on equity in health status using subgroup analysis or targeted analyses of vulnerable populations. Of these, seven conducted subgroup analyses related to health equity which were reported in insufficient detail to judge their credibility. Of these 29 reviews, 18 described implications for policy and practice based on assessment of effects on health equity. CONCLUSION: The quality and completeness of reporting should be enhanced as a priority, because without this policymakers and practitioners will continue lack the evidence base they need to inform decision-making about health inequity. Furthermore, there is a need to develop methods to systematically consider impacts on equity in health status that is currently lacking in systematic reviews

Only if “je est un autre” Can I Recognise You: Reflections on Canada’s Process of Constitutional Recognition of the “Preexistence of Distinctive Aborignial Societies”

1er Prix du concours d'initiation à la recherche organisé par le Regroupement Droit et Changements. La Loi sur les Indiens institutionnalise toujours de nombreuses facettes de ce qu’est être « Indien » pour beaucoup d’individus au Canada et un changement de perspective doit être opéré. Cet essai puise dans la pensée du philosophe Theodor Adorno pour réfléchir aux tentatives de reconnaissance juridique par le Canada des individus et sociétés autochtones en vertu de l’article 35 de la Constitution. L’auteur présente la théorie de la dialectique négative d’Adorno de 1966 sur le rapport à l’altérité, à partir de l’analyse de la professeure Drucilla Cornell, afin d’identifier ce que sa pensée prescrit pour établir des rapports non-oppressants entre Autochtones et non-Autochtones et leurs gouvernements aujourd’hui. La dialectique négative est particulièrement appropriée à la tentative de reconnaissance juridique de l’existence des sociétés autochtones par le Canada, du fait de leur statut marginalisé et de leurs revendications à la spécificité. Après avoir établi un tel cadre, l’auteur souligne que des précédentes tentatives de reconnaissances se sont soldées par des échecs en raison des désaccords au niveau des valeurs impliquées et des concepts utilisés auxquels elles ont donné lieu. Le processus de signature des traités numérotés de 1871-1921 est employé comme illustration en raison de son résultat souvent décrit aujourd’hui comme coercitif et injuste en dépit du discours de négociation sur un pied d’égalité l’ayant accompagné. Les critiques contemporaines de la politique en vigueur de mise en œuvre de l’autonomie gouvernementale autochtone par des accords négociés sont également présentées, afin d’illustrer que des désaccords quant à la manière dont l’État canadien entend reconnaître les peuples autochtones persistent à ce jour. L’auteur ajoute que, du point de vue de la dialectique négative, de tels désaccords doivent nécessairement être résolus pour que des rapports moins oppressifs puissent être établis. L’auteur conclut que la dialectique négative impose à la fois de se considérer soi-même (« je est un autre ») et de considérer l’autre comme au-delà des limites de sa propre pensée. La Cour suprême a déjà reconnu que la seule perspective de la common law n’est pas suffisante pour parvenir à une réconciliation des souverainetés des Autochtones et de la Couronne en vertu de la Constitution. Le concept de common law de fiduciaire présente un véhicule juridique intéressant pour une reconfiguration plus profonde par le gouvernement canadien de son rapport avec les peuples autochtones, priorisant processus plutôt que résultats et relations plutôt que certitude. Il doit toutefois être gardé à l’esprit que la reconnaissance de ces peuples par l’État canadien par le prisme de la pensée d’Adorno présente non seulement le défi d’inclure de nouvelles perspectives, mais également de remettre en cause les prémisses fondamentales à partir desquelles on considère la communauté canadienne en général.1er Prix du concours d'initiation à la recherche organisé par le Regroupement Droit et Changements. The Indian Act still institutionalises numerous facets of what it is to be “Indian” for many individuals in Canada and a change of perspective must be achieved. This essay solicits philosopher Theodor Adorno’s thought to reflect on Canada’s attempts at legal recognition of Aboriginal individuals and societies under section 35 of the Constitution. Adorno’s 1966 theory of the Negative Dialectics on the relationship with alterity is presented on the basis of commentary by Professor Drucilla Cornell, in order to identify what his prescriptions on establishing non-oppressive relationships would imply for Aboriginals and non-Aboriginals and their governments today. The Negative Dialectics is particularly relevant to Canada’s attempt at judicial recognition of the existence of Aboriginal societies, both because of their marginalised status and of their claim to specificity. Having established such a framework, the author then argues that previous attempts at recognition have been flawed by disagreements on the values involved and the concepts referred to. The 1871-1921 Numbered Treaty process is used as an illustration because of its result, today often characterised as coercive and unfair, despite the general discourse of equal-footing bargaining which has surrounded it. Contemporary critique of the current policy aimed at the implementation of self-government through negotiated agreements is also raised to illustrate that disagreement as to the way Aboriginal peoples are recognised by the Canadian State has endured. The author suggests that, from the perspective of the Negative Dialectics, such disagreements must be addressed to achieve less oppressive relationships. The author concludes that the Negative Dialectics imposes both to consider oneself (“je est un autre”) and the other as beyond the limits of our thought. The Supreme Court has already acknowledged that the sole perspective of the common law is not sufficient to achieve reconciliation of Aboriginal and Crown sovereignties under the Constitution. The common law concept of fiduciary presents an interesting legal vehicle for possible further reconfiguration by the Canadian government of its attitude towards Aboriginal peoples, prioritising process over results and relationship over certainty. Nonetheless, it must be remembered that consideration of Aboriginal peoples by the Canadian state through Adorno’s eyes not only presents the challenge of including new perspectives, but also that of questioning fundamental assumptions about the Canadian community in general