An internist's role in perioperative medicine: a survey of surgeons' opinions

<p>Abstract</p> <p>Background</p> <p>Literature exists regarding the perioperative role of internists. Internists rely on this literature assuming it meets the needs of surgeons without actually knowing their perspective. We sought to understand why surgeons ask for preoperative consultations and their view on the internist's role in perioperative medicine.</p> <p>Methods</p> <p>Survey of surgeons in Saskatoon, Saskatchewan, Canada regarding an internist's potential role in perioperative care.</p> <p>Results</p> <p>Fifty-nine percent responded. The majority request a preoperative consultation for a difficult case (83%) or specific problem (81%). While almost half feel that a preoperative consultation is to "clear" a patient for surgery, 33% disagree with this statement. The majority believe the internist should discuss risk with the patient. Aspects of the preoperative consultation deemed most important are cardiac medication optimization (93%), cardiac risk stratification (83%), addition of β-blockers (76%), and diabetes management (74%).</p> <p>Conclusion</p> <p>Surgeons perceive the most important roles for the internist as cardiac risk stratification and medication management. Areas of controversy identified amongst the surgeons included who should inform the patient of their operative risk, and whether the internist should follow the patient daily postoperatively. Unclear expectations have the potential to impact on patient safety and informed consent unless acknowledged and acted on by all. We recommend that internists performing perioperative consults communicate directly with the consulting physician to ensure that all parties are in accordance as to each others duties. We also recommend that the teaching of perioperative consults emphasizes the interdisciplinary communication needed to ensure that patient needs are not neglected when one specialty assumes the other will perform a function.</p

Setting priorities in health care organizations: criteria, processes, and parameters of success

BACKGROUND: Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. DISCUSSION: We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. SUMMARY: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly

Priority setting for new technologies in medicine: A transdisciplinary study

BACKGROUND: Decision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers. DISCUSSION: Daniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based. SUMMARY: We have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution

The role of the economic analysis in the decision making process at the Drug Quality and Therapeutics Committee of Ontario

grantor: University of TorontoThis thesis examines the role of the economic analysis in the decision making process at the Drug Quality and Therapeutics Committee of Ontario. This committee reviews data submitted by pharmaceutical manufacturers who are requesting listing of products on the provincial formulary. A case study approach was taken; nine meetings were observed and seven committee members were interviewed. This thesis found that the role of the economic analysis in the decision making process was important but limited by various factors. The product's clinical merit and the quality of the submission were dominant factors in the decision making process. Interestingly, the type of drug discussed was another key factor that determined the usefulness of the economic analysis. The committee's membership also shaped the discussions; only one member had extensive training in health economics. Finally, the economic analysis was limited by the context in which it was applied, that of resource allocation.M.Sc

Ontario's Formulary Committee: How Recommendations Are Made

Background: In 1996, the provincial government in Ontario, Canada required pharmaceutical manufacturers seeking to list their products on the provincial formulary to provide a formal economic analysis documenting the products' cost effectiveness. The provincial formulary lists pharmaceutical products for which reimbursement is provided for residents on the Ontario Drug Benefit Program (ODB). Objective: To describe how listing decisions are made, and specifically the role of economic analysis in this process. Design: A qualitative case study approach was taken. Data were analysed using the pattern-matching technique. Data consisted of meeting transcripts and interviews with committee members, which were coded and weighted for analysis using the pattern-matching technique. Setting: Nine meetings of the Drug Quality and Therapeutics Committee (DQTC), which makes listing recommendations to the ODB, were observed. Participants: Seven individual committee members were interviewed. Results: Complex economic analyses (i.e. analyses more involved than a simple cost-consequence analysis) played a limited role. The clinical factor dominated the perception of costs. Generic and `me-too' products with no price premium did not require complex economic analyses. Poor quality analyses were not useful and the DQTC members' lack of in-depth knowledge of health economics influenced the extent to which analyses were discussed. The DQTC did discuss economic issues however, and often performed informal economic analyses to guide decisions. Conclusions: Complex economic analyses had an impact on provincial drug benefit decisions in a limited number of circumstances, principally for expensive innovative products. However, the committee did use some form of economic analysis to guide decisions in almost all cases, and therefore requesting economic analyses, even simple ones, from manufacturers seeking formulary listing is a useful healthcare policy.Formularies, Health economics, Pharmacoeconomics

Vitamin D and hypertension in pregnancy

Purpose: Vitamin D Deficiency is common, particularly in northern latitudes. We examined the association between vitamin D status and hypertension in late pregnancy. Methods: A case-control study was conducted during two time periods: September-October, 2008, and January-March, 2009, in women near term. A case was defined as having two or more documented blood pressure readings above 140/90 (either/or) at any time during pregnancy (n=78). Controls had at least two blood pressure readings, with none above 140/90 during pregnancy (n=109). Serum 25-hydroxyvitamin D (25(OH)D) was measured in all participants. Results: In the summer, 13% of controls and 29% of the cases had 25(OH) D levels < 50 nmol/L. During the winter, these numbers rose to 44% and 49% respectively. Both cases and controls were more likely to be vitamin D deficient in the winter (p=0.002). There was a negative correlation between BMI and 25(OH)D (r=-0.202, p=0.002). In univariate analysis, cases had lower 25(OH)D (p=0.046), but also higher body mass index, so that in multivariate analysis 25(OH)D status was no longer significant. There was no difference in mean oral daily vitamin D intake (dietary intake and supplements, 746 and 785 IU respectively). Controls gained less weight in pregnancy. There was a negative correlation between the highest blood pressure measured in pregnancy and 25(OH)D levels (r= -0.118; p=0.012). Conclusion: There is a high prevalence of vitamin D deficiency in pregnant women recruited in Saskatoon, Saskatchewan. Women with low circulating vitamin D concentrations are more likely to have hypertension

Service providers’ use of harm reduction approaches in working with older adults experiencing abuse: a qualitative study

Abstract Background Although abuse experienced by older adults is common and expected to increase, disclosure, reporting and interventions to prevent or mitigate abuse remain sub-optimal. Incorporating principles of harm reduction into service provision has been advocated as a strategy that may improve outcomes for this population. This paper explores whether and how these principles of harm reduction were employed by professionals who provide services to older adults experiencing abuse. Methods Thematic analysis of qualitative interviews with 23 professionals providing services to older adults experiencing abuse across three Western provinces of Canada was conducted. Key principles of harm reduction (humanism, incrementalism, individualism, pragmatism, autonomy, and accountability without termination) were used as a framework for organizing the themes. Results Our analysis illustrated a clear congruence between each of the six harm reduction principles and the approaches reflected in the narratives of professionals who provided services to this population, although these were not explicitly articulated as harm reduction by participants. Each of the harm reduction principles was evident in service providers’ description of their professional practice with abused older adults, although some principles were emphasized differentially at different phases of the disclosure and intervention process. Enactment of a humanistic approach formed the basis of the therapeutic client-provider relationships with abused older adults, with incremental, individual, and pragmatic principles also apparent in the discourse of participants. While respect for the older adult’s autonomy figured prominently in the data, concerns about the welfare of the older adults with questionable capacity were expressed when they did not engage with services or chose to return to a high-risk environment. Accountability without termination of the client-provider relationship was reflected in continuation of support regardless of the decisions made by the older adult experiencing abuse. Conclusions Harm reduction approaches are evident in service providers’ accounts of working with older adults experiencing abuse. While further refinement of the operational definitions of harm reduction principles specific to their application with older adults is still required, this harm reduction framework aligns well with both the ethical imperatives and the practical realities of supporting older adults experiencing abuse