Health care restructuring and family physician care for those who died of cancer

BACKGROUND: During the 1990s, health care restructuring in Nova Scotia resulted in downsized hospitals, reduced inpatient length of stay, capped physician incomes and restricted practice locations. Concurrently, the provincial homecare program was redeveloped and out-of-hospital cancer deaths increased from 20% (1992) to 30% (1998). These factors all pointed to a transfer of end-of-life inpatient hospital care to more community-based care. The purpose of this study was to describe the trends in the provision of Family Physician (FP) visits to advanced cancer patients in Nova Scotia (NS) during the years of health care restructuring. METHODS: Design Secondary multivariate analysis of linked population-based datafiles including the Queen Elizabeth II Health Sciences Centre Oncology Patient Information System (NS Cancer Registry, Vital Statistics), the NS Hospital Admissions/Separations file and the Medical Services Insurance Physician Services database. Setting Nova Scotia, an eastern Canadian province (population: 950,000). Subjects: All patients who died of lung, colorectal, breast or prostate cancer between April 1992 and March 1998 (N = 7,212). Outcome Measures Inpatient and ambulatory FP visits, ambulatory visits by location (office, home, long-term care facility, emergency department), time of day (regular hours, after hours), total length of inpatient hospital stay and number of hospital admissions during the last six months of life. RESULTS: In total, 139,641 visits were provided by family physicians: 15% of visits in the office, 10% in the home, 5% in the emergency department (ED), 5% in a long-term-care centre and 64% to hospital inpatients. There was no change in the rate of FP visits received for office, home and long-term care despite the fact that there were 13% fewer hospital admissions, and length of hospital stay declined by 21%. Age-sex adjusted estimates using negative binomial regression indicate a decline in hospital inpatient FP visits over time compared to 1992–93 levels (for 1997–98, adjusted RR = 0.88, 95%CI = 0.81–0.95) and an increase in FP ED visits (for 1997–98, adjusted RR = 1.18, 95%CI = 1.05–1.34). CONCLUSION: Despite hospital downsizing and fewer deaths occurring in hospitals, FP ambulatory visits (except for ED visits) did not rise correspondingly. Although such restructuring resulted in more people dying out of hospital, it does not appear FPs responded by providing more medical care to them in the community

An epistemic community comes and goes? Local and national expressions of heart health promotion in Canada

<p>Abstract</p> <p>Background</p> <p>The objective of this study is to examine the existence and shape of epistemic communities for (heart) health promotion at the international, national, provincial and regional levels in Canada. Epistemic community may be defined as a network of experts with an authoritative claim to policy relevant knowledge in their area of expertise.</p> <p>Methods</p> <p>An interpretive policy analysis was employed using 60 documents (48 provincial, 8 national and 4 international) and 66 interviews (from 5 Canadian provinces). These data were entered into NUD*IST, a qualitative software analysis package, to assist in the development of codes and themes. These codes form the basis of the results.</p> <p>Results</p> <p>A scientific and policy epistemic community was identified at the international and Canadian federal levels. Provincially and regionally, the community is present as an idea but its implementation varies between jurisdictions.</p> <p>Conclusion</p> <p>The importance of economic, political and cultural factors shapes the presence and shape of the epistemic community in different jurisdictions. The community waxes and wanes but appears robust.</p

Family physician views about primary care reform in Ontario: a postal questionnaire

BACKGROUND: Primary care reform initiatives in Ontario are proceeding with little information about the views of practicing family physicians. METHODS: A postal questionnaire was sent to 1200 randomly selected family physicians in Ontario five months after the initial invitation to join the Ontario Family Health Network. It sought information about their practice characteristics, their intention to participate in the Network and their views about the organization and financing of primary care. RESULTS: The response rate was 50.3%. While many family physicians recognize the need for change in the delivery of primary care, the majority (72%) did not expect to join the Ontario Family Health Network by 2004, or by some later date (60%). Nor did they favour capitation or rostering, 2 key elements of the proposed reforms. Physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004, although these practices comprise 5% of the sample. CONCLUSIONS: The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that an 80% enrollment target is unrealistic

Just regionalisation: rehabilitating care for people with disabilities and chronic illnesses

BACKGROUND: Regionalised models of health care delivery have important implications for people with disabilities and chronic illnesses yet the ethical issues surrounding disability and regionalisation have not yet been explored. Although there is ethics-related research into disability and chronic illness, studies of regionalisation experiences, and research directed at improving health systems for these patient populations, to our knowledge these streams of research have not been brought together. Using the Canadian province of Ontario as a case study, we address this gap by examining the ethics of regionalisation and the implications for people with disabilities and chronic illnesses. The critical success factors we provide have broad applicability for guiding and/or evaluating new and existing regionalised health care strategies. DISCUSSION: Ontario is in the process of implementing fourteen Local Health Integration Networks (LHINs). The implementation of the LHINs provides a rare opportunity to address systematically the unmet diverse care needs of people with disabilities and chronic illnesses. The core of this paper provides a series of composite case vignettes illustrating integration opportunities relevant to these populations, namely: (i) rehabilitation and services for people with disabilities; (ii) chronic illness and cancer care; (iii) senior's health; (iv) community support services; (v) children's health; (vi) health promotion; and (vii) mental health and addiction services. For each vignette, we interpret the governing principles developed by the LHINs – equitable access based on patient need, preserving patient choice, responsiveness to local population health needs, shared accountability and patient-centred care – and describe how they apply. We then offer critical success factors to guide the LHINs in upholding these principles in response to the needs of people with disabilities and chronic illnesses. SUMMARY: This paper aims to bridge an important gap in the literature by examining the ethics of a new regionalisation strategy with a focus on the implications for people with disabilities and chronic illnesses across multiple sites of care. While Ontario is used as a case study to contextualize our discussion, the issues we identify, the ethical principles we apply, and the critical success factors we provide have broader applicability for guiding and evaluating the development of – or revisions to – a regionalised health care strategy

Accuracy of prognosis estimates by four palliative care teams: a prospective cohort study

BACKGROUND: Prognosis estimates are used to access services, but are often inaccurate. This study aimed to determine the accuracy of giving a prognosis range. METHODS AND MEASUREMENTS: A prospective cohort study in four multi-professional palliative care teams in England collected data on 275 consecutive cancer referrals who died. Prognosis estimates (minimum – maximum) at referral, patient characteristics, were recorded by staff, and later compared with actual survival. RESULTS: Minimum survival estimates ranged <1 to 364 days, maximum 7 – 686 days. Mean patient survival was 71 days (range 1 – 734). In 42% the estimate was accurate, in 36% it was over optimistic and in 22% over pessimistic. When the minimum estimate was less than 14 days accuracy increased to 70%. Accuracy was related, in multivariate analysis, to palliative care team and (of borderline significance) patient age. CONCLUSIONS: Offering a prognosis range has higher levels of accuracy (about double) than traditional estimates, but is still very often inaccurate, except very close to death. Where possible clinicians should discuss scenarios with patients, rather than giving a prognosis range

A proposed systems approach to the evaluation of integrated palliative care

<p>Abstract</p> <p>Background</p> <p>There is increasing global interest in regional palliative care networks (PCN) to integrate care, creating systems that are more cost-effective and responsive in multi-agency settings. Networks are particularly relevant where different professional skill sets are required to serve the broad spectrum of end-of-life needs. We propose a comprehensive framework for evaluating PCNs, focusing on the nature and extent of inter-professional collaboration, community readiness, and client-centred care.</p> <p>Methods</p> <p>In the absence of an overarching structure for examining PCNs, a framework was developed based on previous models of health system evaluation, explicit theory, and the research literature relevant to PCN functioning. This research evidence was used to substantiate the choice of model factors.</p> <p>Results</p> <p>The proposed framework takes a systems approach with system structure, process of care, and patient outcomes levels of consideration. Each factor represented makes an independent contribution to the description and assessment of the network.</p> <p>Conclusions</p> <p>Realizing palliative patients' needs for complex packages of treatment and social support, in a seamless, cost-effective manner, are major drivers of the impetus for network-integrated care. The framework proposed is a first step to guide evaluation to inform the development of appropriate strategies to further promote collaboration within the PCN and, ultimately, optimal palliative care that meets patients' needs and expectations.</p

Perceptions of the social determinants of health by two groups more and less affiliated with public health in Canada

BACKGROUND: Despite strong academic recognition of the SDOH both in Canada and internationally, acknowledgement and uptake of the SDOH in health policy and public consciousness have remained weak. This paper aims to discern reasons for limited action on the SDOH by examining the perceptions of the SDOH held by two groups more and less affiliated with public health in Canada. We conducted formal consultation with group members on their interpretation of the SDOH and their thoughts on the nature and basis of differences between those more and less aligned with the SDOH as a basis for action. Thematic analysis was used to evaluate the views of the two groups. FINDINGS: Group 1 (community/public health workers) felt overwhelmed when confronted with questions regarding action on the SDOH within the context of their professional lives. They suggested an expanded list of health determinants that included factors such as voluntarism and happiness, transcending traditional notions of “root causes.” Furthermore, they did not articulate value-based reasons why others would oppose the SDOH; rather, in line with their professional roles, they adopted a value-neutral and pragmatic approach to working to improve health. Group 2 (child and youth advocacy organization members) seemed rooted in the 1986 Ottawa Charter for Health Promotion framework, with their recommendations aligned with strategies such as building healthy public policy and reorienting health services. Neither group made reference to issues of social justice or inequity when they made suggestions for improving health. CONCLUSIONS: We found that two groups with different affiliations to formal public health could discuss the SDOH without acknowledging the inequitable distribution of power and resources that lies at its root. We also found that those working in public health had difficulty moving beyond individual actions that they or their clients could take to improve health. For a group more focused on advocacy than direct service provision, the Ottawa Charter framework seemed more easily suited to their recommendations for action than suggesting actions that would address the SDOH. Our findings indicate that there remains work to be done in terms of translating the SDOH concept into action in Canada

Proceedings of the Senate Standing Senate Committee on Foreign Affairs, no. 10, Tuesday, March 17, 1970

Part of the collection of government and miscellaneous documents relating to the history of IDRC