Factors associated with the decision of family physicians to provide intrapartum care.

OBJECTIVE: To investigate which characteristics and beliefs of family physicians determine their decision to provide intrapartum care. DESIGN: Confidential survey questionnaire mailed in spring 1993. SETTING: Alberta and Ontario. SUBJECTS: Random selection of 207 physicians who had graduated from medical school between 1953 and 1990 and were thought to be in family or general practice. Of 178 eligible physicians, usable replies were received from 104 (58.4%). OUTCOME MEASURES: Beliefs (measured on a 7-point Likert scale) about the relevance of 16 primary factors to the type of obstetric care provided; demographic, training and practice characteristics. RESULTS: The respondents who provided intrapartum care differed from those who did not in their beliefs about the availability of a local hospital suitable for intrapartum care (p < 0.001), their practice partners' views on the role of family physicians in providing obstetric care (p < 0.002), their own concept of the role of family physicians in providing obstetric care (p < 0.001) and women's views on the type of obstetric care they want (p < 0.002). They also differed, although less significantly, in their beliefs about the adequacy of their obstetric training before entering family practice (p < 0.04), the expected effects of providing obstetric care on their free time (p < 0.006), their fear of malpractice litigation (p < 0.028) and their perceived competence in performing practical obstetric procedures (p < 0.05). Logistic regression analysis revealed that certain secondary factors were particularly relevant to the respondents' provision of intrapartum care at present. These included the physician's perceived competence at managing postpartum maternal hemorrhage (odds ratio [OR] 48.90, 90% confidence interval [CI] 4.70 to 509), the belief that medical insurance premiums should not be affected by the type of obstetric care provided (OR 3.55, 90% CI 1.67 to 7.57]) and the number of practice partners who provided intrapartum care (OR 10.08, 90% CI 2.31 to 44.10). CONCLUSION: Several factors appear to influence family physicians in their decision to provide intrapartum care. This information will help to focus efforts to provide appropriate obstetric training for family practice residents and to retain involvement of family physicians in intrapartum care.     

What factors influence primary care physicians'' charges for their services? An exploratory study using standardized patients

OBJECTIVE: To determine the extent of variation in physicians' charges for health care encounters with unannounced standardized patients and factors associated with the variation. DESIGN: Cross-sectional study. SETTING: Family practices open to new patients within 1 hour's drive of Hamilton, Ont. PARTICIPANTS: A stratified random sample of 125 physicians who had responded to an earlier survey regarding preventive care were invited to participate. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew because they closed their practices to new patients. Sixty-two physicians thus participated in the study. INTERVENTION: Unannounced standardized patients posing as new patients to the practice visited study physicians' practices between September 1994 and August 1995, portraying 4 scenarios: 28-year-old woman, 52-year-old woman, 48-year-old man and 70-year-old man. OUTCOME MEASURES: Physician characteristics, encounter characteristics and charges made for services. RESULTS: The 62 physicians had 246 encounters with the standardized patients. Charges were made to the health insurance plan for services by 59 physicians for up to 4 encounters (215 encounters in all). Charges varied considerably both within and across patient scenarios. Time spent with the patient was an important factor predicting charges made (p < 0.01), although the effect of time spent on charges varied across scenarios (p < 0.01). Fee-for-service physicians charged more for their services than physicians who usually had alternative billing arrangements (p < 0.01). Female physicians charged more for their services than their male colleagues (p = 0.03). No relation was found between quality of preventive care and charges made (p = 0.15). CONCLUSIONS: Physician-related factors are better able to account for the variability in charges for their services than patient-related factors. Physicians seeing comparable patients may earn much more or less than their colleagues because of differences in the services they provide and the way they apply the fee schedule. Quality-assurance techniques are likely needed to reduce the variability in charges seen and increase value for money spent in health care.     

Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care.

OBJECTIVE: To evaluate whether physicians' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth. DESIGN: Post-hoc cohort analysis of physicians and patients involved in a randomized controlled trial of episiotomy. SETTING: Two tertiary care hospitals and one community hospital in Montreal. PARTICIPANTS: Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by residents or nurses were excluded. MAIN OUTCOME MEASURES: Patients: intact perineum v. perineal trauma, length of labour, procedures used (instrumental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assigning women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy. RESULTS: Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably (p < 0.05 to < 0.01), and the former physicians were more likely to use oxytocin augmentation of labour. Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that "fetal distress" or cesarean section necessitated exclusion of the subject. They used the lithotomy position for birth more often (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience (p < 0.01) than the patients of physicians who viewed the procedure very unfavourably. CONCLUSIONS: Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.     

Reducing the frequency of episiotomies through a continuous quality improvement program.

OBJECTIVE: To determine the effectiveness of a continuous quality improvement (CQI) program in reducing episiotomy rates. DESIGN: Before-and-after study; CQI methods were used to examine the process of care during labour and birth. INTERVENTIONS: Identification of care factors that would increase the probability of episiotomy. Implementation of initiatives that would change the process of care to minimize the probability of episiotomy. Educational strategies included promotion of better understanding of what constitutes an appropriate episiotomy rate and ways to reduce maternal exhaustion and true fetal distress as well as manoeuvres to protect the perineum during birth. SETTING: Low-risk family practice obstetrics service in a tertiary care hospital in southwestern Ontario. PARTICIPANTS: All 102 family physicians at the study hospital who provided intrapartum care in the year before and the year during which the CQI program was implemented and the women for whom the care was provided (approximately 1,400 per year). OUTCOME MEASURES: Episiotomy rates (overall, among primiparous and multiparous women, and among individual family physicians) and rates of perineal tear, perineal infection and postpartum readmission. RESULTS: Although the planned reduction in the episiotomy rate was not achieved during the study period, the overall rate decreased significantly from 44.5% to 33.3% (p < 0.001). Among the primiparous women the rate decreased from 57.6% to 46.2% (p < 0.001) and among the multiparous women from 34.3% to 23.6% (p < 0.001). The reduced episiotomy rate among the primiparous women was associated with a significant decrease in the rate of third- and fourth-degree perineal tears and a significant increase in the number of women giving birth with an intact perineum or a minor (first-degree) tear. These benefits were not seen among the multiparous women, whose decreased episiotomy rate was associated with a significant increase in the number of women experiencing a second-degree perineal tear. During the intervention period, there was no increase in the rates of vaginal trauma or postpartum bleeding, infection or readmission because of complications related to perineal trauma. The episiotomy rates for most physicians decreased significantly during the intervention period. CONCLUSIONS: The CQI model may be useful in modifying clinical practices such as episiotomy because it focuses on understanding the process of care and the environment in which care is provided, both of which may have a major impact on physician behaviour. Further study is needed to ascertain the sustainability of the effects of this approach and which components of the model had the greatest effect.     

Women in pediatrics: the experience in Quebec.

OBJECTIVES: To compare the practice patterns of female pediatricians in Quebec with those of their male counterparts and to identify specific factors influencing these practice patterns. DESIGN: Matched cohort questionnaire survey. SETTING: Primary, secondary and tertiary care pediatric practices in Quebec. PARTICIPANTS: All 146 female pediatricians and 133 of the 298 male pediatricians, matched for age as well as type and site of practice; 119 (82%) of the female and 115 (86%) of the male pediatricians responded. MAIN OUTCOME MEASURES: Demographic and family data as well as detailed information about the practice profile. RESULTS: The two groups were comparable regarding demographic data, professional work and patient care. Compared with the male respondents, the female pediatricians were younger and saw more outpatients. The mean number of hours worked per week, excluding on-call duty, was 40.5 (standard deviation [SD] 12.4) for the women and 48.9 (SD 12.0) for the men (p < 0.001). The female pediatricians were more likely than their male counterparts to have spouses who were also physicians (40%) or in another profession (45%). The female pediatricians without children worked significantly fewer hours than the male pediatricians with or without children (p < 0.001). Children (p = 0.006), but not the number of children (p = 0.452), had a significant effect on the number of hours worked by the female pediatricians. CONCLUSION: The duality of the role of female physicians as mothers and professional caregivers must be considered during workload evaluations. If the same style of practice and the increase in the proportion of female pediatricians continue, about 20% more pediatricians will be needed in 10 years to accomplish the same workload.     

The delay to thrombolysis: an analysis of patient and hospital characteristics

OBJECTIVE: To describe the various components of the delay to thrombolytic treatment for patients with acute myocardial infarction (MI) and to identify the hospital and patient characteristics related to these delays. DESIGN: Cohort analysis from a hospital registry of patients receiving thrombolytic treatment. SETTING: Forty acute care hospitals in Quebec. SUBJECTS: All 1357 patients who received thrombolysis between January 1995 and May 1996. MAIN OUTCOME MEASURES: Time from onset of symptoms to arrival at hospital and the various components of the in-hospital delay. RESULTS: The median delay before presentation to hospital was 98 (interquartile range [IR] 56 to 180) minutes and was longer for women (p < 0.001), patients over 65 years of age (p < 0.001) and patients with diabetes mellitus (p < 0.01). The median time from arrival at hospital to thrombolysis was 59 (IR 41 to 89) minutes, the medical decision-making component taking a median of 12 (IR 4 to 27) minutes. Women (p < 0.005), older patients (p < 0.001) and patients with a past history of MI (p < 0.001) had increased in-hospital delays to thrombolysis. Delays were longer in community hospitals (p < 0.05) and low-volume centres (p < 0.01) and when a cardiologist made the decision to administer thrombolysis (p < 0.001). Multivariate analysis showed that increased age (odds ratio 1.5, 95% confidence interval 1.3 to 1.7, p < 0.001) and having the medical decision made by a cardiologist (odds ratio 1.8, 95% confidence interval 1.6 to 2.0, p < 0.001) were independently associated with an increased risk of being in the upper median of in-hospital delays. CONCLUSIONS: Despite certain improvements, there remain substantial delays between symptom onset and the administration of thrombolysis for patients with acute MI. A large part of the delay is due to the hesitation of patients (particularly women, older patients and patients with diabetes) to seek medical attention. Although the median time for medical decision-making appears reasonable, care must be taken to ensure that all patient groups receive timely evaluation and therapy. The delay associated with having the treatment decision made by a cardiologist probably represents a marker for more difficult, complex cases. Methods should be developed to permit specialty consultation, if needed, while minimizing treatment delays. Community and low-volume hospitals may require special attention.     

Effect of Pilates exercises on postpartum maternal fatigue

INTRODUCTION

Postpartum fatigue is a pervasive phenomenon and often affects mothers immediately after delivery. The present study aimed to assess the effect Pilates home exercises had on postpartum maternal fatigue.

METHODS

A total of 80 women participated in our clinical trial study. The women were randomly divided into two groups – the intervention group (n = 40) and the control group (n = 40). In the intervention group, the women performed Pilates exercises five times a week (30 min per session) for eight consecutive weeks. The first session was conducted 72 hours after delivery. The control group did not receive any intervention. Each woman’s level of fatigue was evaluated at hospital discharge (as a baseline), and at four and eight weeks after delivery, using the standard Multidimensional Fatigue Inventory (MFI-20) questionnaire and repeated measures analysis.

RESULTS

During the eight weeks of follow-up, we found that the intervention group had lower mean MFI-20 scores than the control group with regard to general fatigue (7.80 ± 2.07 vs. 12.72 ± 1.79; p < 0.001), physical fatigue (7.12 ± 1.41 vs. 10.42 ± 2.02; p < 0.001), reduced activity (6.95 ± 1.35 vs. 11.27 ± 1.70; p < 0.001), reduced motivation (6.20 ± 1.01 vs. 9.80 ± 2.04; p < 0.001) and mental fatigue (6.85 ± 1.45 vs. 10.72 ± 1.98; p < 0.001).

CONCLUSION

The present study’s findings show that physical exercise can significantly reduce postpartum maternal fatigue in all subscales.     

Effect of labour induction on rates of stillbirth and cesarean section in post-term pregnancies

BACKGROUND: Meta-analyses of randomized controlled trials suggest that elective induction of labour at 41 weeks' gestation, compared with expectant management with selective labour induction, is associated with fewer perinatal deaths and no increase in the cesarean section rate. The authors studied the changes over time in the rates of labour induction in post-term pregnancies in Canada and examined the effects on the rates of stillbirth and cesarean section. METHODS: Changes in the proportion of total births at 41 weeks' and at 42 or more weeks' gestation, and in the rate of stillbirths at 41 or more weeks' (versus 40 weeks') gestation in Canada between 1980 and 1995 were determined using data from Statistics Canada. Changes in the rates of labour induction and cesarean section were determined using data from hospital and provincial sources. RESULTS: There was a marked increase in the proportion of births at 41 weeks' gestation (from 11.9% in 1980 to 16.3% in 1995) and a marked decrease in the proportion at 42 or more weeks (from 7.1% in 1980 to 2.9% in 1995). The rate of stillbirths among deliveries at 41 or more weeks' gestation decreased significantly, from 2.8 per 1000 total births in 1980 to 0.9 per 1000 total births in 1995 (p < 0.001). The stillbirth rate also decreased significantly among births at 40 weeks' gestation, from 1.8 per 1000 total births in 1980 to 1.1 per 1000 total births in 1995 (p < 0.001). The magnitude of the decrease in the stillbirth rate at 41 or more weeks' gestation was greater than that at 40 weeks' gestation (p < 0.001). All hospital and provincial sources of data indicated that the rate of labour induction increased significantly between 1980 and 1995 among women delivering at 41 or more weeks' gestation. The associated changes in rates of cesarean section were variable. INTERPRETATION: Between 1980 and 1995 clinical practice for the management of post-term pregnancy changed in Canada. The increased rate of labour induction at 41 or more weeks' gestation may have contributed to the decreased stillbirth rate but it had no convincing influence either way on the cesarean section rate.     

Effect of age upon the induction and maintenance of anticoagulation with warfarin.

We aimed to examine the effect of age upon the control of anticoagulation with warfarin in ordinary clinical practice, using a retrospective examination of routine anticoagulation clinic records from the University Hospital, Nottingham. Considerable over-anticoagulation (international normalisation ratio (INR) > 6.0) during induction occurred in 54 (11%) of 495 patients and was more likely in older patients (p < 0.05). Lesser degrees of over-anticoagulation during induction (INR > 4.0) were also more common in older patients, occurring in 58% of those aged 75 or above. Loading doses of warfarin were not reduced in older patients. INR in the maintenance phase rose with age (p < 0.001) despite lower maintenance doses of warfarin (p < 0.001). An INR > 6.0 in the maintenance phase was noted in 24 (3%) of 739 patients and again was more likely in older patients (p < 0.05). Patients using ambulance transport to the clinic were older than those who did not (p < 0.01) and those aged over 75 had shorter intervals between clinic visits (p < 0.01). We conclude that doctors using warfarin therapy do not take sufficient account of the increased sensitivity of older people to warfarin. Hospital anticoagulant policies need implementation and evaluation.     

Sudden unexpected death in the emergency department: caring for the survivors.

OBJECTIVE: To determine whether emergency department staff met the needs of the next of kin and close friends ("survivors") of patients dying in an emergency department and to assess the effectiveness of a program to improve care of survivors. DESIGN: Mail survey before and after program implementation. SETTING: Emergency department of a tertiary care, adult teaching hospital. PARTICIPANTS: Two groups of survivors, identified through a review of emergency department records of deaths during two 6-month periods. In the first group, surveyed in 1987, before program implementation, 26 (53%) of 49 responded; in the second group, surveyed in 1990, after program implementation, 40 (70%) of 57 responded. INTERVENTIONS: A structured, multidisciplinary protocol for notifying next of kin of death and supporting the survivors was implemented. An educational program was provided to all emergency department staff. An information pamphlet was created and provided to survivors. MAIN OUTCOME MEASURES: Questionnaire responses regarding the adequacy and timeliness of information provided, the support and actions by emergency department staff and the survivors' desire to be present during resuscitation efforts. RESULTS: Comparison of responses before and after program implementation showed that adequate information was provided before notification of death in 32% and 83% of cases respectively (p < 0.001), lengthy delays in receiving medical information occurred in 60% and 15% of cases (p < 0.01), adequate medical information concerning the events of death was provided in 53% and 88% (p < 0.05), the presence of emergency department staff was sufficient in 40% and 79% (p < 0.01), survivors spent less than 2 hours in the emergency department in 50% and 81% (p < 0.05), and survivors expressed a desire to be present during resuscitation efforts in 95% and 11% of cases (p < 0.001). CONCLUSION: The grievous experience of learning that a loved one has suddenly and unexpectedly died in the emergency department can be alleviated somewhat by a structured, multidisciplinary approach combined with staff sensitization and education.     

Comparison of long-term care in an acute care institution and in a long-term care institution

BACKGROUND: Acute care hospitals in Quebec are required to reserve 10% of their beds for patients receiving long-term care while awaiting transfer to a long-term care facility. It is widely believed that this is inefficient because it is more costly to provide long-term care in an acute care hospital than in one dedicated to long-term care. The purpose of this study was to compare the quality and cost of long-term care in an acute care hospital and in a long-term care facility. METHODS: A concurrent cross-sectional study was conducted of 101 patients at the acute care hospital and 102 patients at the long-term care hospital. The 2 groups were closely matched in terms of age, sex, nursing care requirements and major diagnoses. Several indicators were used to assess the quality of care: the number of medical specialist consultations, drugs, biochemical tests and radiographic examinations; the number of adverse events (reportable incidents, nosocomial infections and pressure ulcers); and anthropometric and biochemical indicators of nutritional status. Costs were determined for nursing personnel, drugs and biochemical tests. A longitudinal study was conducted of 45 patients who had been receiving long-term care at the acute care hospital for at least 5 months and were then transferred to the long-term care facility where they remained for at least 6 months. For each patient, the number of adverse events, the number of medical specialist consultations and the changes in activities of daily living status were assessed at the 2 institutions. RESULTS: In the concurrent study, no differences in the number of adverse events were observed; however, patients at the acute care hospital received more drugs (5.9 v. 4.7 for each patient, p < 0.01) and underwent more tests (299 v. 79 laboratory units/year for each patient, p < 0.001) and radiographic examinations (64 v. 46 per 1000 patient-weeks, p < 0.05). At both institutions, 36% of the patients showed anthropometric and biochemical evidence of protein-calorie undernutrition; 28% at the acute care hospital and 27% at the long-term care hospital had low serum iron and low transferrin saturation, compatible with iron deficiency. The longitudinal study showed that there were more consultations (61 v. 37 per 1000 patient-weeks, p < 0.02) and fewer pressure ulcers (18 v. 34 per 1000 patient-weeks, p < 0.05) at the acute care hospital than at the long-term care facility; other measures did not differ. The cost per patient-year was $7580 higher at the acute care hospital, attributable to the higher cost of drugs ($42), the greater use of laboratory tests ($189) and, primarily, the higher cost of nursing ($7349). For patients requiring 3.00 nursing hours/day, the acute care hospital provided more hours than the long-term care facility (3.59 v. 3.03 hours), with a higher percentage of hours from professional nurses rather than auxiliary nurses or nursing aides (62% v. 28%). The nurse staffing pattern at the acute care hospital was characteristic of university-affiliated acute care hospitals. INTERPRETATION: The long-term care provided in the acute care hospital involved a more interventionist medical approach and greater use of professional nurses (at a significantly higher cost) but without any overall difference in the quality of care.     

Spontaneous pneumothorax: use of aspiration and outcomes of management by respiratory and general physicians

Background: Spontaneous pneumothorax is a common problem in hospital practice. Despite the publication of guidelines controversy over its initial management still exists, particularly over the use of simple aspiration. Methods: The management of spontaneous pneumothorax by respiratory and general physicians at our hospital was analysed by retrospective case note review. Eighty five patients were identified over the study period (36 managed by respiratory and 49 by general physicians). Results: There was a significantly greater use of simple aspiration by respiratory (81%) than general physicians (47%, p<0.001) and a higher rate of success in this group. As a result those patients managed by respiratory physicians had fewer intercostal drains inserted and significantly shorter length of stays (mean 5.6 (3.8) days respiratory group and 9.5 (6.8) days in general physicians group, p<0.05). Conclusions: The greater and more successful use of simple aspiration by respiratory physicians as an initial treatment for spontaneous pneumothorax resulted in improved outcomes and reduced length of hospital stays.     

Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians.

OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. Survey: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.     

Female ageing and reproductive outcome in assisted reproduction cycles

INTRODUCTION

Fertility in women declines with increasing age. With the deferment of marriage and childbearing, couples are turning to assisted reproductive technology to counteract this decline. We aimed to evaluate the results of in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) in women of different age groups, and highlight the cost-effectiveness of IVF treatment in these groups while assessing its implications on the national healthcare provision model.

METHODS

Retrospective analysis of 3,412 stimulated IVF/ICSI cycles in a hospital-based IVF centre was performed from January 2008 to December 2010. Patients were stratified into seven age groups: < 30 years; 30–35 years; 36–37 years; 38 years; 39 years; 40–44 years; and ≥ 45 years.

RESULTS

Age had a significant effect on the number of cycles leading to embryo transfer (p < 0.001). The number of oocytes retrieved decreased across the various age groups (p < 0.001) and was the highest among women aged < 30 (mean 18.5 ± 10.3) years. With increasing age, there was a trend toward a lower fertilisation rate. Age also had a significant effect on the rates of clinical pregnancy, live birth and multiple pregnancies (p < 0.001).

CONCLUSION

Patients aged < 30 years had the best IVF outcomes, reflecting optimal reproductive capacity. Age-related decline in fertility starts after 30 years. Women opting for IVF should be counselled about age-specific success rates while taking into account individual risk factors.     

[Fréquence des maladies transmises sexuellement chez des étudiants universitaires.]

OBJECTIVE: To estimate the incidence rate of sexually transmitted diseases (STDs) among university students and evaluate the associated sociodemographic factors. DESIGN: Mail survey in April 1990. Included in the questionnaire were questions about the subjects' STD experience since their admission to the university and the type and date of the infection. SUBJECTS: Of the 19,682 undergraduate students 2920 subjects, in 10 groups of 292, were randomly selected. A total of 1731 (59.4%) completed the questionnaire. MAIN OUTCOME MEASURES: Estimated annualized incidence rates of genital human papillomavirus infection and Chlamydia infection. RESULTS: The estimated annualized incidence rates of genital human papillomavirus and Chlamydia infections were 2.2% and 1.5% respectively. Among the students who indicated being infected with genital human papillomavirus 59% were 18 to 21 years old (p < 0.05), 76% were women (p < 0.01) and 69% had more than one sexual partner (p < 0.01). No statistically significant associations were observed between age, sex and Chlamydia infection. On the other hand, 95% of the cases of Chlamydia infection were found among those who had more than one sexual partner (p < 0.01). CONCLUSION: University students continue to have sexual activities at risk for STDs and should be specifically targetted by general practitioners and health services in an effort to slow the spread of STDs.     

Changes in haemodynamic parameters following Tai Chi Chuan and aerobic exercise in patients recovering from acute myocardial infarction.

In this study, 126 patients (90 males, average age 56 years, range 39-80) were randomised to Wu Chian-Ch''uan style Tai Chi (38), aerobic exercise (41) or a non-exercise support group (47) following acute myocardial infarction. Patients attended twice weekly for three weeks then weekly for a further five weeks. Heart rate and blood pressure were recorded before and after each session. Over the 11 sessions of exercise there was a negative trend in diastolic blood pressure only in the Tai Chi group (Rs = 0.79, p < 0.01). Significant trends in systolic blood pressure occurred in both exercise groups (Rs = 0.64 and 0.63, both p < 0.05). Only four (8%) patients completed the support group eight-week programme which was less than the number completing Tai Chi (82%; p < 0.001) and aerobic exercise groups (73%; p < 0.001).     

Knowledge and attitudes of healthcare professionals and the impact on willingness to donate organs: a tertiary hospital survey

INTRODUCTIONHealthcare professionals (HCPs) working in critical care areas play an important role in the organ donation (OD) process. We studied HCPs’ own willingness to be organ donors and its association with sociodemographic factors as well as their knowledge and attitudes about OD and transplantation.METHODSA cross-sectional survey of HCPs working in four critical care units in a major transplant centre in Malaysia was undertaken using a validated structured questionnaire. Responses were analysed using multivariable analysis with willingness to donate as the dependent variable.RESULTSOf the 412 respondents (response rate 98.1%), the majority were nurses (60.4%), Malay (71.1%) and female (77.2%). Overall, 68.0% were willing to donate. The independent predictors of willingness to donate were profession (p < 0.001) and the Hindu religion (p = 0.001). Ethnicity (p = 0.003), religious belief (p < 0.001), knowledge (p = 0.016), belief in brain death (p = 0.018) and confidence in transplantation (p < 0.001) also independently correlated with willingness to donate, while attitudes to OD did not. Of those willing to donate, only 37.3% were carrying a donor card and only 63.1% had informed their family of their intention to donate.CONCLUSIONAlthough willingness to donate was higher in critical care HCPs than HCPs in general, significant knowledge gaps as well as certain beliefs and perceptions that could pose a barrier to OD were identified in this group. Measures to improve OD rates in Malaysia should include targeted educational programmes for HCPs working in critical care areas.     

Patterns of practice among older physicians in Ontario

BACKGROUND: Policy-makers interested in the supply of doctors in Canada have recently begun focusing attention on older physicians. This study informs the policy debate by analysing the practice patterns of Ontario physicians aged 65 years and over. METHODS: A cross-sectional and longitudinal analysis of physician claims data for fiscal years 1989/90 through 1995/96 was conducted. The number of full-time equivalent (FTE) physicians by age category, urban or rural status, and specialty was calculated by means of an established method, and differences between older physicians, established physicians and recent graduates (in practice for 5 years or less), in terms of the types of services provided and patients seen, were examined. RESULTS: The proportion of FTE physicians aged 65 or more increased from 5.3% to 7.0% during the study period, whereas the proportion of recent graduates decreased from 19.6% to 16.3%. Of the older physicians, 61.4% practised part time (less than 1 FTE). Half of the physicians aged 75 in 1989/90 were still in practice 6 years later. Older physicians were less likely than those under age 65 to practice obstetrics (4.6% v. 16.9%), provide emergency department services (1.1% v. 14.8%) or house calls (38.7% v. 60.4%), or perform many minor procedures (38.7% v. 62.3%) (p < or = 0.001 for all comparisons). Older physicians tended to be male and had older patients in their practices than did younger physicians. Rural regions had higher proportions of older specialists. INTERPRETATION: Ontario's physician corps is aging. This may result in decreasing availability of obstetrics and emergency department coverage in the future. Encouraging retirement may create more openings for recent graduates, but if such policies are enacted, special attention should be paid to ensure that rural communities and older patients continue to be served.     

High STOP-BANG questionnaire scores predict intraoperative and early postoperative adverse events

INTRODUCTION

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder associated with multisystemic organ involvement. The STOP-BANG questionnaire is a concise, validated questionnaire that is used to screen for OSA. This study aimed to establish the use of the STOP-BANG questionnaire for perioperative patient risk stratification.

METHODS

In this retrospective cohort study, we extracted the demographic, medical and perioperative outcome data of all patients who underwent elective surgery, excluding ophthalmic surgeries, from January to December 2011. Multivariate regression analysis was used to predict independent risk factors for intraoperative and early postoperative adverse events.

RESULTS

Of the 5,432 patients analysed, 7.4% had unexpected intraoperative and early postoperative adverse events. We found that the risk of unexpected intraoperative and early postoperative adverse events was greater in patients with STOP-BANG scores ≥ 3 compared to those with a STOP-BANG score of 0 (score 3: odds ratio [OR] 3.6, 95% confidence interval [CI] 2.1–6.3, p < 0.001; score 4: OR 3.4, 95% CI 1.8–6.5, p < 0.001; score 5: OR 6.4, 95% CI 2.7–15.0, p < 0.001; score ≥ 6: OR 5.6, 95% CI 2.1–15.4, p < 0.001). Patients with STOP-BANG scores ≥ 5 had a fivefold increased risk of unexpected intraoperative and early postoperative adverse events, while patients with STOP-BANG scores ≥ 3 had a ‘one in four’ chance of having an adverse event. Other independent predictors included older age (p < 0.001), American Society of Anesthesiologists class ≥ 2 (p < 0.003) and uncontrolled hypertension (p = 0.028).

CONCLUSION

STOP-BANG score may be used as a preoperative risk stratification tool to predict the risk of intraoperative and early postoperative adverse events.     

Evaluation of rubella screening in pregnant women

BACKGROUND: The rationale for rubella vaccination in the general population and for screening for rubella in pregnant women is the prevention of congenital rubella syndrome. The objective of this study was to evaluate the effectiveness of the prenatal rubella screening program in Quebec. METHODS: A historical cross-sectional study was designed. Sixteen hospitals with obstetric services were randomly selected, 8 from among the 35 "large" hospitals in the province (500 or more live births/year) and 8 from among the 50 "small" hospitals (fewer than 500 live births/year). A total of 2551 women were randomly selected from all mothers of infants born between Apr. 1, 1993, and Mar. 31, 1994, by means of stratified 2-stage sampling. The proportions of women screened and vaccinated were ascertained from information obtained from the hospital chart, the physician's office and the patient. RESULTS: The overall (adjusted) screening rate was 94.0%. The rates were significantly different between large and small hospitals (94.4% v. 89.6%). Five large hospitals and one small hospital had rates above 95.0%. The likelihood of not having been screened was statistically significantly higher for women who had been pregnant previously than for women pregnant for the first time (4.8% v. 1.4%; p < 0.001). Of the 200 women who were seronegative at the time of screening (8.4%), 79 had been vaccinated postpartum, had a positive serological result on subsequent testing or did not require vaccination, and 59 had not been vaccinated postpartum; for 62, subsequent vaccination status was unknown. INTERPRETATION: Continued improvement in screening practices is needed, especially in small hospitals. Because vaccination rates are unacceptably low, it is crucial that steps be taken to address this issue.