Community group practices in Canada: are they ready to reform their practice?

INTRODUCTION: Governments and healthcare organizations in Canada are reforming the clinical practice structures and policies to deliver primary care to the population. A key component of primary healthcare reform is the establishment of an interdisciplinary, community-based team approach to patient care. This study was undertaken to provide in-depth insight regarding primary healthcare providers' beliefs and attitudes in regard to their current group practice, what changes they believe are occurring and those necessary to reform group practice settings, their willingness to embrace changes, and the challenges they face to realize the proposed reform. METHODS: This study employed a mixed-method research design (qualitative and quantitative data collection techniques) through day-long focus groups of primary healthcare professionals (eg, family physicians, specialists, dieticians, psychologists) from across Canada. RESULTS: There is considerable variation in the composition of primary care group practices across Canada. Respondents report that group practices are little more than an economic convenience to facilitate sharing of resources. Even when a practice is composed of several disciplines, there is little to no organized or systematic interaction among healthcare professionals aimed at improving patient care, lack of clarity as to identified leaders/managers of the team, and inconsistencies in the model of care provided to patients. However, there is a perception of value and benefit in working in a cohesive group practice to improve patient care. DISCUSSION: Findings revealed that although healthcare providers report themselves ready to make the necessary changes and willing to move to interdisciplinary team-based practices, there are substantive challenges that impede a movement to truly effective interdisciplinary team practice and functioning. These challenges include the type and allocation of funding, interprofessional healthcare provider education, changing the healthcare provision model, and barriers among healthcare professionals regarding shared and equitable team accountability for patient health outcomes.     

Systems are changing: where can they be improved?

Wide-ranging changes of unprecedented scale throughout the delivery of healthcare services are producing consequences we cannot ignore. A need to collaborate to improve healthcare systems is evident. The Society for Healthcare Epidemiology of America (SHEA) and the Health Care Division of the American Society for Quality are responding in jointly sponsoring this symposium concerning problems with medical devices. This presentation and those that follow will explore the quality of management of managed-care corporations; the important threat to out primary source of innovation in medical technology posed by behaviors of consolidated corporations; the impact of these changes on roles of hospital epidemiologists; and measures to ensure proper design, production, delivery, and use of safe medical products. Our profession and SHEA have made significant research-based contributions that document their potential value, but we have not always done as well as we could to market epidemiology as an important asset for sound management decisions in this era of change. We should ally ourselves with related disciplines in order to succeed as we undertake new challenges on a broadening field.     

Drug treatment courts are popular but do they work and are they ethical and appropriate for Canada?

Currently Canada is experimenting with the implementation of drug treatment courts. Pilot projects are underway in both Toronto and Vancouver. In the U.S., drug courts emerged as a response to the overcrowding of the prison system, the end product of the revolving door of substance dependent people moving through the court system. However, this expansion was not accompanied by any rigorous evaluation or critical reflection as to whether drug treatment courts can achieve their desired outcomes or if they are appropriate for dealing with substance dependent offenders. The purpose of this article is to take a critical look at this phenomenon and to discuss whether the drug court model is suitable for Canada.     

The kids aren’t alright: The effects of medical marijuana market size on adolescents

We exploit shocks to US federal enforcement policy to assess how legal medical marijuana market size affects youth marijuana use and consequences for youth traffic-related fatalities. Using hand-collected data on state medical marijuana patient rates to develop a novel measure of market size, we find that legal market growth increases youth marijuana use. Likely mechanisms are lower prices and easier access. Youth die more frequently from alcohol-involved car accidents, suggesting complementarities for youths. The consequences of marijuana legalization for youth are not immediate, but depend on how supply-side regulations affect production and prices.     

Insurance expansions: do they hurt those they are designed to help?

Seeking to redress health disparities across income and race, many policy-makers mandate health insurance benefits, presuming that equalized benefits will help equalize use of beneficial health services. This paper tests that presumption by measuring health care use by a diverse population with comprehensive health insurance. Focusing on use of mental health care and pharmaceuticals, it finds that even when insurance benefits and access are constant, whites and those with high incomes consume more of these benefits than other people do. This suggests that privileged classes extract more health care services even when everyone pays equal premiums for equal insurance coverage.     

The applications of PROs in clinical practice: what are they, do they work, and why?

Background  Precisely defining the different applications of patient-reported outcome measures (PROs) in clinical practice can be difficult. This is because the intervention is complex and varies amongst different studies in terms of the type of PRO used, how the PRO is fed back, and to whom it is fed back. Methods  A theory-driven approach is used to describe six different applications of PROs in clinical practice. The evidence for the impact of these applications on the process and outcomes of care are summarised. Possible explanations for the limited impact of PROs on patient management are then discussed and directions for future research are highlighted. Results  The applications of PROs in clinical practice include screening tools, monitoring tools, as a method of promoting patient-centred care, as a decision aid, as a method of facilitating communication amongst multidisciplinary teams (MDTs), and as a means of monitoring the quality of patient care. Evidence from randomised controlled trials suggests that the use of PROs in clinical practice is valuable in improving the discussion and detection of HRQoL problems but has less of an impact on how clinicians manage patient problems or on subsequent patient outcomes. Many of the reasons for this may lie in the ways in which PROs fit (or do not fit) into the routine ways in which patients and clinicians communicate with each other, how clinicians make decisions, and how healthcare as a whole is organised. Conclusions  Future research needs to identify ways in with PROs can be better incorporated into the routine care of patients by combining qualitative and quantitative methods and adopting appropriate trial designs.