Characteristics of chronic pain patients in a rural teaching practice

Objective

To describe the characteristics of chronic noncancer pain (CNCP) patients taking oxycodone or its derivatives in a rural teaching practice.

Design

Characteristics of CNCP patients taking oxycodone over a 5-year period (September 2003 to September 2008) were compared with those of patients not taking opioid medications using a retrospective chart audit.

Setting

A rural teaching practice in southwestern Ontario.

Participants

A total of 103 patients taking chronic oxycodone therapy for CNCP and a random sample of 104 patients not taking opioid medication.

Main outcome measures

Number of visits, health problems, sex, and previous history of addiction and mental illness.

Results

Patients with CNCP taking oxycodone had significantly more health problems (P < .001), including drug and tobacco addictions. They had more than 3 times as many clinic visits during the same period of time as patients not taking opioid medication (mean of 39.0 vs 12.8 visits, P < .001).

Conclusion

Patients with CNCP in this rural teaching practice had significantly more health issues (P < .001) and were more likely to have a history of addiction than other patients were. They created more work with significantly more visits over the same period compared with the comparison group.     

Ecology of health care in Canada

Objective

To provide a population-based, Canada-wide picture of health care needs and health care use, and present it in a highly accessible manner, allowing provincial comparisons and comparisons with other international jurisdictions.

Design

A comparison of the rates of health care use among jurisdictions, using Canadian-population survey data and health administrative data.

Setting

Provincial jurisdictions across Canada.

Main outcome measures

Canadian and provincial rates of ill health (presence of chronic conditions) and health care use (contacts with family physicians, contacts with other specialist physicians, contacts with nurses, and hospitalizations) as monthly rates per 1000 population standardized by age and sex.

Results

The monthly rate per 1000 population of having at least 1 chronic condition ranged from 524 in Quebec to 638 in Nova Scotia; contacts with family physicians ranged from 158 in Quebec to 295 in British Columbia; contacts with other physician specialists ranged from 53 in Saskatchewan to 79 in Ontario; and contacts with nurses ranged from 23 in British Columbia to 41 in Quebec. Hospital stays ranged from 8 to 11 per 1000 people, and rates were similar among the provinces.

Conclusion

Recognizing the differences among jurisdictions is critical to informing health care policy across the country. Differences persisted when rates were standardized for different age and sex compositions in the provinces. This article provides a straightforward methodology using publicly available data that can be employed in each province to examine, in the future, the evolution over time of health care use by provincial jurisdictions.A panoramic view of the engagement of the population of Canada with health care does not exist. In order for governments, the single payer of health care in Canada, to understand the health behaviour of the citizens, such a view is needed. In order for researchers to appreciate what prevalent issues deserve our attention, this perspective would help. In order for clinicians to understand where they fit into a larger picture, a wide-angle lens is needed.For the first time in the world literature, to our knowledge, a comparison of health systems was made among jurisdictions, using the ecology of health care methodology.^1,2Our goal was to provide a population-based, Canada-wide picture of health care needs and health care use, and present it in a highly accessible manner that would allow provincial comparisons, as well as comparisons with other international jurisdictions.^1,2 We examined chronic conditions, visits with family physicians, visits with other specialist physicians, visits with nurses, and hospitalizations, by province and standardized by age and sex.     

Survey of Ontario primary care physicians' experiences with opioid prescribing

Objective

To measure physicians’ experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.

Design

Mailed survey.

Setting

The province of Ontario.

Participants

A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.

Main outcome measures

Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians’ confidence, comfort, and satisfaction with opioid prescribing; physicians’ opinions on strategies to optimize their prescribing; and physicians’ perspectives of their interactions with pharmacists and nurses.

Results

The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians’ patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.

Conclusion

Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.     

Rural family medicine training site: Proposed framework

Objective

To develop a framework for a successful rural family medicine training program and to assess the potential for a rural family medicine residency training program using the Weyburn and Estevan areas of Saskatchewan as test sites.

Design

A mixed-method design was used; however, the focus of this article was on the qualitative data collected. Questions formulated for the semistructured interviews evolved from the literature.

Setting

Rural Saskatchewan.

Participants

Community physicians and representatives from the Sun Country Regional Health Authority, the Saskatchewan Ministry of Health, and the University of Saskatchewan.

Methods

The data were documented during the interviews using a laptop computer, and the responses were reviewed with participants at the end of their interviews to ensure accuracy. The qualitative data collected were analyzed using inductive thematic analysis.

Main findings

Through the analysis of the data several themes emerged related to implementing a rural family medicine residency training program. Key predictors of success were physical resources, physician champions, physician teachers, educational support, administrative support, and other specialist support. Barriers to the development of a rural family medicine training site were differing priorities, lack of human resources, and lack of physical resources.

Conclusion

A project of this magnitude requires many people at different levels collaborating to be successful.     

Income and heart disease: Neglected risk factor

Objective

To determine the unadjusted and adjusted effects of income on heart disease; its main disease intermediary, high blood pressure; and its main behavioural risk factors, smoking and physical inactivity.

Design

Random-digit dialing telephone survey collected through the Canadian Community Health Survey by Statistics Canada.

Setting

Saskatchewan.

Participants

A total of 27 090 residents aged 20 years and older; each health region in Saskatchewan was represented.

Main outcome measures

Overall, 178 variables related to demographic characteristics, socioeconomic factors, behaviour, life stress, disease intermediaries, health outcomes, and access to health care were analyzed to determine their unadjusted and adjusted effects on heart disease.

Results

The mean age of the sample was 52.6 years. Women represented 55.9% of the sample. Most respondents were married (52.3%) and had some postsecondary or graduate education (52.5%). The mean personal income was $23 931 and the mean household income was $37 533. All models statistically controlled for age. Five covariates independently associated with heart disease included high blood pressure, household income of $29 999 or less per year, being a daily smoker, male sex, and being physically inactive. Five covariates independently associated with high blood pressure included being overweight or obese, being a daily smoker, household income of $29 999 or less per year, male sex, and being physically inactive. Five covariates independently associated with daily smoking included being a visible minority, household income of $29 999 or less per year, not being overweight or obese, education level of less than secondary school, and male sex. Six covariates independently associated with physical inactivity included being a visible minority, being overweight or obese, education level of less than secondary school, male sex, household income of $29 999 or less per year, and being a daily smoker.

Conclusion

Household income was strongly and independently associated with heart disease; its main disease intermediary, high blood pressure; and its main behavioural risk factors, smoking and physical inactivity. Income inequality is a neglected risk factor worthy of appropriate public debate and policy intervention.     

Colorectal cancer screening practices in Saskatchewan: Survey of family physicians

Objective

To evaluate current colorectal cancer (CRC) screening practices in Saskatchewan and identify barriers to screening with the goal of improving current practice.

Design

Survey of family physicians.

Setting

Saskatchewan.

Participants

A total of 773 family physicians were surveyed.

Main outcome measures

Demographic characteristics, individual screening practices, and perceived barriers to screening.

Results

The response rate to the survey was 44.5%. When asked what method they used for fecal occult blood testing, almost 40% of respondents were either unsure or did not answer the question. Of those who did respond, 35.8% employed hemoccult testing following digital rectal examination, a practice not recommended for CRC screening. Screening guidelines for average-risk patients were generally well adhered to, with 79.9% of respondents recommending screening beginning at age 50. For screening patients at increased risk of CRC owing to family history, only 64.2% of respondents began screening 10 years before the age of the index patient at diagnosis. Physicians who were more likely to follow guidelines were female, in practice fewer than 10 years, trained in Canada, and practising in urban areas. More than 90% of family physicians agreed that a standard provincewide screening program would be beneficial.

Conclusion

We have identified considerable knowledge gaps with regard to CRC screening. There is confusion about which fecal occult blood tests are recommended for screening. Also, screening guidelines for patients with a family history of CRC are poorly understood. These findings suggest that better physician education about CRC screening is required. Introduction of a provincewide screening program should improve overall screening success.     

Prescription opioid use and misuse: Piloting an educational strategy for rural primary care physicians

Objective

To evaluate the feasibility and effectiveness of a multifaceted educational intervention to improve the opioid prescribing practices of rural family physicians in a remote First Nations community.

Design

Prospective cohort study.

Setting

Sioux Lookout, Ont.

Participants

Family physicians.

Interventions

Eighteen family physicians participated in a 1-year study of a series of educational interventions on safe opioid prescribing. Interventions included a main workshop with a lecture and interactive case discussions, an online chat room, video case conferencing, and consultant support.

Main outcome measures

Responses to questionnaires at baseline and after 1 year on knowledge, attitudes, and practices related to opioid prescribing.

Results

The main workshop was feasible and was well received by primary care physicians in remote communities. At 1 year, physicians were less concerned about getting patients addicted to opioids and more comfortable with opioid dosing.

Conclusion

Multifaceted education and consultant support might play an important role in improving family physician comfort with opioid prescribing, and could improve the treatment of chronic pain while minimizing the risk of addiction.     

Implementing an evidence-informed faculty development program

Objective

To establish an evidence-informed faculty development program.

Design

Survey derived from a needs-assessment tool.

Setting

Department of Academic Family Medicine at the University of Saskatchewan, which is geographically dispersed across the province.

Participants

Full-time faculty members in the Department of Academic Family Medicine at the University of Saskatchewan.

Main outcome measures

Creation of an evidence-informed faculty development program.

Results

The response rate was 77.3% (17 of 22). The data were stratified by 2 groups: faculty members with less than 5 years of experience and those with 5 or more years of experience. Those with less than 5 years of experience rated the following as their top priorities: teaching, developing scholarly activities, and career development. Those with 5 or more years of experience rated the following as their top priorities: administration and leadership, teaching, and information technology. Although there were differences in overall priorities, the 2 groups identified 17 out of 54 skills as important to faculty development.

Conclusion

The results of the needs-assessment tool were used to shape a dynamic, evidence-informed faculty development program with full-time faculty in the Department of Academic Family Medicine at the University of Saskatchewan. Future programs will continue to be dynamic, faculty-centred, and evidence-informed.     

Narcotic-exposed neonates in a First Nations population in northwestern Ontario: incidence and implications

Objective

To document the incidence of neonatal abstinence syndrome (NAS) and the rate of narcotic use during pregnancy in northwestern Ontario, where narcotic abuse is a growing social and medical problem.

Design

Retrospective chart review.

Setting

The Sioux Lookout Meno Ya Win Health Centre catchment area in northwestern Ontario.

Participants

Mothers and neonates for the 482 live births that took place in the 18-month study period (January 2009 to June 2010).

Main outcome measures

Maternal drug use and neonatal outcomes were documented.

Results

The incidence of narcotic (oxycodone) abuse during pregnancy increased from a low of 8.4% at the beginning of the study period to a high of 17.2% by mid-2010. Narcotic-using mothers were more likely to also use nicotine and alcohol, to have premature deliveries, and to be episodic users. Narcotic-exposed neonates experienced NAS 29.5% of the time; daily maternal use was associated with a higher rate of NAS (66.0%). While all infants roomed in with their mothers, exposed infants were more likely to require transfer to a tertiary care nursery. Infants with severe NAS were treated with oral morphine and had significantly longer hospital stays compared with the entire cohort (4.5 vs 1.5 days, P = .004). Narcotic abuse during pregnancy in our region is not currently associated with increased rates of HIV or hepatitis C infection, as intravenous route of administration is less common at present than intranasal and oral ingestion.

Conclusion

Narcotic abuse during pregnancy is a considerable problem in First Nations communities in northwestern Ontario. Community-based initiatives need to be developed to address this issue, and medical and nursing staff need to develop surveillance, assessment, and therapeutic responses. Passive neonatal addiction and withdrawal result from maternal narcotic use during pregnancy. Rates of opioid use among pregnant Canadian women are unknown.     

Diagnoses of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians

Objective

To investigate family physicians’ differential diagnoses of clinical-scenario patients presenting with symptoms of either generalized anxiety disorder (GAD) or a major depressive episode (MDE).

Design

Cross-sectional survey.

Setting

Saskatchewan.

Participants

A total of 331 family physicians practising in Saskatchewan as of December 2007.

Main outcome measures

Type and number of physicians’ differential diagnoses for a GAD-scenario patient and an MDE-scenario patient.

Results

The survey response rate was 49.7% (331 of 666 surveys returned). Most physicians suggested a diagnosis of anxiety (82.5%) for the GAD-scenario patient and a diagnosis of depression (84.2%) for the MDE-scenario patient. In descending order, the 5 most frequent differential diagnoses for the GAD-scenario patient were anxiety, hyperthyroidism, depression, panic disorder or attack, and bipolar disorder. The 5 most frequent differential diagnoses for the MDE-scenario patient were depression, anxiety, hypothyroidism, irritable bowel syndrome, and anemia. Neither a diagnosis of anxiety nor a diagnosis of depression was associated with physicians’ personal attributes (sex, age, and years in practice) or organizational setting (number of total patient visits per week, private office or clinic, solo practice, Internet access, and rural practice setting). However, physicians in solo practice suggested fewer differential diagnoses for the GAD-scenario patient than those in group practice; physicians in practice 30 years or longer suggested fewer differential diagnoses for the MDE-scenario patient than those in practice fewer than 10 years. On average, physicians suggested 3 differential diagnoses for each of the scenarios.

Conclusion

Most family physicians recognize depression and anxiety in patients presenting with symptoms of these disorders and consider an average of 3 differential diagnoses in each of these cases.     

Socioeconomic composition of low-acuity emergency department users in Ontario

Objective

To describe the associations between the socioeconomic status of emergency department (ED) users and age, sex, and acuity of medical conditions to better understand users’ common characteristics, and to better meet primary and ambulatory health care needs.

Design

A retrospective, observational, population-based analysis. A rigorous proxy of socioeconomic status was applied using census-based methods to calculate a relative deprivation index.

Setting

Ontario.

Participants

All Ontario ED visits for the fiscal year April 1, 2008, to March 31, 2009, from the National Ambulatory Care Reporting System data set.

Main outcome measures

Emergency department visits were ranked into deprivation quintiles, and associations between deprivation and age, sex, acuity at triage, and association with a primary care physician were investigated.

Results

More than 25% of ED visits in Ontario were from the most deprived population; almost half of those (12.3%) were for conditions of low acuity. Age profiles indicated that a large contribution to low-acuity ED visits was made by young adults (aged 20 to 30 years) from the most deprived population. For the highest-volume ED in Ontario, 94 of the 499 ED visits per day were for low-acuity patients from the most deprived population. Most of the highest volume EDs in Ontario (more than 200 ED visits per day) follow this trend.

Conclusion

Overall input into EDs might be reduced by providing accessible and appropriate primary health care resources in catchment areas of EDs with high rates of low-acuity ED visits, particularly for young adults from the most deprived segment of the population.     

Cervical cancer screening among vulnerable women: Factors affecting guideline adherence at a community health centre in Toronto, Ont

Objective

To see if refugee women at a community health centre (CHC) in Toronto, Ont, are appropriately screened for cervical cancer and if there are any demographic characteristics that affect whether they are screened.

Design

Chart review.

Setting

A CHC in downtown Toronto.

Participants

A total of 357 eligible refugee women attending the CHC.

Main outcome measures

Papanicolaou test received or documented reason for no Pap test.

Results

Ninety-two percent of women in the study sample were either appropriately screened for cervical cancer or had been approached for screening. Eighty percent of women were appropriately screened. Demographic variables including pregnancy, being uninsured, not speaking English, recent migration to Canada, and being a visible minority did not affect receipt of a Pap test after migration in multivariate analyses. Not speaking English was associated with a delay to receiving a first Pap test after migration.

Conclusion

The clients at our centre are demographically similar to women who are typically overlooked for Pap tests in the greater Toronto area. Despite belonging to a high-risk population, refugee women in this multidisciplinary CHC were screened for cervical cancer at a higher rate than the local population.     

Physical activity in youth: Prevalence, risk indicators, and solutions

Objective

To determine the unadjusted and adjusted associations between developmental, environmental, psychological, social, or demographic factors and meeting the Health Canada physical activity standard.

Design

Survey.

Setting

Saskatoon, Sask.

Participants

Every student in grades 5 to 8 in Saskatoon was asked to complete the Saskatoon School Health Survey; 4197 students did so.

Main outcome measures

Whether students met the Health Canada standard for daily physical activity and associated risk factors for not meeting the standard.

Results

Among the 4197 youth who participated in the survey, only 7% met the Health Canada standard of daily physical activity longer than 1 hour of somewhat hard intensity or higher. Although there were 23 unadjusted factors associated with youth meeting the Health Canada standard, only 5 were significant after multivariate adjustment: 1) their fathers were employed (odds ratio [OR] 2.29, P = .027), 2) their parents watched them participate in physical activities or sports every day (OR 1.23, P < .001), 3) their friends encouraged them to do physical activities or sports every day (OR 1.19, P < .001), 4) their friends or classmates did not tease them for not doing well at physical activities or sports every day (OR 1.20, P = .001), and 5) they played sports or physical activities with coaches or instructors more than 4 times a week (OR 1.44, P < .001).

Conclusion

Given the low rates of physical activity among youth, we believe that a reduced list of independent risk indicators is required to focus our limited human and financial resources for successful intervention in the community.     

Examining the geographic distribution of French-speaking physicians in Ontario

Objective

To determine how many physicians in Ontario express a proficiency in providing services in the French language, and to assess the geographic distribution of such physicians.

Design

Population-based analysis of the 2007 College of Physicians and Surgeons of Ontario Annual Membership Renewal Survey.

Setting

Ontario.

Participants

A total of 22 688 GPs, FPs, and other specialists certified by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada who responded to the survey.

Main outcome measures

First official language spoken and languages of competency to conduct practice.

Results

The physician-to-patient ratio by first official language spoken is 1 physician per 138 Francophone patients in Ontario. There is 1 French-speaking GP or FP for every 297 Francophone patients, and most French-speaking physicians are located in southern Ontario (91.4%), at a ratio of 1 physician per 111 Francophone patients. The most promising French-speaking physician–to–Francophone patient ratios are found in southern Ontario (1:248 for GPs and FPs, and 1:202 for other specialists) and in urban Ontario (1:266 for GPs and FPs, and 1:209 for other specialists).

Conclusion

Clearly, there is a promising number of physicians, relative to the amount of French-speaking residents in Ontario, who identified a competency in offering services in French. However, while the number of physicians who indicated a self-assessed competency to deliver health services in French is promising, it is the maldistribution of such services that is of concern. Thus, efforts must be made to attract French-speaking physicians to areas where there is the greatest demand, particularly in the northern part of the province.     

Black Hawk Down: The evolution of resuscitation strategies in massive traumatic hemorrhage

Citation

Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, Sebesta J, Jenkins D, Wade CE, Holcomb JB: The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 2007, 63: 805–813 [1].

Background

Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.

Methods

Objective

To determine whether the ratio of plasma to RBCs transfused would affect survival by decreasing death from hemorrhage.

Design

Retrospective chart review.

Setting

United States Army combat support hospital in Iraq.

Subjects

246 patients who received a massive transfusion (≥10 units of RBCs in 24 hours) from November 2003 to September 2005. Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion.

Intervention

None.

Outcome

Hospital mortality rates and the cause of death were compared among groups. Multivariable logistic regression was used to determine the independent association between plasma to RBC ratio and hospital mortality.

Results

For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range (IQR), 0:12–1:5), for the medium ratio group, 1:2.5 (IQR, 1:3.0–1:2.3), and for the high ratio group, 1:1.4 (IQR, 1:1.7–1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (IQR, 14–25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1–35.2).

Conclusion

In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.     

Predicting international medical graduate success on college certification examinations: Responding to the Thomson and Cohl judicial report on IMG selection

Objective

To determine predictors of international medical graduate (IMG) success in accordance with the priorities highlighted by the Thomson and Cohl judicial report on IMG selection.

Design

Retrospective assessment using regression analyses to compare the information available at the time of resident selection with those trainees’ national certification examination outcomes.

Setting

McMaster University in Hamilton, Ont.

Participants

McMaster University IMG residents who completed the program between 2005 and 2011.

Main outcome measures

Associations between IMG professional experience or demographic characteristics and examination outcomes.

Results

The analyses revealed that country of study and performance on the Medical Council of Canada Evaluating Examination are among the predictors of performance on the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada certification examinations. Of interest, the analyses also suggest discipline-specific relationships between previous professional experience and examination success.

Conclusion

This work presents a useful technique for further improving our understanding of the performance of IMGs on certification examinations in North America, encourages similar interinstitutional analyses, and provides a foundation for the development of tools to assist with IMG education.