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Biomedical subjects

A P Contandriopoulos

Publications and source records attributed to A P Contandriopoulos.

At least 19 recordsLinked to original sources
PubMed2000

Occurrence and risk factors of oral candidiasis treated with oral antifungals in seniors using inhaled steroids.

Oral candidiasis (OC) is a frequent side effect of inhaled corticosteroids (iCSTs). This study estimated occurrence and significance of risk factors of OC treated with antifungals in users of iCSTs under conditions of normal use. This retrospective analysis used data drawn from drug insurance plan records in Quebec, Canada. The sample contained 27,000 seniors using anti-asthma medications during 1990. Three years of data (1989-1991) were searched for use of oral antifungals concurrent with exposure to iCSTs. A case-control study examined factors leading to increased probability of first incidence of OC in new users of iCSTs. Three-year occurrence for OC was 7%. Increased risk for a first occurrence of OC was significantly associated with higher doses of iCST, increased length of iCST exposure, use of antibiotics, use of oral steroids, having three or more prescribers, a history of use of both high and low strengths of iCST, and concurrent use of oral steroids and diabetes medications. The occurrence of OC is relatively high. Knowledge of factors leading to increased risk could facilitate the targetting of patients who need timely intervention, under conditions of normal use.

Aged↗
PubMed2000

Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients.

BACKGROUND: With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned. METHODS: A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs. RESULTS: The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met, and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours. CONCLUSION: Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.

Activities of Daily Living↗
PubMed2000

Cost-effectiveness analysis of psychiatric deinstitutionalization.

BACKGROUND: The cost-effectiveness of the eventual deinstitutionalization of patients with severe and persistent mental disorders who are currently hospitalized in long-term care remains a controversial matter. METHODS: A retrospective cohort of 96 pairs of psychiatric hospital patients with 1 member deinstitutionalized between 1989 and 1998 was followed up for nearly 10 years. All use of medical and social services was documented. Patients were evaluated at the start and end of the study on various clinical and social dimensions, as well as on quality of life. RESULTS: On several dimensions, deinstitutionalized patients scored more positively than did those patients still hospitalized. The lower daily cost of living accommodations for deinstitutionalized patients easily offsets the cost of services required for treatment in the community. CONCLUSION: Deinstitutionalization, as implemented in the hospital studied, remains for many patients a less costly option than continued hospitalization and is likely to improve their mental state and well-being.

Adult↗
PubMed2000

Organizational analysis of deinstitutionalization in a psychiatric hospital.

BACKGROUND: Few studies have been conducted of the organizational aspects that impact on the course of psychiatric deinstitutionalization. METHOD: A case study was undertaken of 10 years of deinstitutionalization in a Montreal psychiatric hospital. RESULTS: Deinstitutionalization has forged ahead in the hospital over the past few years, although the course it has taken is not the one initially plotted by its promoters. Care management of deinstitutionalized patients remains under the control of the psychiatric hospital and its physicians. However, the patients' well-being has remained a focus of concern and does not seem to have been detrimentally affected by this development. CONCLUSION: Deinstitutionalization is both a solution to the criticisms levelled at the hospital-psychiatric approach of managing persons with severe and persistent mental disorders and an extremely useful tool in the power struggle among the various stakeholders in mental health services reform. Deinstitutionalization has become unavoidable.

Case Management↗
PubMed2000

[Evaluation in the health sector: concepts and methods].

The practice of evaluation has existed in one form or another for as long as one can remember and is central to all processes of learning. Today, evaluation is a popular concept grouping together multiple and diverse realities. This article aims to propose a conceptual framework for evaluation that is broad and universal enough to allow all those concerned with evaluation of health services (regardless of their disciplines and interests) to better understand each other, to perform better evaluations, and to use them in a more pertinent manner. We will begin by defining evaluation as the process which consists of making a judgement on the value of an intervention by implementing a system which can provide scientifically valid and socially legitimate information on regarding this particular intervention (or any of its components) to the different stakeholders concerned, such that they can form an opinion from their perspective on the intervention and reach a judgement which can translate into action. We define "intervention" as any organized system of action (a structure, actors and their practices, processes of action, one or many finalities and an environment) aiming to, in a given environment, during a given time period, modify the foreseeable course of a phenomenon to correct a problematic situation. An intervention can be a technique, a medication, a treatment, an organisation, a program, a policy or even a complex system like the health care system. Various interventions, regardless of their nature, can be the object of two types of evaluation. Normative evaluation is based on appreciation of each component of the intervention according to criteria and standards. This type of evaluation is defined as an activity which consists of making a judgement regarding an intervention by comparing the resources utilized and their organisation (structure); services and goods produced (process) and results obtained to criteria and standards (in other words, summaries of what is good and right). Did the intervention correspond to what should have been done according to the standards utilized? Evaluative research aims to employ valid scientific methods to analyze relationships between different components of an intervention. More specifically, evaluation research can be classified into six types of analysis, which employ different research strategies. Strategic analysis allows appreciation of the pertinence of an intervention; logical analysis, the soundness of the theoretical and operational bases of the intervention; productivity analysis, the technical efficiency with which resources are mobilized to produce goods or services; analysis of effects, effectiveness of goods and services in producing results; efficiency analysis, relations between the costs of the resources (or the services) used and the results; implementation analysis, appreciation of interactions between the process of the intervention and the context of implementation in the production of effects. The official finalities of all evaluation processes are of four types: (1)strategic, to aid the planning and development of an intervention, (2) formative, to supply information to improve an intervention in progress, (3) summative, to determine the effects of an intervention (to decide if it should be maintained, transformed or suspended), (4) fundamental, to contribute to the advancement of empirical and theoretical knowledge regarding the intervention. In addition, experience acquired in the field of evaluation suggests that evaluation is also productive in that it allows actors, in an organized setting, to reconsider the links between the objectives given, practices developed and their context of action. This task of achieving coherence is continuous and is one of the intrinsic conditions of action in an organized setting. In this perspective, evaluation can have a key role, given that it is not employed to legitimize new forms of control but rather to favor debate and th

Cost-Benefit Analysis↗
PubMed1998

A conceptual framework for the analysis of health care organizations' performance.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

Canada↗
PubMed1997

Care for Canada's frail elderly population: fragmentation or integration?

Budget constraints, technological advances and a growing elderly population have resulted in major reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals and increasing pressure on the primary care and continuing care networks. The present system of care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of services, negative incentives and the absence of accountability. This is turn leads to the inappropriate and costly use of health and social services, particularly in acute care hospitals and long-term care institutions. Canada needs to develop a publicly managed community-based system of primary care to provide integrated care for the frail elderly. The authors describe such a model, which would have clinical and financial responsibility for the full range of health and social services required by this population. This model would represent a major challenge and change for the existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address issues raised by its introduction.

Aged↗
PubMed1997

Resource constraints and strategic change in a public hospital system.

It has been suggested that strategic management in public services tends to be oriented towards preserving and perpetuating current patterns of service provision, rather than changing priorities. However, faced with severe resource constraints combined with growing demand and rapidly developing technology, public hospitals in Canada have come under increasing pressure. Based on an empirical study of strategic management and change in 32 Montreal hospitals, this paper examines the relationship between financial adversity and the extent and nature of strategic change in these organizations. Strategic change indicators considered in the study include overall product mix, product diversity, product complexity, market demographics, efficiency, and revenue diversification. Results suggest that resource constraints have indeed stimulated changes within these organizations. In particular, hospitals suffering more severe financial difficulties have reduced their size and focused on a narrower range of services. Moreover, there is evidence that greater complementarity has been achieved among the entire sample of hospitals.

Data Collection↗
PubMed1997

Utilization of anti-asthma medications in two Quebec populations of anti-asthma medication users: a prescription database analysis.

This study describes the utilization of anti-asthma medications in two groups of users of such medications in the province of Quebec, Canada, during the year from June 1, 1990, to May 31, 1991. It is based on a secondary analysis of existing data banks recording the medications reimbursed by two government-funded ambulatory drug reimbursement programs that cover individuals aged 65 and over (seniors) and income security (welfare) recipients (ISRs). The study analyzed the use of the anti-asthma medications included in the list of medications eligible for reimbursement for program beneficiaries. Use was studied in two random samples of individuals who had at least one prescription filled for an anti-asthma medication (2566 seniors and 3695 ISRs). The most commonly used medication in both groups was inhaled salbutamol 100 mcg. Various forms of theophylline tablets were also used by a high proportion of the sample studied. Over 75% of the seniors and 68% of the ISR group used at least one form of theophylline during the course of the year. Inhaled corticosteroids were used by 43% of the seniors and by 36% of the ISR group, and sympathomimetics (beta 2-agonists), by 63% of seniors and 68% of ISRs.

Adolescent↗
PubMed1996

The diluting effect of medical work groups on feedback efficacy in changing physician's practice.

Feedback intervention has been advocated as a successful method to modify the way that physicians practice medicine. However, most studies concerned with modifying physician profiles have focused on interns and residents. The results presented here concern regular staff and therefore provide a better basis for generalization. Over a 2.5-year period, we analyzed the use of clinical resources by physicians practicing in four medical specialties in two hospitals. Hierarchical multiple regression models were used to control case mix in order to identify the specific effects attributable to feedback. The information failed to modify the physicians' practice profiles. Our results suggest that this failure is related to the organization of inpatient medical practice as a group effort. This mode of practice has a negative effect on feedback efficacy. First, it weakens one of the main feedback mechanisms, that is personal identification with the data. Second, it probably generates mutual adjustment among physicians, thus eliminating practice variations at the source.

Adult↗
PubMed1996

["Avoidable" infant mortality in two cities of northeastern Brazil: quality indicator of the local health system].

This paper seeks to discover the magnitude and causality structure of infant mortality--considered a "sentinel even" for quality-of-care indexes in health--in two municipalities of Northeastern Brazil. This is a population based study of the "invoked experimentation" type comparing observed infant mortality with that expected, given a properly functioning maternal and infant care program, allowing for the calculation of a "preventable index" (PDI) for these two municipalities. The preliminary step consisted of an active search and epidemiological investigation of deaths in order to eliminate their underreporting as events. Infant mortality rates in the two areas were relatively low--39 and 44 per thousand live births, respectively--but PDI in both was classified of the order of 40%, thus indicating a causality structure compatible with mortality rates of 100 per thousand. These findings suggest an uneven distribution of deaths, proved by an analytical comparison of the low income population with that of other income brackets (with risk ratios of 8 and 17.6 for total infant mortality and infant mortality from infectious diseases, respectively). PDI proved to be a useful index of preventability of infant deaths, and has the advantage of being simple and easy for health system managers concerned with the quality of health programs devoted to mothers and children to use.

Brazil↗
PubMed1995

Convergence or divergence of male and female physicians' hours of work and income.

This article verifies if the increase in the percentage of women in the medical profession led to the convergence of male and female physicians' hours of work as well as income. Active physicians in Quebec in 1978 were compared to the ones in 1988. Data were obtained from the computerized files of the Quebec Corporation of Physicians and the Régie d'assurance-maladie du Quebec. Despite the increasing representation of women in the medical profession, gender differences in hours worked and income remained. However, results also showed a tendency toward a convergence in total hours of work, more behavioral variation among women physicians and some behavioral change among men. The experience of the past should thus not be used as the basis for projections of future physician productivity or for medical manpower planning purposes without a careful analysis of trends in behavioral changes.

Adult↗
PubMed1995

Cost utility of chemotherapy and best supportive care in non-small cell lung cancer.

Polychemotherapy is the therapeutic option recommended for nonresectable, non-small cell lung cancer (NSCLC). However, the modest gains in survival, and the frequent and often serious adverse effects, associated with chemotherapy should also be considered when deciding on therapy. We therefore performed a cost-utility analysis of chemotherapy and best supportive care in NSCLC. Effectiveness and costs were analysed on 70 patients who were randomised to receive one of 3 treatments: VP (vindesine and cisplatin), CAP (cyclophosphamide, doxorubicin and cisplatin), or best supportive care. Subsequently, an assessment of the value of polychemotherapy and best supportive care was performed by oncology personnel using the time trade-off technique. Polychemotherapy was found to be more effective than best supportive care, but was also more costly and had a lower value score. Because of its cost utility and its higher value, best supportive care should not be discarded as an alternative for the treatment of NSCLC.

Antibiotics, Antineoplastic↗
PubMed1995

The economic effects of introducing vigabatrin, a new antiepileptic medication.

Epilepsy is a common disorder, the prevalence of which is estimated at between 0.1 and 1% of the population. Although there are a number of medications available for treating the disorder, 20 to 35% of affected individuals are resistant to standard treatments. Many of these patients could benefit from a new anti-epileptic, vigabatrin. Because the current indication for vigabatrin is as an adjunct in a specific subgroup of epileptic patients, which implies an increased cost of drug therapy, an ex ante economic appraisal of the expected consequences of its introduction in the treatment of epilepsy is valuable. This would provide decision makers with information to complement standard clinical data. Using administrative records of healthcare services utilisation by epileptic patients, we performed a simulation of the expected economic repercussions of vigabatrin use on direct costs related to disease management. The results show that whether or not the introduction of vigabatrin results in an increase or a reduction in costs to the healthcare system depends largely on 3 factors: (i) the administered dosage of vigabatrin; (ii) the effect that vigabatrin has on hospital admissions; and (iii) the proportion of epileptic patients who take the drug. Moreover, this study underlines the usefulness of administrative data in forecasting the economic impact of new health technologies.

Anticonvulsants↗
PubMed1995

The role of protocols and professional judgement in emergency medical dispatching.

The task of evaluating incoming calls to Emergency Medical Services (EMS) systems in order to determine the most appropriate response is performed in many different ways in current EMS systems. At one end of the spectrum, the process is entirely dependent on the judgement of professionals, while at the other end protocols specify the exact questions to be asked and corresponding decisions. This case study describes the experience of the Montreal EMS system, Urgences santé, where professional telephone evaluation performed by nurses since 1981 was replaced by a protocolized system in 1992. During the professional era, there were many attempts to formalize the nurses' decision-making process. These first revealed that professional judgement tended to override decision-support tools that did not allow a flexible processing of the information spontaneously provided by callers. Second, the choice of a single protocol for each call was unnatural for professionals who could spontaneously integrate multiple aspects of a problem in parallel. Third, when protocols were used by professionals, it was a posteriori in order to document their decisions rather than actually support them. Fourth, the use of Artificial Intelligence (AI) methods in order to formalize professional judgement revealed its great complexity, which was confirmed by cognitive analyses of the nurses' decision-making processes. In particular, decisions of not sending EMS resources seemed to be the most difficult. These unsuccessful attempts at formalizing professional judgement led to an evaluation of its performance in terms of results, i.e. to which extent actual decisions minimized errors (both false positives and false negatives) and decision times. A random sample of 1006 calls was collected and the ideal decision was determined by concensus of experts for each call based on the patient's clinical condition. This theoretical decision was considered as a goal standard to which actual decisions were compared. Data analysis revealed that sensitivity of telephone triage (i.e. decision to send EMS resources or not) was almost perfect and specificity was 0.55. The necessary compromise between sensitivity and specificity varied with the types of decisions. Decision times were related to the urgency of the situations, more urgent calls being processed more rapidly. These results were interpreted as representing sophisticated optimization processes in professional judgement. The professional system was replaced by a non-professional protocolized system in 1992. This new system has not yet been formally evaluated in terms of results, but many sources of evidence suggest that it was accompanied by a deterioration of performance. Many contextual factors influence the organization of telephone assessment in EMS systems. This case study suggests that professional judgement may be most useful in contexts where the demand for EMS services often exceeds the availability of resources. On the other hand, protocolized systems may be more appropriate in the absence of such constraints, and where the litigation context prohibits the occurrence of any false negative.

Artificial Intelligence↗
PubMed1993

The reform of the Quebec health care system: potential for innovation?

The recent reform of the health care system in Quebec can be viewed as the result of a continuous process that originated with the first reform launched in the early 70s. The reform focuses on three elements: decentralization, citizen participation, and outcome-centered management. The context in which the reform is being launched contains both favorable conditions and obstacles to its successful implementation.

Community Health Services↗