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Biomedical subjects

R Pineault

Publications and source records attributed to R Pineault.

At least 19 recordsLinked to original sources
PubMed2007

Non-patient factors related to rates of ruptured appendicitis.

BACKGROUND: Adult rates of ruptured appendicitis vary from 13.2 to 41.9 per cent in urban hospitals, despite controlling for individual factors. This suggests an effect of hospital organization. Surgeons report that appendicectomies may be delayed because of lack of access to operating rooms. METHODS: Combining interviews with hospital personnel and information from medical records for 1998-1999, a cross-sectional study using logistic regression, taking hospital clustering of patients into account, was conducted on 861 patients from 12 hospitals. Hospitals were grouped into organizational models. The diagnostic information was recoded to ensure interhospital validity. RESULTS: Hospitals with high activity and volumes of patients, but without an operating room designated for urgent surgery, were associated with a significantly higher risk of peritonitis (P<0.050). Time to surgery was very long in all hospitals, particularly time after departure from the emergency department and for elderly patients. CONCLUSION: Organizational characteristics, in unfavourable combinations, influence the course of time-dependent diseases such as appendicitis. Difficulties in gaining access to operating rooms, even for urgent operations, have emerged. Delays in treatment must be addressed when planning healthcare reforms.

Adolescent↗
PubMed2006

[Development and application of a clinical vignette to assess the quality of cancer care].

BACKGROUND: In conjunction with a study focusing on the implementation and effect of an integrated care network for cancer patients in the Monteregie region in Quebec, the vignette research strategy was adopted to assess the quality of care provided by the interdisciplinary teams working with this clientele. This research strategy has only recently been used to assess professional practices. This article adopts a resolutely methodological angle in order to describe a rigorous, innovative, transferable experience from the standpoint of the elaboration of a vignette. METHODS: We adopted a six-step approach to elaborate the vignette. This vignette includes the description of collaboration with clinicians. The approach assured us of attaining high content validity from the standpoint of facets of its relevance, completeness and intelligibility to respondents. Our clinical vignette describes a sequence of events stemming from the care coordination of a 58-year-old man suffering from rectal cancer. Data were collected through group interviews with the interdisciplinary teams (n=5) under study. The professionals present were asked to describe their usual practices with respect to the events described in the vignette. We adopted two data analysis strategies: (i) a comparison of practices revealed through the interviews with anticipated responses in light of the guidelines of the "Programme québécois de lutte contre le cancer"; and (ii) an analysis according to facets of the quality of care. RESULTS: Team professional practices seem to evolve towards the care package valued by the "Programme québécois de lutte contre le cancer". Differences were also observed between the teams from the standpoint of the continuity of care. CONCLUSION: Our study shows that it is possible to develop a vignette that enables us to understand professional practices in an interdisciplinary context provided that a rigorous approach is adopted. This approach, which can be transferred to the study of similar phenomena, makes it possible to document the care offered and contribute to the renewal of professional practices.

Colonic Neoplasms↗
PubMed2006

Delivery of high-tech home care by hospital-based nursing units in Quebec: clinical and technical challenges.

BACKGROUND: The role that hospital-based nurses should play in the delivery of high-tech home care, and how they should be supported in that role, are topics that remain understudied. Our research objective was to document how hospital-based nursing teams perceive and deal with the clinical and technical challenges associated with the provision of high-tech home care. METHODS: Four home care interventions were selected: antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. A self-administered survey was sent to all hospital-based units providing these interventions in the province of Quebec, Canada (n = 154; response rate: 70.8%). We used descriptive statistical analyses to derive mean values for scores on either a five- or a six-level Likert scale. RESULTS: Despite variation across the four interventions, our results indicate that while nursing teams believe these interventions increase patients' autonomy, they also recognize that they generate anxiety and impose constraints on patients' lives. Nurses must increase efforts to deal with both clinical and technical challenges and help patients overcome the barriers to appropriate use of home care technologies. CONCLUSIONS: While nursing teams generally perceive high-tech home care as beneficial, they still experience significant technical and clinical challenges. Some of these challenges could be addressed by strengthening professional training initiatives, while others require broader home care policy interventions.

Adaptation, Psychological↗
PubMed2005

Correlation between nutritional biomarkers and breast cancer: a case-control study.

A case-control study to explore associations between retinoids, tocopherols, total and beta-carotenes and breast cancer was conducted by analysing concentrations of these biomarkers in adipose tissue, cheek cells and plasma. A total of 414 French-Canadians in Montreal with new diagnoses of breast cancer were age-matched to 429 population-based controls. Subjects were interviewed using a questionnaire, and biological samples from 287 cases and 112 controls were collected within 3 months of the diagnosis. Mean beta carotene concentrations in cheek cells were significantly lower among controls. Odds ratios (ORs) from logistic regression analysis were used to compare higher and lower tercile concentrations. Significant positive associations were observed in adipose tissue for retinoid [OR=2.11; 95% CI (1.09-4.08)] and beta carotene [OR=3.18; 95% CI (1.70-5.93)]; in cheek cells for beta carotene [OR=2.22; 95% CI (1.21-4.50)] and for total carotenes [OR=2.94; 95% CI (1.59-5.42)] and in plasma for beta carotene [OR=1.53; 95% CI (0.80-2.93)] and total carotenes [OR=1.04; 95% CI (0.53-2.05)]. Among the control groups, significant Pearson correlations were observed between cheek cells and adipose tissue for total carotenes (r=0.27; p=0.01) and cheek cells and plasma (r=0.22; p=0.04). In contrast to previous works, this study shows that high concentrations of retinoids and carotenes in adipose tissue and cheek cells are associated with increased risk of breast cancer. However, all these studies are limited by small sample size. Although our study tested a limited number of controls, important associations were observed. These results suggest that the effect of disease on biomarkers is fundamental to the interpretation of epidemiological data. We suggest either that the high levels of these biomarkers found in cancer patients in this study may be due to the disease process that affects the pharmacokinetics of the biomarker or that the disease causes a change in dietary habits. In addition, in studies involving the application of biomarkers to cancer epidemiology it is imperative that a typical biomarker concentration is not associated with breast cancer risk before further examination of the methodological limitations of epidemiological studies investigating this relationship. Therefore, sample size, selection bias, information bias, and confounding should be considered in the design of studies investigating the aetiological relationship between biomarkers and breast cancer.

Adipose Tissue↗
PubMed2001

Loyalty to the regular care provider: patients' and physicians' views.

BACKGROUND: Changes in the organization of primary care practices are likely to have repercussions on the manner in which patients and physicians perceive loyalty to a regular source of care. A better understanding of their views will contribute to conceptual reflections on this poorly documented topic and, where needed, will reinforce efforts to adapt services to patient expectations. OBJECTIVES: The aims of this study are to document and compare the views that patients and GPs have of loyalty to the regular care provider. METHODS: This exploratory study uses the focus group technique. In 1997, we set up three groups of patients and three groups of physicians practising in Montreal. A total of 23 patients and 14 physicians participated in the study. The meetings investigated the participants' points of view on various aspects of the notion of loyalty. Analysis was based on transcripts of the meetings. The emerging themes were identified and the viewpoints were coded independently and then revised (when necessary) in order to obtain a consensus. RESULTS: Patients and physicians have a relatively congruent vision of the notion of loyalty. This tendency to use the regular source of care over time appears to be rooted in a formal or informal contract between patients and their physicians and implies a sustained partnership and a strong interpersonal relationship. The relationship established is neither exclusive nor permanent. Patients periodically reconsider it by evaluating their physician's technical and interpersonal skills. CONCLUSIONS: This study highlights the dynamic and multidimensional nature of the notion of loyalty. It shows that patients clearly identify with a particular physician rather than a clinic. The results challenge the prevailing methods of assessing longitudinality of care.

Adult↗
PubMed2000

Patient perception of quality following a visit to a doctor in a primary care unit.

BACKGROUND: Assessment of the quality of primary care services may be enhanced by including patient perceptions as well as professional judgment of quality. There is a need for reliable and valid instruments to measure these perceptions. OBJECTIVES: (i) To present a scale for measuring patient perception of quality of care following a visit to a doctor; and (ii) to analyse the responses given by patients recruited in primary care units in the Montreal region. The scale is composed of 22 items regrouped into three sub-scales referring to the patient-physician relationship (five items); the technical aspects of care (12 items); and the outcomes of the visit (five items). Distinctive features of the scale are that it focuses on patients' opinions about quality rather than on satisfaction, and that it includes items related to outcomes of the visit. METHODS: A survey was conducted on 473 patients who visited a physician in 11 primary care units in the Montreal region. Randomly selected patients received mailed questionnaires 5-7 days following their visit. Various statistical procedures were used to assess the reliability and the validity of the global scale and the sub-scales, and to analyse patients' patterns of response. RESULTS: The analysis of the psychometric properties of the global scale and the three sub-scales provides favourable evidence concerning their reliability and validity. The results of the factor analysis, the inter-item correlations and the Cronbach's alpha coefficients all support the distinction made between the interpersonal processes, the technical processes and the outcomes, and, at the same time, confirm the complex nature of the notion of perceived quality. The analysis of patients' responses allows the identification of items associated with global perception about quality of care. This global perception results from patients' perception of the physician's professional and interpersonal skills as well as from the outcomes of care. CONCLUSION: The scale can be used by physicians or primary health care units and has a wide range of applications.

Attitude to Health↗
PubMed1999

Practice guidelines for clinical prevention: do patients, physicians and experts share common ground?

BACKGROUND: Clinical practice guidelines, such as those of the Canadian Task Force on Preventive Health Care, although based on sound evidence, may conflict with the perceived needs and expectations of patients and physicians. This may jeopardize the implementation of such guidelines. This study was undertaken to explore patients' and family physicians' acceptance of the task force's recommendations and the values and criteria upon which the opinions of these 2 groups are based. METHODS: Focus groups were used to collect study data. In total, 35 physicians (in 7 groups) and 75 patient representatives (in 9 groups) participated in the focus groups. An inductive approach was used to develop coding grids and to generate themes from the transcripts of the interviews. RESULTS: Physicians expressed resistance to discontinuing the annual check-up, which they viewed as an organizational strategy to counteract the many barriers to preventive care that they encounter. They reported difficulties in explaining to their patients the recommendations of the Canadian Task Force on Preventive Health Care, which they found complex and inconsistent with popular wisdom. Both patients and physicians attributed high value to the detection of insidious diseases, even in the absence of proof of the effectiveness of such activity. INTERPRETATION: The patients and family physicians who participated in this study shared many opinions on the value of preventive activities that depart from the values used by "prevention experts" such as the Canadian Task Force on Preventive Health Care in establishing their recommendations. A better understanding of the values of patients and physicians would help guideline developers to create better targeted communication strategies to take these discrepancies into account.

Adult↗
PubMed1997

An assessment of the use of costs and quality of life as outcomes in endoscopic research.

BACKGROUND: Costs and quality of life are increasingly important study outcomes. We quantitatively and qualitatively assessed their use in recent endoscopic research. METHODS: All Medline-retrieved 1985 to 1995 published gastrointestinal endoscopic research using cost and/or quality of life as outcomes were analyzed. RESULTS: Sixty-eight (1.2%) of an estimated 5568 publications discussed costs and/or quality of life as endoscopic outcomes (24 quality of life, 37 cost-effectiveness, 7 cost-benefit). Their use did not increase with time. Cost or quality of life was infrequently a primary study outcome. Twenty of 24 (83%) quality of life papers used an objective scale. However, of these, 15 of 20 (75%) used symptom indexes, performance scales, or other nonvalidated quality of life instruments. Two of 24 (8%) evaluated quality of life in nonmalignant disease. Eight of 40 (20%) papers claimed endoscopy was cost-effective, with no evidence of formal cost assessment. Ten of 32 (31%) substituted charges for costs. Of 21 papers reporting cost data, 4 (19%) specified cost type (e.g., direct vs other), 6 (29%) specified cost perspective, and 9 (43%) reported sensitivity analysis. Sixteen of 27 (59%) cost-effectiveness papers did not correlate costs with changes in a health outcome. CONCLUSIONS: The overall cost and quality of life assessment in endoscopic research has been limited and must be improved. Accurate cost and quality of life assessment will require cooperation between gastroenterologists and experts in these fields.

Cost-Benefit Analysis↗
PubMed1996

Quality of life assessment and HIV infection: a review.

In the last few years, survival of patients infected with human immunodeficiency virus (HIV) has been improved because of a decreased incidence of some opportunistic complications attributable to prophylactic treatments and antiretroviral drugs. The impact of these agents should also be reflected in the quality of life (QoL) of patients. We have reviewed this topic with an emphasis on different types of measurements such as Q-TWIST, MOS and the Spitzer score which seem to be most appropriate for this patient population. We do not think that a special type of assessment should be designed for HIV-infected persons. It would be less time-consuming to improve already existing validated scores focusing on HIV infection. QoL in intravenous drug users with HIV should be evaluated more often.

Clinical Trials as Topic↗
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↗
PubMed1994

Utilization of a specialized clinic following an ecological accident.

On August 23, 1988, a fire broke out in a warehouse storing PCBs, forcing the evacuation of 5,500 citizens. Three days later, a specialized clinic was opened to examine and reassure the population. Seventy percent of the evacuated people showed up at the clinic. The aim of this case-control study was to identify the determinants of utilization of this clinic among the evacuated population. Cases and controls were sampled from the cohort of the evacuated adults. Both cases and controls were randomly selected among those who consulted and those who did not consult at the clinic. A logistic regression identified nine predictors of utilization: age, family type of household, annual income less than $40,000, objective and perceived exposure to the toxic smoke, reaction to the risk, perceived scale of the evacuation, number of moves during the evacuation period and consultation elsewhere with a physician. Results showed that the fear resulting from exposure created a stronger motive to consult the clinic than physical symptoms and needs.

Accidents, Occupational↗
PubMed1993

Outcome of rationing access to open-heart surgery: effect of the wait for elective surgery on patient outcome.

OBJECTIVE: To assess the effect of the waiting period before elective open-heart surgery on patient outcomes. DESIGN: Retrospective analysis. SETTING: The Montreal Heart Institute, a referral centre in cardiology and cardiac surgery. PATIENTS: All 568 patients who underwent open-heart surgery on an elective basis or following urgent admission or interhospital transfer between October 1991 and February 1992. MAIN OUTCOME MEASURES: In-hospital death rate, incidence of postoperative complications, length of stay in the intensive care unit (ICU) and total length of hospital stay. RESULTS: A total of 206 patients (151 men and 55 women with an average age of 59.0 [standard error of the mean (SEM) 1] years) underwent elective surgery, and 362 patients (264 men and 98 women with an average age of 62.0 [SEM 1] years) underwent urgent surgery. The mean wait for elective surgery was 2.8 (SEM 0.2) months. There was no significant difference between the two groups in the in-hospital death rate (4% v. 4%), the average length of stay in the ICU (4.4 [SEM 0.2] days v. 5.8 [SEM 1] days) or the average total length of hospital stay (9.0 [SEM 0.4] days v. 9.1 [SEM 1] days). As would be expected, postoperative complications developed in significantly more patients in the urgent group (27%) than the elective group (18%) (p = 0.02). Eight patients were admitted on an urgent basis for surgery owing to worsening symptoms or acute myocardial infarction after a mean wait of 4.6 months. One patient died suddenly at home 1 month after medical investigation while awaiting repeat coronary artery bypass grafting. Among the 206 patients who underwent elective surgery there was no relation between waiting time and adverse clinical outcomes after surgery. CONCLUSIONS: The results suggest that the wait before elective open-heart surgery had no effect on patient outcome after surgery in our institution. A policy of a short waiting period before elective open-heart surgery for patients whose condition is stable is safe and acceptable only if rapid access to medical and surgical treatment is available should it become necessary.

Analysis of Variance↗
PubMed1993

Organizational and environmental determinants of the performance of public health units.

In the wake of the reform of the Quebec health care system in the early 1970s, thirty-two public health units (DSCs) were created. They were administratively and geographically integrated into short-term care hospitals throughout the province. This study aimed at determining: (1) the influence of environmental and organizational factors on the way in which those public health units carried out their mandate; (2) the influence of these same factors on their performance in terms of level of innovation and in terms of the fulfillment of their mandate as assessed by their main clients; and (3) the influence of their activities on their performance. Our results show that the most innovative units appear to be those that have directed a large part of their efforts toward research and that have maintained close ties with other institutions and agencies. The public health units main clients differ however on their perception of the DSCs' performance.

Community Health Services↗
PubMed1993

A task contingent model of medical practice organization.

The treatment of acute episodes of morbidities in hospitalized patients is a complex and uncertain task. To accomplish this task, physicians organize themselves into teams in an effort to overcome two constraints: the necessity to offer both complete care and continuous care. This study examines the extent to which the nature and size of medical teams is explained by task difficulty and task variability, which are two dimensions of task uncertainty. The results support globally the hypothesis that the organization of medical practice is contingent upon the nature of the task defined in terms of uncertainty. However, the results also suggest that the task contingent model should be adjusted to take into account the fact that formal organizational characteristics may have an a priori influence on team structure.

Analysis of Variance↗
PubMed1993

Factors influencing the practice of vaginal birth after cesarean section.

OBJECTIVES: Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians. METHODS: A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice. RESULTS: The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education. CONCLUSIONS: This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm.

Adult↗
PubMed1993

Medical team interdependence as a determinant of use of clinical resources.

OBJECTIVE: Our objective, based on organization theory, is to examine whether interdependence among physicians leads to coordination problems that in turn may explain variations observed in the use of clinical resources. DATA SOURCES/STUDY SETTING: Secondary data about episodes of in-hospital care were collected over a 14-month period in two midsize acute care hospitals located in two suburbs of Montreal, Quebec. STUDY DESIGN: Hierarchical regression analysis was used to assess the marginal effect of medical team interdependence on clinical resource utilization after taking into account the effect attributable to the nature of several morbidities taken as specific and distinct tasks. PRINCIPAL FINDINGS: Medical team interdependence is found within medical specialties as well as between specialties. The largest portion of resource utilization was explained by morbidity characteristics, whereas team interdependence had a weaker, but systematic effect for all morbidities studied (15 regression models out of 18 performed). Task coordination was found to become more difficult as the number of physicians coming from different specialties increased in the context of teamwork. CONCLUSIONS: Results suggest that team practice does not entirely overcome coordination problems inherent to task (morbidity) interdependence. In considering the individual (especially the attending) physician as the main factor responsible for resource utilization, other factors related to team practice may too readily be overlooked.

Dependency, Psychological↗