PubMed Health⌕ Search

Biomedical subjects

Ross E G Upshur

Publications and source records attributed to Ross E G Upshur.

At least 19 recordsLinked to original sources
PubMed2006

Pandemic influenza preparedness: an ethical framework to guide decision-making.

BACKGROUND: Planning for the next pandemic influenza outbreak is underway in hospitals across the world. The global SARS experience has taught us that ethical frameworks to guide decision-making may help to reduce collateral damage and increase trust and solidarity within and between health care organisations. Good pandemic planning requires reflection on values because science alone cannot tell us how to prepare for a public health crisis. DISCUSSION: In this paper, we present an ethical framework for pandemic influenza planning. The ethical framework was developed with expertise from clinical, organisational and public health ethics and validated through a stakeholder engagement process. The ethical framework includes both substantive and procedural elements for ethical pandemic influenza planning. The incorporation of ethics into pandemic planning can be helped by senior hospital administrators sponsoring its use, by having stakeholders vet the framework, and by designing or identifying decision review processes. We discuss the merits and limits of an applied ethical framework for hospital decision-making, as well as the robustness of the framework. SUMMARY: The need for reflection on the ethical issues raised by the spectre of a pandemic influenza outbreak is great. Our efforts to address the normative aspects of pandemic planning in hospitals have generated interest from other hospitals and from the governmental sector. The framework will require re-evaluation and refinement and we hope that this paper will generate feedback on how to make it even more robust.

Coercion↗
PubMed2006

Seasonality of service provision in hip and knee surgery: a possible contributor to waiting times? A time series analysis.

BACKGROUND: The question of how best to reduce waiting times for health care, particularly surgical procedures such as hip and knee replacements is among the most pressing concern of the Canadian health care system. The objective of this study was to test the hypothesis that significant seasonal variation exists in the performance of hip and knee replacement surgery in the province of Ontario. METHODS: We performed a retrospective, cross-sectional time series analysis examining all hip and knee replacement surgeries in people over the age of 65 in the province of Ontario, Canada between 1992 and 2002. The main outcome measure was monthly hospitalization rates per 100,000 population for all hip and knee replacements. RESULTS: There was a marked increase in the rate of hip and knee replacement surgery over the 10-year period as well as an increasing seasonal variation in surgeries. Highly significant (Fisher Kappa = 16.05, p < 0.01; Bartlett-Kolmogorov-Smirnov Test = 0.31, p < 0.01) and strong (R2Autoreg = 0.85) seasonality was identified in the data. CONCLUSION: Holidays and utilization caps appear to exert a significant influence on the rate of service provision. It is expected that waiting times for hip and knee replacement could be reduced by reducing seasonal fluctuations in service provision and benchmarking services to peak delivery. The results highlight the importance of system behaviour in seasonal fluctuation of service delivery.

Aged↗
PubMed2006

Time series analysis of age related cataract hospitalizations and phacoemulsification.

BACKGROUND: Cataract surgery remains a commonly performed elective surgical procedure in the aging and the elderly. The purpose of this study was to utilize time series methodology to determine the temporal and seasonal variations and the strength of the seasonality in age-related (senile) cataract hospitalizations and phacoemulsification surgeries. METHODS: A retrospective, cross-sectional time series analysis was used to assess the presence and strength of seasonal and temporal patterns of age-related cataract hospitalizations and phacoemulsification surgeries from April 1, 1991 to March 31, 2002. Hospital admission rates for senile cataract (n = 70,281) and phacoemulsification (n = 556,431) were examined to determine monthly rates of hospitalization per 100,000 population. Time series methodology was then applied to the monthly aggregates. RESULTS: During the study period, age-related cataract hospitalizations in Ontario have declined from approximately 40 per 100,000 to only one per 100,000. Meanwhile, the use of phacoemulsification procedures has risen dramatically. The study found evidence of biannual peaks in both procedures during the spring and autumn months, and summer and winter troughs. Statistical analysis revealed significant overall seasonal patterns for both age-related cataract hospitalizations and phacoemulsifications (p < 0.01). CONCLUSION: This study illustrates the decline in age-related cataract hospitalizations in Ontario resulting from the shift to outpatient phacoemulsification surgery, and demonstrates the presence of biannual peaks (a characteristic indicative of seasonality), in hospitalization and phacoemulsification during the spring and autumn throughout the study period.

Aging↗
PubMed2005

Chaperone use during intimate examinations in primary care: postal survey of family physicians.

BACKGROUND: Physicians have long been advised to have a third party present during certain parts of a physical examination; however, little is known about the frequency of chaperone use for those specific intimate examinations regularly performed in primary care. We aimed to determine the frequency of chaperone use among family physicians across a variety of intimate physical examinations for both male and female patients, and also to identify the factors associated with chaperone use. METHODS: Questionnaires were mailed to a randomly selected sample of 500 Ontario members of the College of Family Physicians of Canada. Participants were asked about their use of chaperones when performing a variety of intimate examinations, namely female pelvic, breast, and rectal exams and male genital and rectal exams. RESULTS: 276 of 500 were returned (56%), of which 257 were useable. Chaperones were more commonly used with female patients than with males (t = 9.09 [df = 249], p < 0.001), with the female pelvic exam being the most likely of the five exams to be attended by a chaperone (53%). As well, male physicians were more likely to use chaperones for examination of female patients than were female physicians for the examination of male patients. Logistic regression analyses identified two independent factors--sex of physician and availability of a nurse--that were significantly associated with chaperone use. For female pelvic exam, male physicians were significantly more likely to report using a chaperone (adjusted Odds Ratio [OR] 40.62, 95% confidence interval [CI] 16.91-97.52). Likewise, having a nurse available also significantly increased the likelihood of a chaperone being used (adjusted OR 6.92, 95% CI 2.74-17.46). This pattern of results was consistent across the other four exams. Approximately two-thirds of respondents reported using nurses as chaperones, 15% cited the use of other office staff, and 10% relied on the presence of a family member. CONCLUSION: Clinical practice concerning the use of chaperones during intimate exams continues to be discordant with the recommendations of medical associations and medico-legal societies. Chaperones are used by only a minority of Ontario family physicians. Chaperone use is higher for examinations of female patients than of male patients and is highest for female pelvic exams. The availability of a nurse in the clinic to act as a chaperone is associated with more frequent use of chaperones.

Adult↗
PubMed2005

Does socioeconomic status affect mortality subsequent to hospital admission for community acquired pneumonia among older persons?

BACKGROUND: Low socioeconomic status has been associated with increased morbidity and mortality for various health conditions. The purpose of this study was twofold: to examine the mortality experience of older persons admitted to hospital with community acquired pneumonia and to test the hypothesis of whether an association exists between socioeconomic status and mortality subsequent to hospital admission for community-acquired pneumonia. METHODS: A population based retrospective cohort study was conducted including all older persons patients admitted to Ontario hospitals with community acquired pneumonia between April 1995 and March 2001. The main outcome measures were 30 day and 1 year mortality subsequent to hospital admission for community-acquired pneumonia. RESULTS: Socioeconomic status for each patient was imputed from median neighbourhood income. Multivariate analyses were undertaken to adjust for age, sex, co-morbid illness, hospital and physician characteristics. The study sample consisted of 60,457 people. Increasing age, male gender and high co-morbidity increased the risk for mortality at 30 days and one year. Female gender and having a family physician as attending physician reduced mortality risk. The adjusted odds of death after 30-days for the quintiles compared to the lowest income quintile (quintile 1) were 1.02 (95% CI: 0.95-1.09) for quintile 2, 1.04 (95% CI: 0.97-1.12) for quintile 3, 1.01 (95% CI: 0.94-1.08) for quintile 4 and 1.03 (95% CI: 0.96-1.12) for the highest income quintile (quintile 5). For 1 year mortality, compared to the lowest income quintile the adjusted odds ratios were 1.01 (95% CI: 0.96-1.06) for quintile 2, 0.99 (95% CI: 0.94-1.04) for quintile 3, 0.99 (95% CI: 0.93-1.05) for quintile 4 and 1.03 (95% CI: 0.97-1.10) for the highest income quintile. CONCLUSION: Socioeconomic status is not associated with mortality in the older persons from community-acquired pneumonia in Ontario, Canada.

Aged↗
PubMed2005

Oral vitamin B12 therapy in the primary care setting: a qualitative and quantitative study of patient perspectives.

BACKGROUND: Although oral replacement with high doses of vitamin B12 is both effective and safe for the treatment of B12 deficiency, little is known about patients' views concerning the acceptability and effectiveness of oral B12. We investigated patient perspectives on switching from injection to oral B12 therapy. METHODS: This study involved a quantitative arm using questionnaires and a qualitative arm using semi-structured interviews, both to assess patient views on injection and oral therapy. Patients were also offered a six-month trial of oral B12 therapy. One hundred and thirty-three patients who receive regular B12 injections were included from three family practice units (two hospital-based academic clinics and one community health centre clinic) in Toronto. RESULTS: Seventy-three percent (63/86) of respondents were willing to try oral B12. In a multivariate analysis, patient factors associated with a "willingness to switch" to oral B12 included being able to get to the clinic in less than 30 minutes (OR 9.3, 95% CI 2.2-40.0), and believing that frequent visits to the health care provider (OR 5.4, 95% CI 1.1-26.6) or the increased costs to the health care system (OR 16.7, 95% CI 1.5-184.2) were disadvantages of injection B12. Fifty-five patients attempted oral therapy and 52 patients returned the final questionnaire. Of those who tried oral therapy, 76% (39/51) were satisfied and 71% (39/55) wished to permanently switch. Factors associated with permanently switching to oral therapy included believing that the frequent visits to the health care provider (OR 35.4, 95% CI 2.9-432.7) and travel/parking costs (OR 8.7, 95% CI 1.2-65.3) were disadvantages of injection B12. Interview participants consistently cited convenience as an advantage of oral therapy. CONCLUSION: Switching patients from injection to oral B12 is both feasible and acceptable to patients. Oral B12 supplementation is well received largely due to increased convenience. Clinicians should offer oral B12 therapy to their patients who are currently receiving injections, and newly diagnosed B12-deficient patients who can tolerate and are compliant with oral medications should be offered oral supplementation.

Administration, Oral↗
PubMed2005

Simplicity within complexity: seasonality and predictability of hospital admissions in the province of Ontario 1988-2001, a population-based analysis.

BACKGROUND: Seasonality is a common feature of communicable diseases. Less well understood is whether seasonal patterns occur for non-communicable diseases. The overall effect of seasonal fluctuations on hospital admissions has not been systematically evaluated. METHODS: This study employed time series methods on a population based retrospective cohort of for the fifty two most common causes of hospital admissions in the province of Ontario from 1988-2001. Seasonal patterns were assessed by spectral analysis and autoregressive methods. Predictive models were fit with regression techniques. RESULTS: The results show that 33 of the 52 most common admission diagnoses are moderately or strongly seasonal in occurrence; 96.5% of the predicted values were within the 95% confidence interval, with 37 series having all values within the 95% confidence interval. CONCLUSION: The study shows that hospital admissions have systematic patterns that can be understood and predicted with reasonable accuracy. These findings have implications for understanding disease etiology and health care policy and planning.

Acute Disease↗
PubMed2005

Croup hospitalizations in Ontario: a 14-year time-series analysis.

OBJECTIVE: Croup is the most common form of airway obstruction in children. Known to be primarily viral, the seasonality of croup has been examined largely through its association with the human parainfluenza viruses. This study examined the seasonal pattern of croup hospitalizations in relation to age and gender for the province of Ontario during a 14-year period. METHODS: A retrospective, population-based study design was used to examine seasonal and temporal patterns of croup hospitalizations from April 1, 1988, to March 31, 2002. All residents of Ontario who were aged 0 to 4 years and eligible for universal health coverage during the study period were included for analysis. Time-series analyses then were conducted on monthly aggregations of hospitalizations. RESULTS: This study found strong evidence of croup hospitalization seasonality, with a biennial midautumn peak and annual summer trough, evident throughout the 14-year study period (Fisher's kappa = 51.11; Bartlett Kolmogorov Smirnov = 0.552). The pattern was observed in all children aged 0 to 4, although boys were hospitalized 2 times more often than girls of the same age. Rates of croup hospitalization were lower for children aged 1 to 4 years than for children aged 0 to <1. A marked decrease in croup hospitalizations was observed after the winter of 1993/1994 and continued to decrease in a step-wise manner for the remainder of the study period. CONCLUSIONS: This study delineates a clear biennial pattern of seasonal croup hospitalizations, varying by age and gender, with a large decrease in hospitalizations after the winter of 1993/1994. It is expected that these findings will have important implications for the treatment and management of childhood croup.

Child, Preschool↗
PubMed2005

Temporal analysis of acute myocardial infarction in Ontario, Canada.

BACKGROUND: Acute myocardial infarction (AMI) is a substantial cause of morbidity and mortality in Canada. Evidence suggests that the incidence and mortality of AMI increase in the winter. Determining the strength and nature of seasonality patterns in relation to age and sex may be helpful in health care planning. OBJECTIVES: To examine the seasonal patterns of AMI hospital admissions by age and sex, to assess the strength of the seasonal patterns and to examine the overall trends in admissions. METHODS: A retrospective population-based study was conducted to assess temporal patterns in 14 years of hospital admissions for AMI (from April 1, 1988, to March 31, 2002) in Ontario. Seasonality was assessed using the autoregression coefficient (R2Autoreg), and Fisher's Kappa and Bartlett's Kolmogorov-Smirnov tests. RESULTS: There were 271,321 people in the cohort, of whom 63% (n = 171,546) were male and 37% (n = 99,775) were female. There was an increase in AMI admissions since 1988 that reached a plateau in 1992, which was attributable mostly to the increased rate in the oldest age groups (70 years and older), where admission rates more than doubled. An association between seasonality and AMI admissions was found in most age and sex groups, with men consistently exhibiting a stronger seasonality pattern. The greatest difference in the cohort, 2.5 per 100,000 per month (134 admissions), occurred between December and September (13.64 per 100,000 in September versus 16.14 per 100,000 in December). CONCLUSIONS: AMI admissions show seasonality patterns, which are more pronounced in men. Although statistically significant, the seasonal differences are small in terms of absolute numbers, and are likely irrelevant in health care planning.

Adult↗
PubMed2005

Contextual factors in clinical decision making: national survey of Canadian family physicians.

OBJECTIVE: Many factors are at play in the process of clinical decision making, but to date, the interaction of these factors has not been well understood. Such information could have important implications for teaching and promoting evidence-based medicine (EBM) in primary care. This study was designed to explore the relationship between physician-related variables and management of patient-related contextual factors in clinical decision making. A secondary objective was to examine the extent to which this relationship varies by type of clinical decision. DESIGN: Cross-sectional randomized postal survey of 1134 Canadian primary care physicians stratified by age, sex, and practice location. Nonrespondents were sent reminders at 4 weeks and again at 8 weeks; at 12 weeks, all remaining nonrespondents were mailed replacement copies of the questionnaire. SETTING: Family practices in Canada. PARTICIPANTS: Of the final sample of 431 family physicians, 52% were men, 63% practised in urban locations, and 71% were in group practice. MAIN OUTCOME MEASURES: Self-reported likelihood of considering various contextual factors during the course of clinical decision making. RESULTS: Despite the three follow-up mailings, the final response rate was 42%; however, nonrespondents did not differ significantly from respondents on three important demographic factors: age, sex, and practice location. Using multinomial logistic regression analysis, the data showed that female family physicians and practitioners less strongly identified with EBM were more likely to consider contextual factors in clinical decision making. The effect was more obvious for ordering tests than for decisions about treatment. CONCLUSION: The evolving model of EBM should consider important physician-related variables in clinical decision making. Our data indicate that physicians' sex and identification with the tenets of EBM influence management of contextual factors. These results have important implications because they indicate that clinicians strongly identified with the EBM model of clinical practice are less sensitive to context, which might be an obstacle to efforts to integrate patient values and clinical circumstances into patient-centred care. We believe these findings support continued development of the model of "context-sensitive medicine" previously proposed as an alternative to EBM.

Adult↗
PubMed2004

SARS and hospital priority setting: a qualitative case study and evaluation.

BACKGROUND: Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, amplifies the difficulties of hospital priority setting. The purpose of this study is to describe and evaluate priority setting in a hospital in response to SARS using the ethical framework 'accountability for reasonableness'. METHODS: This study was conducted at a large tertiary hospital in Toronto, Canada. There were two data sources: 1) over 200 key documents (e.g. emails, bulletins), and 2) 35 interviews with key informants. Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation. RESULTS: Participants described the types of priority setting decisions, the decision making process and the reasoning used. Although the hospital leadership made an effort to meet the conditions of 'accountability for reasonableness', they acknowledged that the decision making was not ideal. We described good practices and opportunities for improvement. CONCLUSIONS: 'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals. In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.

Attitude of Health Personnel↗
PubMed2004

Feasibility of a patient decision aid regarding disclosure of personal health information: qualitative evaluation of the Health Care Information Directive.

BACKGROUND: Concerns regarding the privacy of health information are escalating owing both to the growing use of information technology to store and exchange data and to the increasing demand on the part of patients to control the use of their medical records. The objective of this study was to evaluate the Health Care Information Directive (HCID), a recently-developed patient decision aid that aims to delineate the level of health information an individual is willing to share. METHODS: We convened a series of four focus group meetings with several communities in a large Canadian city. A total of 28 men and women participated, representing health care consumer advocates, urban professionals, senior citizens, and immigrants who speak English as a second language. Data were analysed using qualitative methods. RESULTS: Participants lacked substantial knowledge regarding the fate and uses of personal health information. They expressed mistrust concerning how their information will be used and protected. Several suggestions were made towards customizing the use of data according to specific needs rather than broad and full access to their charts. Furthermore, despite concern regarding the implementation of a tool like the HCID, participants were hopeful that a refined instrument could contribute to the improved regulation of health information. CONCLUSION: This study indicated poor knowledge concerning the uses of personal health information, distrust concerning security provisions, and cautious support for a patient decision aid such as the HCID to improve control over health data.

Access to Information↗
PubMed2004

Patients' perspectives on taking warfarin: qualitative study in family practice.

BACKGROUND: Despite the well-documented benefits of using warfarin to prevent stroke, physicians remain reluctant to initiate therapy, and especially so with the elderly owing to the higher risk of hemorrhage. Prior research suggests that patients are more accepting of the risk of bleeding than are physicians, although there have been few qualitative studies. The aim of this study was to employ qualitative methods to investigate the experience and perspective of individuals taking warfarin. METHODS: We conducted face-to-face interviews with 21 older patients (12 male, 9 female) who had been taking warfarin for a minimum of six months. Participants were patients at a family practice clinic situated in a large, tertiary care teaching hospital. We used a semistructured interview guide with four main thematic areas: decision-making, knowledge/education, impact, and satisfaction. Data were analysed according to the principles of content analysis. RESULTS AND DISCUSSION: Participants tended to have minimal input into the decision to initiate warfarin therapy, instead relying in great part on physicians' expertise. There appeared to be low retention of information received regarding the therapy; half the patients in our sample possessed only a superficial level of understanding of the risks and benefits. This notwithstanding, participants reported a high level of satisfaction with the care provided and a low level of impact on their day-to-day lives. CONCLUSIONS: Minimal patient involvement in the initial decision and modest knowledge did not appear to diminish satisfaction with warfarin management. At the same time, care providers exert a tremendous influence on the initiation of warfarin therapy and should strive to incorporate patient preferences and expectations into the decision-making process.

Aged↗