Danielle Larouche

Emergency Department Visits and Primary Care Among Adults With Chronic Conditions

Background:An emergency department (ED) visit may be a marker for limited access to primary medical care, particularly among those with ambulatory care sensitive chronic conditions (ACSCC). Objectives:In a population with universal health insurance, to examine the relationships between primary care characteristics and location of last general physician (GP) contact (in an ED vs. elsewhere) among those with and without an ACSCC. Research Design:A cross-sectional survey using data from 2 cycles of the Canadian Community Health Survey carried out in 2003 and 2005. Subjects:The study sample comprised Québec residents aged ≥18 who reported at least one GP contact during the previous 12 months, and were not hospitalized (n = 33,491). Measures:The primary outcome was place of last GP contact: in an ED versus elsewhere. Independent variables included the following: lack of a regular physician, perceived unmet healthcare needs, perceived availability of health care, number of contacts with doctors and nurses, and diagnosis of an ACSCC (hypertension, heart disease, chronic respiratory disease, diabetes). Results:Using multiple logistic regression, with adjustment for sociodemographic, health status, and health services variables, lack of a regular GP and perceptions of unmet needs were associated with last GP contact in an ED; there was no interaction with ACSCC or other chronic conditions. Conclusions:Primary care characteristics associated with GP contact in an ED rather than another site reflect individual characteristics (affiliation with a primary GP and perceived needs) rather than the geographic availability of healthcare, both among those with and without chronic conditions.

When Is Knowledge Ripe for Primary Care? An Exploratory Study on the Meaning of Evidence

The objectives of this study were to explore the meaning of scientific evidence as it is understood by primary care physicians. Individual interviews were conducted with actors chosen for their roles in the production and use of knowledge: 22 family physicians, 13 specialist physicians, and 6 researchers. Two situations served as points of reference for these discussions: screening for genetic breast cancer and treatment of hypertension. The results suggest that there may be a misunderstanding between the producers of knowledge and primary care practitioners with respect to what constitutes “evidence”— knowledge ready for integration into the clinical practice of primary care. These potential differences go beyond the issues of how information is disseminated. Rather, many of the questions raised by family physicians concern how knowledge is developed. In the interests of fostering better dissemination of new knowledge and encouraging its adoption, new links should be created between knowledge “producers” and potential users.

Strategic planning for hospitals— A health-needs approach

Abstract This paper presents a strategic planning approach which provides methods for analysing hospitals in relation to their environment and for assessing their community dependency. Hospitals must not only focus on their clienteles but must also plan their future in relation to the needs of their constituency while taking into account the other elements of the health services network. The proposed approach also takes into account the need for all the actors concerned with the future of the hospital to become involved through an active-reactive- adaptive process.

Outcomes of Community-dwelling Seniors Vary by Type of Emergency Department

OBJECTIVES The specific objectives were: 1) to compare the characteristics and 6-month outcomes of community-dwelling seniors in Quebec, Canada, who visited three different emergency department (ED) types and 2) to explore whether the differences in outcomes by ED type were seen among subgroups of seniors. METHODS The three types of ED were most specialized, less community-oriented (n = 12); moderately specialized, less community-oriented (n = 28); and least specialized, more community-oriented (n = 28). Administrative databases were used to create a cohort of 223,120 seniors who visited these 68 EDs during a 14-month period. Using a multilevel approach, the following patient characteristics were compared across ED types: sociodemographic (age, sex, urban vs. rural residence, proximity to ED); medical diagnoses and comorbidity burden; and utilization of hospital and physician services during the 16 months before the index ED visit. Cox regression analysis was used to model the relationships between ED type and two 6-month outcomes, adjusting for patient characteristics: 1) serious outcomes (death, acute or long term-care admission) among all individuals who made an index visit and 2) outpatient ED visits (without hospital admission) among those discharged either from the ED or hospital. Interactions between ED type and patient age, sex, urban-rural residence, and comorbidity burden were explored. RESULTS Compared to patients treated at the least specialized EDs, those at the most specialized EDs were more often urban-dwelling, resided outside the health service area of the ED, and had the highest disease burden and prior specialist utilization. Those treated at the moderately specialized EDs were intermediate between these two groups. During the 6 months after the ED visit, the rate of serious outcomes was higher and the rate of outpatient ED visits was lower for the most specialized compared to the least specialized EDs, even after adjustment for patient characteristics. The differences in these outcomes by ED type were attenuated among older patients and those with greater comorbidity. CONCLUSIONS More vulnerable community-dwelling seniors tend to be treated in more specialized EDs, which have worse linkages to community services. Improved linkages between more specialized EDs and the community (physicians, home care, and other services) and increased access to community services may improve outcomes in this population. Seniors treated at more specialized EDs were more likely to experience serious outcomes, but were less likely to make a return outpatient ED visit.

The effects of Quebec home aid services on the utilization profile of sociosanitory resources: a substitution study.

The development of home aid services in Quebec is based on the hypothesis that this new program will help to maintain at home people who would otherwise be institutionalized and also contribute to reducing costs in the health care sector. Accordingly, home aid services can be viewed as a substitute for conventional health care services. This study evaluates utilization modifications of health care services subsequent to the introduction of a home-aid program in October 1977. A modified, non-equivalent, control group design was used on a target population including all residents aged 65 or more in one region of Quebec. Multiple regression was used to explain variations in resources utilization in relation to population characteristics and different health care settings. Results for the utilization of hospitals are discussed. We discovered that the anticipated substitutive effects of a home-aid program on the use of health care services cannot be ascertained.

Conceptual and Methodological Challenges in Producing Research Syntheses for Decision-and Policy-Making: An Illustrative Case in Primary Healthcare

This article presents and discusses five challenges encountered in conducting a knowledge synthesis on primary healthcare, commissioned by the Canadian Health Services Research Foundation. These challenges are (1) conceptualizing, defining and operationalizing complex interventions; (2) integrating quantitative and qualitative studies and assessing strength of evidence; (3) incorporating expert opinions and decision-makers’ viewpoints; (4) producing timely results; and (5) presenting the results in a concise yet understandable form. We also propose methods and operational tools to deal with these issues, particularly regarding integration of qualitative and quantitative evidence and incorporation of expert opinions into syntheses. The major challenge of the synthesis was to provide pertinent and useful information for decision- and policy-makers, while maintaining an acceptable level of scientific rigour. This approach seems promising for knowledge syntheses, which sustain a deliberative process that leads to more enlightened decision and policy-making.

Strategic Planning for Hospitals—A Health-needs Approach

This paper presents a strategic planning approach which provides methods for analysing hospitals in relation to their environment and for assessing their community dependency. Hospitals must not only focus on their clienteles but must also plan their future in relation to the needs of their constituency while taking into account the other elements of the health services network. The proposed approach also takes into account the need for all the actors concerned with the future of the hospital to become involved through an active-reactive-adaptive process.