Deborah M. Gregory

Long-term health-related quality of life in bariatric surgery patients: A systematic review and meta-analysis.

Bariatric surgery results in significant weight loss in the majority of patients. Improvement in health‐related quality of life (HRQoL) is an equally important outcome; however, there are few studies reporting long‐term (≥5 years) HRQoL outcomes. This study assesses the quality of evidence and effectiveness of surgery on HRQoL ≥ 5 years.

Patients' perceptions of waiting for bariatric surgery: a qualitative study.

BackgroundIn Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients’ perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients’ perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience.MethodsTwenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery.ResultsThematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants’ accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon’s office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others.ConclusionPatients’ perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible.

Restructuring acute care hospitals in Newfoundland and Labrador

In Canada, the use of hospital services has changed over time, with inpatient days declining steadily, other than for the elderly, from 1969 to 1995/6. Similar trends have been noted in other countries, including the United States, the Netherlands and England. As Canadian provincial tax revenues fell in the early 1990s, the proportion spent on health care rose rapidly, an economic problem for which governments sought a solution. Although steadily declining, expenditure on hospitals was still the single largest component of health care spending under direct government control in Canada in 1990. By then, a series of provincial commissions and inquiries had also suggested that hospital capacity could be further reduced. In response, many provinces sharply cut per capita spending on hospitals from 1992 to 1997, which was followed by about a 30% reduction in the number of Canadian hospitals and hospital beds in the five years from 1995/ 6. At the same time, with growth in the use of day surgery, at least in some jurisdictions, surgical activity remained constant, despite a reduction in inpatient capacity. A variety of methods of cost containment have been applied to hospital services in Canada. These include the provision of global budgets through the longestablished single-payer financing system. In more recent years, regionalization and, to a lesser extent, use of information systems (such as the Canadian Institute for Health Information) to inform decisionmakers have been applied in an effort to control hospital costs. Since the late 1980s, there has been a focus on hospital restructuring (or hospital redesign) aimed at enhancing efficiency (possible within one organization), strategic alliances, whereby organizations work together aiming at enhanced efficiency, and rationing of care, under which services may be made less available. Following the introduction of Medicare in the 1960s, regionalization of the health care system has been an important mechanism for reform in Canada. Quebec led the country in establishing regional health authorities in 1989. Without much supporting data, proponents of regionalization have suggested that it might lead to improved efficiency, coordination and integration of services and, partly through economies of scale, assist in cost containment. By 2002, all provinces and territories, with the exception of Ontario, had regionalized the governance of their health care systems. Throughout the early 1990s, the health care system in Newfoundland and Labrador (NL) experienced substantial reform. Regionalization, as a process for change, is meant to ‘transfer the present level of power and authority from one level of government (i.e. the provincial ministry) to another level of government (i.e. the regional health board)’, in essence, a devolution of responsibility and accountability. The primary goals of regionalization were similar across provinces and included: the containment of escalating hospital costs; increased efficiency and effectiveness; integrated care; and the provision of a system that was more responsive to the needs of the local population. However, health care systems across the country varied with regard to their terms of governance (appointed or elected boards), type of board (community, institutional, integrated, district) and the type of services provided under the board (long-term care, acute care, social services). In order to understand the challenges facing health services providers in NL, the reader needs to appreciate the vast geography of the province. NL has an area of 405,720 km, more than three times the total area of the Maritime Provinces (Nova Scotia, New Brunswick and Prince Edward Island). NL ranks fourth in size behind Alaska, Texas and California. It is almost oneand-three-quarter times the size of Great Britain. The total population of the province was reported as 512,930 in 2003, with approximately half of the population living on the Avalon Peninsula in Newfoundland. The proportion of health spending on institutions in NL was 60% in 1995, considerably above the Canadian average of 44.1%. Heavy dependence on institutional services reached a critical level in the late 1980s and early 1990s. In 1994, almost 60 institutional community boards were responsible for health care delivery. Commissions and task forces were formed to identify solutions, and in 1995 regionalization of health boards was initiated to reform the health care system. The history of the evolution and implementation of regionalization in NL is described in detail in the paper by Twells et al. Six health care regions and 14 health boards were established in 1995/96. Integrated boards responsible for acute care, long-term care and community care services were initiated in two regions, Labrador and Northern. In three regions (Western, Central East and Central West), acute care and long-term care were combined and responsible to institutional boards, and separate community health boards were created. In the St John’s region, three boards governing acute care institutions, long-term care institutions and community care, as well as one provincially focused board addressing the cancer treatment and research needs of the province were established. In 1998, social services (child welfare, rehabilitation and corrections) were

Complications with Angio-Seal™ Vascular Closure Devices Compared with Manual Compression after Diagnostic Cardiac Catheterization and Percutaneous Coronary Intervention

OBJECTIVES This study assessed and compared vascular complications in CATHs and PCIs using an Angio-Seal™ vascular closure device (VCD) versus manual compression (MC). METHODS Secondary data analysis of a population-based multiyear cohort database was conducted to compare femoral access-related vascular outcomes in cardiac procedures using VCD and MC between May 1, 2006 and December 31, 2010. The primary outcome was any vascular complication. Propensity score adjusted analysis was conducted to reduce bias associated with covariate imbalance between the groups compared. RESULTS Of the 11,897 procedures, 7,063 (59.4%) used a VCD. Vascular complications occurred in 174/8,796 (2.0%) of CATHs and 82/3,004 (2.7%) of PCIs. In the CATH sample, the odds of vascular complication were 57% lower if a VCD was used (OR = 0.43, 95% CI 0.31-0.60). For the PCI sample, the risk was 49% lower if a VCD was used (OR = 0.51, 95% CI 0.31-0.81). CONCLUSIONS A low incidence of vascular complications was observed with the use of an Angio-Seal VCD relative to MC for both procedures.

Health care provider outcomes during and shortly after acute care restructuring in Newfoundland and Labrador.

Objectives To monitor changes in human resource indicators during six years of restructuring in Newfoundland and Labrador, and to measure providers’ perceptions of reform impact and attitudinal and behavioural reactions comparing changes in the St Johns region, where hospital aggregation occurred, to other regions. Methods Data on human resource indicators from 1995/96 to 2001/02 were obtained and analysed. The Employee Attitude Survey was sent to acute care staff (n=5353) to assess perceptions of reform impact on workplace conditions, work-related attitudes, turnover intentions and personal characteristics. The response rate for 2000 and 2002 was approximately 42% (n=1222 and 1034, respectively). Only respondents to both surveys (n=589) were used in the analysis. Results Increases in average employee and full-time equivalent numbers occurred in the St Johns region, despite hospital closure and aggregation. Increases in staff dislocation and turnover were observed, but paid sick hours decreased. Sick leave and overtime costs increased. Although perceived workplace conditions, and attitudes and behaviours were generally negative, there was evidence of improvement over time, especially in St Johns. Few significant regional or provider group differences were observed on most study variables. Conclusions Aggregation of hospitals in StJohns did not lead to a decrease in employee counts, or deterioration in human resource indicators or attitudes. However, province-wide initiatives are needed to promote more positive work environments and increase organizational effectiveness.

The breast cancer hormone receptor retesting controversy in Newfoundland and Labrador, Canada: lessons for the health system.

The treatment of newly diagnosed breast cancer patients with hormonal treatment is determined by the presence of estrogen receptor and progesterone receptor status in breast cancer. In Newfoundland and Labrador (NL), 425 of 1,088 (39.1%) patients who had original “negative” receptor tests conducted between 1997 and 2005, had positive results upon retesting in a specialized laboratory. This commentary addresses (1) the diagnostic utility of estrogen and progesterone testing for breast cancer in general, (2) specific testing problems that occurred in NL, (3) scientific problems associated with retesting, and (4) the impact on public trust and the resulting legal and political responses that occurred as a result of the adverse events associated with false-negative hormone receptor tests. Finally, the lessons learned will be discussed including known high false-negative rates associated with the tests and the bias associated with retesting, the need for quality assurance and national standards, public education, and appropriate communication with patients and the public.

Acute care restructuring in Newfoundland and Labrador: the history and impact on expenditure

Objectives To document the history of regionalization and its effects on the Newfoundland and Labrador acute care health system, and to describe changes in acute care expenditure in the St Johns region where hospital redesign, closure and aggregation occurred in relation to other regions not exposed to aggregation. Methods Interviews were conducted with senior health officials. Transcripts and other reports were reviewed. Financial data were abstracted from audited general ledger statements received from the Ministry of Health. Results Regionalization achieved its objectives of hospital aggregation in St Johns. The average number of full-time equivalent employees increased slightly by 2% (5304–5416). In some regions, integration of services was delayed because of conflict and resistance to change. There was some disparity between the Provincial Governments objectives for cost control and the CEOs’ perceptions of economies of scale. Between 1995/96 and 2002/03, total expenditures for the St Johns region and the other five regional hospitals increased by 46% and 54%, respectively; total personal income of the population and government revenues increased by only 18% and 16%, respectively. Conclusions Regionalization in Newfoundland and Labrador facilitated aggregation of hospitals, but did not control the number of front-line workers and, consequently, total acute care expenditure. Expenditure increased significantly between1995 and 2002, at a rate which exceeded the increase in government revenues. The governments ability to pay for acute care will not be achieved unless employee costs are controlled or provincial income increases.

Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of hospitals in the StJohns region. Methods Retrospective chart audits for the years 1995/96, 1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery andwomens health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the StJohns region, and separately for hospitals in the rest of the province. Results There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St Johns. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronaryartery by pass grafting (CABG) morbid event rate improved, although access to CABG was not optimal. Conclusions Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.

Deletion of the MC4R Gene in a 9-Year-Old Obese Boy

BACKGROUND The most common monogenic form of obesity is caused by mutations in the melanocortin 4 receptor (MC4R) gene. More than 150 mutations have been reported in the MC4R gene, the majority being point mutations. Most individuals with MC4R gene mutations have early-onset obesity, hyperphagia, and increased longitudinal growth. METHODS A 9-year-old Caucasian boy was referred to genetics for obesity, food-seeking behavior, and developmental delay. History and physical exam were not consistent with Prader Willi syndrome, but revealed several minor anomalies. Owing to significant obesity and hyperphagia, a Prader Willi syndrome methylation test and a microarray were requested. RESULTS Methlylation testing for Prader Willi syndrome was normal. Microarray analysis revealed two changes: (1) A 2.6-Mb deletion at chromosome 18q21.31 was identified and contained several OMIM genes, including the MC4R gene, and (2) an 0.87-Mb duplication at chromosome region 16p13.3 was found and contained one gene. Parental samples revealed that the boys father had the same deletion and duplication. This case appears to be the first with a deletion of 18q21.31 encompassing the MC4R gene presenting with features of hyperphagia and obesity. CONCLUSIONS Haploinsufficiency of the MC4R gene either through whole gene deletion or nonsense or missense mutations is associated with a significant risk of obesity. The case emphasizes both the role of the MC4R gene in obesity as well as the importance of looking for chromosomal microdeletions/duplications as a cause of obesity in children with minor anomalies or developmental delay.

The Relationship between Body Mass Index and the Severity of Coronary Artery Disease in Patients Referred for Coronary Angiography

Background and Aim. Obesity is associated with an increased risk of cardiovascular disease and may be associated with more severe coronary artery disease (CAD); however, the relationship between body mass index [BMI (kg/m2)] and CAD severity is uncertain and debatable. The aim of this study was to examine the relationship between BMI and angiographic severity of CAD. Methods. Duke Jeopardy Score (DJS), a prognostic tool predictive of 1-year mortality in CAD, was assigned to angiographic data of patients ≥18 years of age (N = 8,079). Patients were grouped into 3 BMI categories: normal (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obese (≥30 kg/m2); and multivariable adjusted hazard ratios for 1-year all-cause and cardiac-specific mortality were calculated. Results. Cardiac risk factor prevalence (e.g., diabetes, hypertension, and hyperlipidemia) significantly increased with increasing BMI. Unadjusted all-cause and cardiac-specific 1-year mortality tended to rise with incremental increases in DJS, with the exception of DJS 6 (p < 0.001). After adjusting for potential confounders, no significant association of BMI and all-cause (HR 0.70, 95% CI .48–1.02) or cardiac-specific (HR 1.11, 95% CI .64–1.92) mortality was found. Conclusions. This study failed to detect an association of BMI with 1-year all-cause or cardiac-specific mortality after adjustment for potential confounding variables.