Hélène Ouellette-Kuntz

Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability‐a population perspective

BACKGROUND There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was to compare hospitalisation rates for ambulatory care sensitive conditions between persons with and without an ID in a publicly insured population. METHODS Persons with an ID were identified among the general population of a Canadian province between 1999 and 2003. Using a list of conditions applicable to persons with an ID, rates of hospitalisations for ambulatory care sensitive conditions for persons with and without an ID were calculated and compared. Regression models were used to adjust for age, sex and place of residence. Hospitalisation rates for specific conditions were also compared, controlling for differences in disease prevalence where possible. RESULTS Persons with an ID were consistently hospitalised for ambulatory care sensitive conditions at a higher rate than persons without an ID. Between 1999 and 2003 the adjusted rate ratio (RR) was 6.1 [95% confidence interval (CI) = 5.6, 6.7]. Rate ratios were highest when comparing persons with, to persons without, an ID between the ages of 30-39 (RR = 13.1; 95% CI = 10.6, 16.2) and among urban area dwellers (RR = 7.0; 95% CI = 6.2, 7.9). Hospitalisation rates for epilepsy and schizophrenic disorders were, respectively, 54 and 15 times higher for persons with compared with persons without an ID. Rate ratios for diabetes and asthma remained significant after controlling for the population prevalence of these diseases. CONCLUSIONS The large discrepancy in rates of hospitalisation between persons with and without an ID is an indicator of inadequate primary care for this vulnerable population. Decreasing the number of ambulatory care sensitive condition hospitalisations through specialised outpatient programmes for persons with an ID would potentially lead to better health, improved quality of life and cost savings. Future research should include potentially important factors such as disease severity, socio-economic variables and measures of health service organisation in the analysis. International comparisons of ambulatory care sensitive condition hospitalisation rates could point to the benefits and limitations of the health service policy directions adopted by different countries.

The Association Between Nutritional Adequacy and Long-Term Outcomes in Critically Ill Patients Requiring Prolonged Mechanical Ventilation: A Multicenter Cohort Study.

Objective:To examine the association between short-term nutritional adequacy received while in the ICU and long-term outcomes including 6-month survival and health-related quality of life in critically ill patients requiring prolonged mechanical ventilation. Design:Retrospective analysis of data prospectively collected in the context of a multicenter randomized controlled trial. Setting:An international sample of ICUs. Patients:Adult patients who were mechanically ventilated for more than 8 days in the ICU. Interventions:None. Measurements and Main Results:Nutritional adequacy was obtained from the average proportion of prescribed calories received over the amount prescribed during the first 8 days. Survival status and health-related quality of life as assessed using the Short-Form 36 v2 were obtained at 3- and 6 months post ICU admission. Of the 1,223 patients enrolled in the randomized controlled trial, 475 met the inclusion criteria for this study. At 6-month follow-up, 302 of the 475 patients (64%) were alive. Survival time in those who received low nutritional adequacy was significantly shorter than those who received high nutritional adequacy while adjusting for important covariates (adjusted hazard ratio, 1.7; 95% CI, 1.1–2.6). At 3-month follow-up, a 25% increase in nutritional adequacy was associated with improvements in Physical Functioning and Role Physical of 7.3 (p = 0.02) and 8.3 (p = 0.004) points, respectively. At 6-month follow-up, adjusted increases in Physical Functioning and Role Physical scores for every 25% increase in nutrition adequacy became smaller and were no longer statistically significant (adjusted estimate for Physical Functioning = 4.2, p = 0.14; for Role Physical = 3.2, p = 0.25). Conclusions:Greater amounts of nutritional intake received during the first week in the ICU were associated with longer survival time and faster physical recovery to 3 months but not 6 months post ICU discharge in critically ill patients requiring prolonged mechanical ventilation. Current recommendations to underfeed critically ill patients may cause harm in some long-stay patients.

Understanding Adherence to Guidelines in the Intensive Care Unit Development of a Comprehensive Framework

BACKGROUND Clinical practice guidelines (CPGs) have been hailed as a useful method of translating evidence into practice. Several CPGs have been published that provide recommendations for feeding patients in the intensive care unit (ICU). Despite a rigorous development process and active dissemination of these guidelines, their impact on nutrition practice has been modest. The purpose of this study was to develop a comprehensive framework for understanding adherence to nutrition CPGs in the critical care setting. METHODS Multiple case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each ICU site who were asked about their perceptions and attitudes toward guidelines in general and the Canadian Critical Care Nutrition CPGs specifically. Interview transcripts and related documents were analyzed qualitatively using a framework approach. RESULTS The 5 key components of the developed framework were characteristics of the CPGs, the implementation process, institutional factors, provider intent, and the clinical condition of the patient. These key themes encapsulate numerous itemized factors that contribute to guideline adherence either as barriers or enablers. CONCLUSIONS Adherence to nutrition CPGs is determined by a complex interaction of multiple factors that act as barriers or enablers. The comprehensive framework for adherence to CPGs in the ICU attempts to elucidate this process and provides a useful template for future research. Future quality improvement initiatives should assess local barriers to change and design interventions to overcome these barriers.

Length of stay for psychiatric inpatient services: A comparison of admissions of people with and without developmental disabilities

This study investigated associations between the presence of developmental disabilities and length of inpatient stay for mental health care. All psychiatric admissions of people with developmental disabilities over a 5-year period were selected (n=294), and were compared using survival analysis to a random sample of admissions from the general psychiatric population (n=287). Overall, people with developmental disabilities stayed in hospital longer than those without developmental disabilities, and this extra stay was partially attributed to casemix differences between the cohorts. Subanalyses in both cohorts showed that those going back to their usual living arrangement stayed a shorter period than those who were discharged elsewhere, and that people with developmental disabilities were less likely to be discharged to their usual living arrangement than were people without the disability. This study highlighted the importance of specialized residential and personal supports for people with developmental disabilities and a coexisting mental disorder.

Physical mobility limitations in adults with intellectual disabilities: a systematic review

BACKGROUND Mobility limitations increase with age in the general population. Despite a growing population of older adults with intellectual disabilities (ID), mobility is rarely studied in the ID literature. The specific aim of this study was to identify and summarise primary literature investigating mobility limitations in adults with ID. METHODS This study was a systematic review of the epidemiological literature (incidence and prevalence) of mobility limitations among adults with ID. Four electronic databases were searched from January 1980 to May 2007 for publications according to predefined inclusion/exclusion criteria. Additional sources were consulted. Two reviewers extracted data from each of the included articles. RESULTS Thirty-two publications representing 31 studies were ultimately included. In general, studies did not focus on mobility but were conducted for other purposes. All studies were conducted in industrialised countries. Only one study used a longitudinal design; the remainders were cross-sectional. Few investigators reported on the representativeness of the sample or the validity of the measurement tool. Study samples differed substantially and investigators used numerous definitions of mobility limiting comparability between studies. CONCLUSIONS There is a need for increased research on mobility limitations among adults with ID, particularly longitudinal research. Researchers investigating mobility limitations should use validated measurement tools and offer detailed descriptions of the study sample and how it compares with an identifiable population.

Acute psychiatric inpatient care for people with a dual diagnosis: patient profiles and lengths of stay.

Objective: This study describes characteristics of psychiatry inpatients with developmental disabilities (DD) and their admissions to psychiatry wards in 2 acute care hospitals. It also compares differences in lengths of stay between admissions of this group with a comparison sample of inpatient admissions without DD. Method: A retrospective chart review was conducted on all individuals with DD who were psychiatric inpatients at 2 Kingston, Ontario, general hospitals, within a 4-year period (1994 to 1998). A comparison sample of admissions of patients without DD was chosen. Frequency tables were used to describe the inpatients with DD and to describe the 2 samples of admissions. Nonparametric statistics were used to compare the median length of stay between the 2 samples. Associations between length of stay and other covariates were explored within the sample of patient admissions with DD. Results: The 62 individuals with DD had 101 admissions over the study period. Suicidal ideation was the most common admission reason (46%), and mood disorder was the most common discharge diagnosis (29%). The median length of stay for patients with DD was 8 days, which did not differ meaningfully from the comparison sample. Variables that were significantly associated with length of stay among individuals with DD included sex, referral source, and diagnosis. Conclusion: When individuals with DD are psychiatric inpatients, their length of stay is affected by some factors that have been identified in previous studies not specific to DD (for example, referral source and diagnosis). Our finding that male patients with DD have longer lengths of stay than do female patients in the same sample has not been reported in previous research.

A Comparison of the Prevalence of Chronic Disease Among People with and Without Intellectual Disability

Some studies have reported the presence of health disparities in people with intellectual disability. This study compared the prevalence of chronic health conditions between people with and without intellectual disability (ID). Health-related data for 791 people with ID were collected through a province-wide mail survey in Quebec, Canada. The distribution of chronic health conditions reported was compared to the data on the health status of the general population. People with ID had higher reported rates of heart disease and thyroid disorder than the general population. We also found that people with ID were less likely to report suffering from arthritis, migraines, back or spinal pain, and food allergies. Significant health differences were found when the ID sample was stratified by etiology (i.e., Down syndrome) and severity of intellectual deficits. We discuss these results and the need for future research to understand the differences found in the health status of people with ID.

Untapped potential: Perspectives on the employment of people with intellectual disability

OBJECTIVE While individuals with intellectual disabilities can make valuable contributions in community workplaces, they typically experience low rates of paid employment. The goal of this article is to explore the reasons for the limited involvement of this population in competitive employment, provide a rationale for including individuals with intellectual disabilities as employees, and propose policy, structural and attitudinal changes that would be necessary to include them more meaningfully in the workforce. METHODS The authors conducted a review of the literature relevant to the key theoretical concepts of disability, employment, organizational management and inclusion. RESULTS The analysis reveals a number of theoretical, philosophical, legal and business arguments for and against the inclusion of workers with intellectual disabilities as employees, and suggests system level changes needed to mitigate challenges to recruiting, hiring and retaining these workers. CONCLUSIONS Changes to the employment situation for workers with intellectual disabilities will require major shifts in government policy, workplace practices and vocational preparation of youth with intellectual disabilities. Continued research is necessary to identify best practices.

Are Cervical and Breast Cancer Screening Programmes Equitable? The Case of Women with Intellectual and Developmental Disabilities.

BACKGROUND Effective cancer screening must be available for all eligible individuals without discrimination. Lower rates of cervical and breast cancer screening have been reported in certain groups compared with women from the general population, such as women with intellectual and developmental disabilities (IDD). Research on the factors explaining those observed differences is crucial to determine whether practices are unfair and could be improved. The aim of this population-based study was to describe cancer screening utilisation by women with IDD in Ontario, Canada compared with other women in Ontario. The specific objectives were (1) to estimate the rates of cervical and breast cancer screening among eligible women with IDD in Ontario; (2) to compare the rates of cervical and breast cancer screening between eligible women with and without IDD; and (3) to examine if any observed differences between women with and without IDD persist after factors such as age, socio-economic status, rurality and healthcare utilisation are accounted for. METHOD This study draws women with IDD from an entire population, and draws a randomly selected comparison group from the same population. It controls for important confounders in cancer screening within the limitations of the data sources. The study was conducted using health administrative databases and registries in Ontario, Canada. Two cohorts were created: a cohort of all women identified as having an IDD and a cohort consisting of a random sample of 20% of the women without IDD. RESULTS The proportion of women with IDD who are not screened for cervical cancer is nearly twice what it is in the women without IDD, and 1.5 times what it is for mammography. CONCLUSIONS Findings suggest that women with IDD experience inequities in their access to cancer screening. Public health interventions targeting this population should be implemented.

Unmet Needs of Families of School-Aged Children with an Autism Spectrum Disorder.

BACKGROUND To aid decision making regarding the allocation of limited resources, information is needed on the perceived unmet needs of parents of school-aged children with an autism spectrum disorder. MATERIALS AND METHODS A cross-sectional survey was conducted of 101 Canadian families of school-aged children with an autism spectrum disorder. RESULTS Commonly reported unmet needs were for social activities for the child (78.2%), information about services (77.2%) and continuous service provision (74.3%). CONCLUSIONS This study provides insight into needs which have not been met by the service system. Information about the unmet needs of children with an autism spectrum disorder and their families may help policy makers and service providers to develop resources and services that are responsive to their client group.