Neil Drummond

What is a health expectation? Developing a pragmatic conceptual model from psychological theory

Introduction  Examination of the existing literature in respect of health expectations revealed both ambiguity in relation to terminology, and relatively little work in respect of how abstract theories of expectancy in the psychological literature might be used in empirical research into the influence of expectations on attitudes and behaviours in the real world. This paper presents a conceptual model for the development of health expectations with specific reference to Alzheimers disease.

Validating the 8 CPCSSN Case Definitions for Chronic Disease Surveillance in a Primary Care Database of Electronic Health Records

PURPOSE The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada’s first national chronic disease surveillance system based on electronic health record (EHR) data. The purpose of this study was to develop and validate case definitions and case-finding algorithms used to identify 8 common chronic conditions in primary care: chronic obstructive pulmonary disease (COPD), dementia, depression, diabetes, hypertension, osteoarthritis, parkinsonism, and epilepsy. METHODS Using a cross-sectional data validation study design, regional and local CPCSSN networks from British Columbia, Alberta (2), Ontario, Nova Scotia, and Newfoundland participated in validating EHR case-finding algorithms. A random sample of EHR charts were reviewed, oversampling for patients older than 60 years and for those with epilepsy or parkinsonism. Charts were reviewed by trained research assistants and residents who were blinded to the algorithmic diagnosis. Sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) were calculated. RESULTS We obtained data from 1,920 charts from 4 different EHR systems (Wolf, Med Access, Nightingale, and PS Suite). For the total sample, sensitivity ranged from 78% (osteoarthritis) to more than 95% (diabetes, epilepsy, and parkinsonism); specificity was greater than 94% for all diseases; PPV ranged from 72% (dementia) to 93% (hypertension); NPV ranged from 86% (hypertension) to greater than 99% (diabetes, dementia, epilepsy, and parkinsonism). CONCLUSIONS The CPCSSN diagnostic algorithms showed excellent sensitivity and specificity for hypertension, diabetes, epilepsy, and parkinsonism and acceptable values for the other conditions. CPCSSN data are appropriate for use in public health surveillance, primary care, and health services research, as well as to inform policy for these diseases.

Why health expectations and hopes are different: the development of a conceptual model

Background  In the literature, ‘hope’ has often been thought of as an ideal expectation. However, we believe the classification of hope as a type of expectation is problematic. Although both hopes and expectations are future‐oriented cognitions, expectations are distinct in that they are an individual’s probability‐driven assessment of the most likely outcomes, while hopes are an assessment of the most desirable – but not necessarily the most probable – outcomes.

Pathways to diagnosis: exploring the experiences of problem recognition and obtaining a dementia diagnosis among Anglo-Canadians.

Increasing evidence suggests that early diagnosis and management of dementia-related symptoms may improve the quality of life for patients and their families. However, individuals may wait from 1-3 years from the onset of symptoms before receiving a diagnosis. The objective of this qualitative study was to explore the perceptions and experiences of problem recognition, and the process of obtaining a diagnosis among individuals with early-stage dementia and their primary carers. From 2006-2009, six Anglo-Canadians with dementia and seven of their carers were recruited from the Alzheimers Society of Calgary to participate in semi-structured interviews. Using an inductive, thematic approach to the analysis, five major themes were identified: becoming aware of memory problems, attributing meanings to symptoms, initiating help-seeking, acknowledging the severity of cognitive changes and finally obtaining a definitive diagnosis. Individuals with dementia reported noticing memory difficulties earlier than their carers. However, initial symptoms were perceived as ambiguous, and were normalised and attributed to concurrent health problems. The diagnostic process was typically characterised by multiple visits and interactions with health professionals, and a diagnosis was obtained as more severe cognitive deficits emerged. Throughout the diagnostic pathway, carers played dynamic roles. Carers initially served as a source of encouragement to seek help, but they eventually became actively involved over concerns about alternative diagnoses and illness management. A better understanding of the pre-diagnosis period, and the complex interactions between peoples beliefs and attributions about symptoms, may elucidate some of the barriers as well as strategies to promote a timelier dementia diagnosis.

Incidence and predictors of excess disability in walking among nursing home residents with middle-stage dementia: a prospective cohort study.

BACKGROUND Inability to walk compromises the well-being of the growing number of nursing home residents with dementia. The purpose of this study was to estimate the incidence and identify predictors of walking disability that may be remediable. METHODS A cohort was followed fortnightly for a year in 15 nursing homes in western Canada. The study participants comprised 120 ambulatory residents with middle-stage Alzheimers, vascular or mixed dementia. Standardized measures of potential predictors of disability included the Charlson Comorbidity Index, Global Deterioration Scale, and Professional Environment Assessment Protocol. Walking disability was defined as using a wheelchair to go to meals in the dining room. RESULTS Incidence of walking disability was 40.8% (95% confidence interval (CI): 32.7-50.2). Approximately half of this (27.0%; 95% CI: 19.7-36.5) was excess disability. Residents with more advanced dementia and living in a less supportive nursing home environment experienced an increased hazard of walking disability (Hazard Ratio (HR): 2.1; 95% CI: 1.2-3.8 and HR: 2.4; 95% CI: 1.3-4.4 respectively). After adjusting for age, comorbidity and stage of dementia, predictors of excess disability in walking included using antidepressants (HR: 2.2; 95% CI: 1.02-4.6), and not using cognitive enhancers (HR: 2.6; 95% CI: 1.03-6.4). CONCLUSIONS Over half of walking disability in nursing home residents with middle-stage dementia may be modifiable. Creating supportive environments, ensuring access to cognitive enhancer drugs, and preventing and treating depression and the adverse effects of antidepressants, may help to reduce walking disability and excess disability.

Perinatal Care for South Asian Immigrant Women and Women Born in Canada: Telephone Survey of Users

BACKGROUND Previous research findings suggest that pregnant immigrant women receive less adequate perinatal care than pregnant non-immigrant women. This study was designed to assess the use of perinatal care services by newly immigrated South Asian women and Canadian-born women, and to determine any perceived barriers to receiving care. METHOD We conducted a telephone survey of women who delivered at an academic community hospital in Calgary, Alberta. Two groups of women were interviewed at seven weeks postpartum: South Asian women who had immigrated within the last three years, and Canadian-born women of any ethnicity. Women who spoke Hindi, Punjabi, and/or English were eligible. Interviews consisted mainly of closed-ended questions. The main outcomes we sought were the proportion of women receiving perinatal care (such as attending prenatal classes or fetal monitoring), and any perceived barriers to care. RESULTS Thirty South Asian and 30 Canadian-born women were interviewed. Most women in each group reported having pregnancy evaluations carried out. Fewer South Asian women than Canadian-born women understood the purpose of symphysis-fundal height measurement (60% vs. 90%, P = 0.015) and tests for Group B streptococcus (33% vs. 73%, P = 0.004). Thirteen percent of South Asian and 23% of Canadian-born women attended prenatal classes. Most women (87-97%) believed they had received all necessary medical care. Language barriers were most commonly reported by South Asian women (33-43% vs. 0 for Canadian-born women). CONCLUSION South Asian women considered language to be the most common barrier to receiving perinatal care. Such barriers may be overcome by wider availability of multilingual staff and educational materials in a variety of formats including illustrated books and videos.

Representativeness of patients and providers in the Canadian Primary Care Sentinel Surveillance Network: a cross-sectional study

BACKGROUND The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) has established a national repository of primary care patient health data that is used for both surveillance and research. Our main objective was to determine how representative the data for patients and primary care practitioners in the CPCSSN are when compared with the Canadian population. METHODS In this cross-sectional study, we compared the 2013 CPCSSN patient sample with age and sex information from the 2011 census. The CPCSSN provider sample in 2013 was compared with the 2013 National Physician Survey. Results were stratified by 5 clinically relevant age categories and sex, and male-to-female ratios were calculated. RESULTS Patients who were 65 years of age and older represented 20.4% of the CPCSSN sample but only represented 14.8% of the Canadian population (2011 census). Among young adults (20-39 yr), 39.3% fewer men than women visited their primary care practitioner within 2 years. CPCSSN sample practitioners were more likely to be under 45 years of age, more likely to be female and more likely to be in an academic practice. INTERPRETATION It is important to consider adjusting for age and sex when using CPCSSN data. CPCSSN practitioners are likely not representative of family physicians; therefore, CPCSSN needs to recruit more nonacademic practices, community clinics and practices that have a larger proportion of male providers.

Pathways to dementia diagnosis among South Asian Canadians

Urban centers are increasingly ethnically diverse. However, some visible minorities are less likely than their majority counterparts to seek and receive services and treatment for dementia. This study explored experiences of South Asian Canadians, Canada’s largest visible minority group, prior to dementia diagnosis. Six persons with dementia and eight of their family carers described their early perceptions of dementia-related changes, actions taken, including help seeking and diagnosis, and affective responses. Early signs were attributed to aging or personality. Even after cognitive enhancers were prescribed, some respondents continued to believe that the dementia symptoms were ‘normal’. Family carers’ affective responses may be related to their attributions. Before seeking medical attention, family carers modified physical or social environments because of symptoms. Help seeking was delayed up to four years, even with significant dementia symptoms. Recognition of a health problem was influenced by safety concerns, emergence of new symptoms following trauma, and treatment for other health problems. For some, relatives living outside the home or outside Canada were instrumental in recognizing a problem and convincing family carers and persons with dementia to seek medical attention. The pathway to diagnosis might be easier with outreach to help South Asian immigrants differentiate between normal aging and dementia. Symptom recognition by physicians treating other acute conditions was a portal to dementia services for others. Screening and referral in acute care could result in earlier diagnosis and treatment.

Goal achievement as a patient‐generated outcome measure for stress urinary incontinence

Objectives  To explore women’s goals and goal attainment for the conservative and surgical treatment of stress urinary incontinence (SUI), and to examine the feasibility of Goal Attainment Scaling (GAS) as an outcome measure in this population.

Role expectations in dementia care among family physicians and specialists.

Background The assessment and ongoing management of dementia falls largely on family physicians. This pilot study explored perceived roles and attitudes towards the provision of dementia care from the perspectives of family physicians and specialists. Methods Semi-structured, one-to-one interviews were conducted with six family physicians and six specialists (three geriatric psychiatrists, two geriatricians, and one neurologist) from University of Toronto-affiliated hospitals. Transcripts were subjected to thematic content analysis. Results Physicians’ clinical experience averaged 16 years. Both physician groups acknowledged that family physicians are more confident in diagnosing/treating uncomplicated dementia than a decade ago. They agreed on care management issues that warranted specialist involvement. Driving competency was contentious, and specialists willingly played the “bad cop” to resolve disputes and preserve long-standing therapeutic relationships. While patient/caregiver education and support were deemed essential, most physicians commented that community resources were fragmented and difficult to access. Improving collaboration and communication between physician groups, and clarifying the roles of other multi-disciplinary team members in dementia care were also discussed. Conclusions Future research could further explore physicians’ and other multi-disciplinary members’ perceived roles and responsibilities in dementia care, given that different health-care system-wide dementia care strategies and initiatives are being developed and implemented across Ontario.