Nicole Leduc

Genetics in Health Care: An Overview of Current and Emerging Models

Background: With advances in genetic and genomic medicine, the optimal integration of genetic services into the health care system remains of major concern in many countries. Objectives: To review the current organisation of genetic services, mostly in Europe, North America and Australia, explore emerging service delivery models, and probe challenges inherent in the transition process. Methods: We conducted a literature review of genetics in clinical practice: testing, diagnosis, counselling, and treatment. We examined the basic structures of genetic services, examples of integrated networks, and existing professional resources. We investigated services belonging traditionally in medical genetics as well as those developed for more common diseases. Results: Multidisciplinary specialist clinics and coordinated services appeared to be key to delivering proper care in rare genetic disorders. For oncogenetics, neurogenetics and cardiogenetics, interprofessional collaboration between geneticists and other specialists seemed to be favoured. On the other hand, there was also a tendency toward the integration of genetic services directly into primary care. Among the most pressing challenges was the morphing of paediatric care into adult care. Conclusion: The coordination of activities between professionals in first-, second-, and third-line medical care is a primary objective calling for the reconfiguration of professional roles and responsibilities. This entails the forging of new relationships as well as an enhanced sharing of expertise and genetic information, including information regarding services. Barriers to overcome include the redistribution of roles, sharing of data and databases, and the lack of preparedness of non-genetics professionals and of the health care system in general.

Anthropometric Characteristics of Mohawk Children Aged 6 to 11 Years: A Population Perspective

OBJECTIVE Recent studies have concluded that Native North American children have higher proportions of overweight and obesity than children from the general North American population. This study presents anthropometric data on a representative sample of children from the Mohawk Nation that can be used for comparison with other Native American populations. DESIGN This is a cross-sectional study comparing distributions of anthropometric characteristics of Mohawk children to the corresponding age and gender data from the Second National Health and Nutrition Examination Survey (NHANES II). Weight, height, triceps and subscapular skinfold thickness, and waist and hip circumferences were measured in 527 children. SUBJECTS/SETTING All children in grades 1 to 6 (aged 6 to 11 years) in the 3 elementary schools of 2 Mohawk communities in Canada, for whom parental consent was obtained, were enrolled in the present study. There were no exclusion criteria. With a participation rate of 83%, the 527 children enrolled in this study represent an unbiased sample of the population from 2 Mohawk territories. RESULTS Compared with children studied in NHANES II, Mohawk children were similar in height and triceps skinfolds but were generally heavier, had thicker subscapular skinfolds, and had greater waist and hip circumferences. These differences were greater in older children. Mohawk children who had extreme-high weight values compared with their population means were heavier than their NHANES II counterparts. APPLICATIONS/CONCLUSIONS Results indicated that, on average, Mohawk children seem to be slightly heavier than children in NHANES II. Except for those with extreme overweight values, Mohawk children show less variation of weight and body mass index than children in NHANES II. Finally, overweight Mohawk children seem to be more likely to carry their excess body fat truncally, compared with overweight children from NHANES II. Health practitioners working with Native American populations should be careful when assessing childhood obesity. Simple comparisons of weight or body mass index with NHANES standards may lead to inappropriate risk assessments.

Understanding the self-care strategies of patients with asthma

OBJECTIVE The objective was to understand how adults living with asthma deal with their chronic illness, perceive self-management and develop self-care strategies. METHODS 24 in-depth, semi-structured interviews were conducted in Montreal, Canada with low- and middle-income adults living with asthma. The interviews were tape-recorded and transcribed for purposes of analysis. The analysis consisted of debriefing sessions, coding and interpretive analysis. RESULTS We identified 3 types of self-care strategies adopted by the participants in order to deal with asthma: (1) strategy of controlling symptoms leads to patients following the recommendations of their physician; (2) strategy of preventing symptoms involves a holistic approach to treating illness, and leads patients to prefer lay methods and alternative treatments for preventing symptoms instead of relying on medications; (3) strategy of tolerating symptoms leads people to experience aggravated symptoms and to seek emergency care. CONCLUSION This study reveals that important subjective as well social factors influence the way people deal with a chronic illness like asthma. Future research should: (1) identify the difficulties encountered by vulnerable patients in regard to treatment and care interactions; (2) provide health professionals with the right tools so that they can take into consideration the treatment perceptions and the effects of life conditions on self-management. PRACTICE IMPLICATIONS Patients with asthma need comprehensive care that addresses social conditions, reluctance to take medication, exploration of lay and alternative treatment and difficulties in accessing preventive care.

Outcomes of interprofessional collaboration for hospitalized cancer patients.

This study aims to evaluate the effect of the intensity of interprofessional collaboration on hospitalized cancer patients. We conducted a cross-sectional study of 312 patients to examine the effects of intensity of interprofessional collaboration (low vs high intensity collaboration) on patient satisfaction, uncertainty, pain management, and length of stay. Data on the intensity of interprofessional collaboration, patient satisfaction, and uncertainty were collected from professionals and patients using valid and reliable instruments. Administrative and clinical records were used to calculate the index of pain management and length of hospital stay. The analysis revealed the existence of significant differences between patients who are cared for by teams operating with a high intensity of collaboration and those who are cared for by teams operating with a low intensity of collaboration, as measured by the mean satisfaction (P < .001) among a specific group of patients (patients who have a high level of education and perceive their state of health as poor), mean uncertainty (P = .047), and adequacy of pain management (P = .047). The analysis also found no significant difference (P = .217) in their length of hospital stay. The findings suggest that intensity of interprofessional collaboration has a positive effect on patient satisfaction, reduces uncertainty, and improves pain management, yet they also suggest that the degree of collaboration does not influence the length of hospital stay.

Caregiver satisfaction with support services: influence of different types of services.

OBJECTIVES This article examines factors influencing satisfaction with support services of caregivers of frail older adults and determines what types of support services are associated with greater satisfaction, controlling for frail individual and caregiver characteristics. METHODS The study includes 291 frail older adults-caregiver dyads from Montreal in which caregivers receive support services. The Client Satisfaction Questionnaire-8 is used to measure caregiver satisfaction with these services. RESULTS Caregivers receiving information, advice, or emotional support, and those caring for seniors receiving integrated care are more likely to be highly satisfied. Other factors increasing satisfaction are fewer number of health problems of frail individuals, caregiver being the spouse of the frail person, as well as greater caregiver perceived health, autonomy in instrumental activities of daily living, and available social support. DISCUSSION The results support the importance of integrated care for frail seniors and informational services for their caregivers.

Evaluation of the implementation fidelity of an ergonomic training program designed to prevent back pain

The aim of this study was to evaluate the implementation fidelity of a multidimensional ergonomic program designed to prevent back pain injuries among healthcare personnel. The program, provided by peer trainers included training intended to modify patient handling and transfer behaviour, trainee follow-up, prevention activities aimed at work environment improvements and follow-up monitors training. Two hundred twenty-one peer trainers at 139 Quebec healthcare institutions participated in our study. Only 61.5% were involved in training; most of them taught safe patient handling, positioning, transfer, and preparation techniques, which are the cornerstones of the program; 72.7% were involved in prevention activities, 46.1% in follow-up activities, and 10.7% in follow-up monitors training. The study results should help organizations anticipate and prevent potential discrepancies between prescribed and implemented programs.

Relationship between home hazards and falling among community-dwelling seniors using home-care services

BACKGROUND Evidence linking home hazards to falls has not been well established. The evidence-based approach to fall-risk assessment in longitudinal studies becomes difficult because of exposures that change during follow-up. We conducted a cohort study to determine the prevalence of hazards and to resolve whether they are linked to the risk of falls among 959 seniors receiving home-care services. METHODS A home hazards assessment was completed at entry and every six months thereafter using a standardized form. The adjusted (for a number of confounding factors) relationship between home hazards and falls was estimated using a survival model taking into account updated time-varying exposures and multiple events. Falls leading to a medical consultation were examined as a secondary outcome, hypothesized as a measure of severity. FINDINGS Home environmental hazards were found in 91% of homes, with a mean of 3.3 risks per individual. The bathroom was the most common place for hazards. The presence of hazards was significantly associated with all falls and fall-related medical consultations, and showed relatively constant effects from one fall to another. IMPLICATIONS The current study is innovative in its approach and useful in its contribution to the understanding of the interaction between home environmental hazards and falls. Our results indicate that inattention to changes in exposure masks the statistical association between home hazards and falls. Each environmental hazard identified in the home increases the risk of falling by about 19%. These findings support the positive findings of trials that demonstrate the effectiveness of this home hazard reduction program, particularly for at-risk people.

Humanized birth in high risk pregnancy: barriers and facilitating factors

The medical model of childbearing assumes that a pregnancy always has the potential to turn into a risky procedure. In order to advocate humanized birth in high risk pregnancy, an important step involves the enlightenment of the professional’s preconceptions on humanized birth in such a situation. The goal of this paper is to identify the professionals’ perception of the potential obstacles and facilitating factors for the implementation of humanized care in high risk pregnancies. Twenty-one midwives, obstetricians, and health administrator professionals from the clinical and academic fields were interviewed in nine different sites in Japan from June through August 2008. The interviews were audio taped, and transcribed with the participants’ consent. Data was subsequently analyzed using content analysis qualitative methods. Professionals concurred with the concept that humanized birth is a changing and promising process, and can often bring normality to the midst of a high obstetric risk situation. No practice guidelines can be theoretically defined for humanized birth in a high risk pregnancy, as there is no conflict between humanized birth and medical intervention in such a situation. Barriers encountered in providing humanized birth in a high risk pregnancy include factors such as: the pressure of being responsible for the safety of the mother and the fetus, lack of the women’s active involvement in the decision making process and the heavy burden of responsibility on the physician’s shoulders, potential legal issues, and finally, the lack of midwifery authority in providing care at high risk pregnancy. The factors that facilitate humanized birth in a high risk include: the sharing of decision making and other various responsibilities between the physicians and the women; being caring; stress management, and the fact that the evolution of a better relationship and communication between the health professional and the patient will lead to a stress-free environment for both. Humanized birth in a high risk pregnancy is something that goes beyond just curing women of their illnesses. It can be considered as a token of caring, and continued support, which positively consolidates the doctor-patient relationship. As yet, it has not been described as a practiced guideline, due to its ever-changing complexities.

Short-term geriatric assessment units: 30 years later.

BackgroundThe increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them.MethodsIn 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their units operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile.ResultsOverall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAUs operation.ConclusionsThe GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAUs primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.

Determinants of Adult Day Center Attendance Among Older Adults With Functional Limitations

Objective: To examine factors related to regularity of adult day center (ADC) attendance among seniors with functional limitations. Methods: Using data collected as part of a larger study, we identified the proportion of scheduled days attended among 101 ADC users in Montréal and identified determinants of this attendance. Results: More regular attendance was associated with previous profession of ADC participant or spouse in a sector other than health care, receiving formal help for activities of daily living or instrumental activities of daily living on days of expected ADC participation, participating for the whole day rather than half a day, lower participation in prevention and health-promotion activities, and lower caregiver burden among persons with cognitive impairments and higher caregiver burden among persons without cognitive impairments. Discussion: To enhance ADC intervention effects, levels of participation should be maximized. Study findings suggest ways to promote more regular attendance.