Peter G. Norton

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada

Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.

Snoring as a risk factor for disease: an epidemiological survey.

In a study conducted in four family practice units in Toronto, Canada, 2001 subjects reported on snoring and medical conditions in members of their households. For spouses the prevalence of snoring increased with age up to the seventh decade, with a higher prevalence of nearly 85% in husbands. For 11 medical problems an association existed between snoring, its frequency, and the presence of the condition. This association continued when the data were corrected for sex, age, and marital state. For hypertension both men and women who snored between the fifth and 10th decades had a twofold increase over non-snorers. The prevalence of heart disease and other conditions, except for diabetes and asthma, also increased in snorers in this age group. When corrected for smoking and obesity the association between snoring, hypertension, and heart disease persisted. These findings extend those of Lugaresi et al, and if they could be confirmed snoring as a risk factor for conditions other than sleep apnoea and sleep disorders might be considered. Methods of alleviating the acoustic annoyance of snoring may also provide direct medical benefits.

Health researchers in Alberta: an exploratory comparison of defining characteristics and knowledge translation activities

BackgroundCanadian funding agencies are no longer content to support research that solely advances scientific knowledge, and key directives are now in place to promote research transfer to policy- and decision-makers. Therefore, it is necessary to improve our understanding of how researchers are trained and supported to facilitate knowledge translation activities. In this study, we investigated differences in health researcher characteristics and knowledge translation activities.MethodsOur sample consisted of 240 health researchers from three Alberta universities. Respondents were classified by research domain [basic (n = 72) or applied (n = 168)] and faculty [medical school (n = 128) or other health science (n = 112)]. We examined our findings using Mode I and Mode II archetypes of knowledge production, which allowed us to consider the scholarly and social contexts of knowledge production and translation.ResultsDifferences among health researcher professional characteristics were not statistically significant. There was a significant gender difference in the applied researcher faculty group, which was predominantly female (p < .05). Research domain was linked to translation activities. Applied researchers reported engaging in significantly more Mode II activities than basic researchers (p < .001), and scored higher than basic researchers regarding the perceived importance of translation activities (Mode I, p = .01; Mode II, p < .001). Main effects of faculty were limited to engaged dissemination (medical school < other faculties; p = .025) and number of publications (medical school > other faculties; p = .004). There was an interaction effect for research domain and faculty group for number of publications (p = .01), in that applied researchers in medical faculties published more than their peers in other faculty groups.ConclusionOur findings illustrate important differences between health researchers and provide beginning insights into their professional characteristics and engagement in Mode I and Mode II activities. A future study designed to examine these dimensions in greater detail, including potential covariates across more varied institutions, would yield richer insights and enable an examination of relative influences, needs and costs of each mode of activity.

Association of socio-economic status with diabetes prevalence and utilization of diabetes care services

BackgroundLow income appears to be associated with a higher prevalence of diabetes and diabetes related complications, however, little is known about how income influences access to diabetes care. The objective of the present study was to determine whether income is associated with referral to a diabetes centre within a universal health care system.MethodsData on referral for diabetes care, diabetes prevalence and median household income were obtained from a regional Diabetes Education Centre (DEC) database, the Canadian National Diabetes Surveillance System (NDSS) and the 2001 Canadian Census respectively. Diabetes rate per capita, referral rate per capita and proportion with diabetes referred was determined for census dissemination areas. We used Chi square analyses to determine if diabetes prevalence or population rates of referral differed across income quintiles, and Poisson regression to model diabetes rate and referral rate in relation to income while controlling for education and age.ResultsThere was a significant gradient in both diabetes prevalence (χ2 = 743.72, p < 0.0005) and population rates of referral (χ2 = 168.435, p < 0.0005) across income quintiles, with the lowest income quintiles having the highest rates of diabetes and referral to the DEC. Referral rate among those with diabetes, however, was uniform across income quintiles. Controlling for age and education, Poisson regression models confirmed a significant socio-economic gradient in diabetes prevalence and population rates of referral.ConclusionLow income is associated with a higher prevalence of diabetes and a higher population rate of referral to this regional DEC. After accounting for diabetes prevalence, however, the equal proportions referred to the DEC across income groups suggest that there is no access bias based on income.

Study protocol for the translating research in elder care (TREC): building context – an organizational monitoring program in long-term care project (project one)

BackgroundWhile there is a growing awareness of the importance of organizational context (or the work environment/setting) to successful knowledge translation, and successful knowledge translation to better patient, provider (staff), and system outcomes, little empirical evidence supports these assumptions. Further, little is known about the factors that enhance knowledge translation and better outcomes in residential long-term care facilities, where care has been shown to be suboptimal. The project described in this protocol is one of the two main projects of the larger five-year Translating Research in Elder Care (TREC) program.AimsThe purpose of this project is to establish the magnitude of the effect of organizational context on knowledge translation, and subsequently on resident, staff (unregulated, regulated, and managerial) and system outcomes in long-term care facilities in the three Canadian Prairie Provinces (Alberta, Saskatchewan, Manitoba).Methods/DesignThis study protocol describes the details of a multi-level – including provinces, regions, facilities, units within facilities, and individuals who receive care (residents) or work (staff) in facilities – and longitudinal (five-year) research project. A stratified random sample of 36 residential long-term care facilities (30 urban and 6 rural) from the Canadian Prairie Provinces will comprise the sample. Caregivers and care managers within these facilities will be asked to complete the TREC survey – a suite of survey instruments designed to assess organizational context and related factors hypothesized to be important to successful knowledge translation and to achieving better resident, staff, and system outcomes. Facility and unit level data will be collected using standardized data collection forms, and resident outcomes using the Resident Assessment Instrument-Minimum Data Set version 2.0 instrument. A variety of analytic techniques will be employed including descriptive analyses, psychometric analyses, multi-level modeling, and mixed-method analyses.DiscussionThree key challenging areas associated with conducting this project are discussed: sampling, participant recruitment, and sample retention; survey administration (with unregulated caregivers); and the provision of a stable set of study definitions to guide the project.

Advancing Measurement of Patient Safety Culture

OBJECTIVE To examine the psychometric and unit of analysis/strength of culture issues in patient safety culture (PSC) measurement. DATA SOURCE Two cross-sectional surveys of health care staff in 10 Canadian health care organizations totaling 11,586 respondents. STUDY DESIGN A cross-validation study of a measure of PSC using survey data gathered using the Modified Stanford PSC survey (MSI-2005 and MSI-2006); a within-group agreement analysis of MSI-2006 data. Extraction Methods. Exploratory factor analyses (EFA) of the MSI-05 survey data and confirmatory factor analysis (CFA) of the MSI-06 survey data; Rwg coefficients of homogeneity were calculated for 37 units and six organizations in the MSI-06 data set to examine within-group agreement. PRINCIPAL FINDINGS The CFA did not yield acceptable levels of fit. EFA and reliability analysis of MSI-06 data suggest two reliable dimensions of PSC: Organization leadership for safety (alpha=0.88) and Unit leadership for safety (alpha=0.81). Within-group agreement analysis shows stronger within-unit agreement than within-organization agreement on assessed PSC dimensions. CONCLUSIONS The field of PSC measurement has not been able to meet strict requirements for sound measurement using conventional approaches of CFA. Additional work is needed to identify and soundly measure key dimensions of PSC. The field would also benefit from further attention to strength of culture/unit of analysis issues.

Translating research in elder care: an introduction to a study protocol series

BackgroundThe knowledge translation field is undermined by two interrelated gaps – underdevelopment of the science and limited use of research in health services and health systems decision making. The importance of context in theory development and successful translation of knowledge has been identified in past research. Additionally, examination of knowledge translation in the long-term care (LTC) sector has been seriously neglected, despite the fact that aging is increasingly identified as a priority area in health and health services research.AimsThe aims of this study are: to build knowledge translation theory about the role of organizational context in influencing knowledge use in LTC settings and among regulated and unregulated caregivers, to pilot knowledge translation interventions, and to contribute to enhanced use of new knowledge in LTC.DesignThis is a multi-level and longitudinal program of research comprising two main interrelated projects and a series of pilot studies. An integrated mixed method design will be used, including sequential and simultaneous phases to enable the projects to complement and inform one another. Inferences drawn from the quantitative and qualitative analyses will be merged to create meta-inferences.OutcomesOutcomes will include contributions to (knowledge translation) theory development, progress toward resolution of major conceptual issues in the field, progress toward resolution of methodological problems in the field, and advances in the design of effective knowledge translation strategies. Importantly, a better understanding of the contextual influences on knowledge use in LTC will contribute to improving outcomes for residents and providers in LTC settings.

The Relationship between Organizational Leadership for Safety and Learning from Patient Safety Events

OBJECTIVE To examine the relationship between organizational leadership for patient safety and five types of learning from patient safety events (PSEs). STUDY SETTING Forty-nine general acute care hospitals in Ontario, Canada. STUDY DESIGN A nonexperimental design using cross-sectional surveys of hospital patient safety officers (PSOs) and patient care managers (PCMs). PSOs provided data on organization-level learning from (a) minor events, (b) moderate events, (c) major near misses, (d) major event analysis, and (e) major event dissemination/communication. PCMs provided data on organizational leadership (formal and informal) for patient safety. EXTRACTION METHODS Hospitals were the unit of analysis. Seemingly unrelated regression was used to examine the influence of formal and informal leadership for safety on the five types of learning from PSEs. The interaction between leadership and hospital size was also examined. PRINCIPAL FINDINGS Formal organizational leadership for patient safety is an important predictor of learning from minor, moderate, and major near-miss events, and major event dissemination. This relationship is significantly stronger for small hospitals (<100 beds). CONCLUSIONS We find support for the relationship between patient safety leadership and patient safety behaviors such as learning from safety events. Formal leadership support for safety is of particular importance in small organizations where the economic burden of safety programs is disproportionately large and formal leadership is closer to the front lines.

Advancing the argument for validity of the Alberta Context Tool with healthcare aides in residential long-term care

BackgroundOrganizational context has the potential to influence the use of new knowledge. However, despite advances in understanding the theoretical base of organizational context, its measurement has not been adequately addressed, limiting our ability to quantify and assess context in healthcare settings and thus, advance development of contextual interventions to improve patient care. We developed the Alberta Context Tool (the ACT) to address this concern. It consists of 58 items representing 10 modifiable contextual concepts. We reported the initial validation of the ACT in 2009. This paper presents the second stage of the psychometric validation of the ACT.MethodsWe used the Standards for Educational and Psychological Testing to frame our validity assessment. Data from 645 English speaking healthcare aides from 25 urban residential long-term care facilities (nursing homes) in the three Canadian Prairie Provinces were used for this stage of validation. In this stage we focused on: (1) advanced aspects of internal structure (e.g., confirmatory factor analysis) and (2) relations with other variables validity evidence. To assess reliability and validity of scores obtained using the ACT we conducted: Cronbachs alpha, confirmatory factor analysis, analysis of variance, and tests of association. We also assessed the performance of the ACT when individual responses were aggregated to the care unit level, because the instrument was developed to obtain unit-level scores of context.ResultsItem-total correlations exceeded acceptable standards (> 0.3) for the majority of items (51 of 58). We ran three confirmatory factor models. Model 1 (all ACT items) displayed unacceptable fit overall and for five specific items (1 item on adequate space for resident care in the Organizational Slack-Space ACT concept and 4 items on use of electronic resources in the Structural and Electronic Resources ACT concept). This prompted specification of two additional models. Model 2 used the 7 scaled ACT concepts while Model 3 used the 3 count-based ACT concepts. Both models displayed substantially improved fit in comparison to Model 1. Cronbachs alpha for the 10 ACT concepts ranged from 0.37 to 0.92 with 2 concepts performing below the commonly accepted standard of 0.70. Bivariate associations between the ACT concepts and instrumental research utilization levels (which the ACT should predict) were statistically significant at the 5% level for 8 of the 10 ACT concepts. The majority (8/10) of the ACT concepts also showed a statistically significant trend of increasing mean scores when arrayed across the lowest to the highest levels of instrumental research use.ConclusionsThe validation process in this study demonstrated additional empirical support for construct validity of the ACT, when completed by healthcare aides in nursing homes. The overall pattern of the data was consistent with the structure hypothesized in the development of the ACT and supports the ACT as an appropriate measure for assessing organizational context in nursing homes. Caution should be applied in using the one space and four electronic resource items that displayed misfit in this study with healthcare aides until further assessments are made.

Influences on physicians' choices of intravenous colloids

AbstractObjectives. Controversy over the optimal intravenous fluid for volume resuscitation continues unabated. Our objectives were to characterize the demographics of physicians who prescribe intravenous colloids and determine factors that enter into their decision to choose a colloid. Design. Questionnaire with 61 items. Participants and setting. Ten percent (n=364) of frequent intravenous fluid prescribers in the province of Ontario, Canada. Results. The response rate was 74%. Colloid use in the past year was reported by 79% of the responding physicians. Important reasons for choosing a colloid included blood loss and manipulation of oncotic pressure. Physicians tended to prefer either albumin or pentastarch, but no important reasons were found for choosing between the two. Albumin with or without crystalloid was preferred in 5/13 scenarios by more than 50% of the respondents, whereas pentastarch was not favored by more than 50% of respondents in any scenario. Physicians practising in critical care areas and teaching hospitals generally preferred pentastarch to albumin. Physicians reporting pentastarch as representing greater than 90% of total colloid use were more likely to have been visited by a drug detailer for pentastarch than those who used less synthetic colloid (54 vs 22%, p<0.001). Conclusions. The majority of physicians surveyed prescribe colloid products and the reported use of albumin and pentastarch has a bimodal distribution. Although albumin appeared to be preferred in more clinical niches, most physicians did not state reasons for choosing between products. Marketing, specialty, location of practice and clinical scenario appear to play significant roles in the utilization of colloid products.