Improving the quality of health care in Canada

Obstetrics care in Indonesia: Determinants of maternal mortality and stillbirth rates

PROBLEM

The Indonesian Healthcare Program starting in 2014 enabled access to healthcare delivery for large population groups. Guidance of usage, infrastructure and healthcare process development were the most challenging tasks during the implementation period. Due to the high social impact obstetric care and related quality assurance require evidence-based developmental strategies. This study aims for analysis of outcome and maternal health care utilization, as well as differences related to demographic and economic subgroups.

METHODS

For univariate group comparison ANOVA method was applied and combined with Scheffé procedure and Bonferoni correction for post-hoc tests. Meanwhile, multivariate approaches through regression analysis based on insurance reimbursement data antenatal, perinatal and postnatal care were performed at the province level. Maternal mortality (MMR) and stillbirth rates were used for outcome. Demographic characteristics, availability of obstetricians (SPOG), midwifes and healthcare infrastructure were included for their determinants.

RESULTS

Specialized hospital facilities (type A/B) for advanced care covered a large part of uncomplicated cases (~35%). Differences between insurance membership groups (poor, non-poor) were not seen. Availability of human resources (SPOG, midwifes) (R2 = 0.728; p<0.001) and rural setting (R2 = 0.288; p = 0.001) are correlated with reduced insufficient referral. Their presence within provinces was related to lower occurrence of complicated cases (R2 = 0.294; p = 0.001). However, higher SPOG rates within provinces were also related to high C-section rates (p<0.001). MMR and stillbirth rates can be predicted by availability of human resources and C-section rates explaining 49.0% of variance.

CONCLUSIONS

Improvement of perinatal outcome should focus on sufficient referral processes, availability of SPOG in provinces dominated by rural/remote demography and avoidance of overtreatment by high C-section rates. It is very important to regulate the education of obstetricians and gynecologists in Indonesia as well as distribution arrangements regarding to solve the problems with pregnancy complications in remote and rural areas.

Perceived Access to Healthcare of Indigenous Peoples in Canada With Rheumatoid Arthritis and Their First-Degree Relatives

OBJECTIVE

There are complex and interrelated factors that lead to inequitable healthcare delivery in Canada. Many of the factors that underlie these inequities for Canada's geographically dispersed Indigenous peoples remain underexamined.

METHODS

A cohort of 831 First Nations (FN) individuals from urban and remote communities were recruited into a longitudinal study of rheumatoid arthritis (RA) risk from 2005 to 2017. Data from each participant's initial enrollment visit were assessed using a survey that captured concerns with healthcare access.

RESULTS

We found that remote participants with RA reported poor access compared to remote first-degree relatives (FDRs; P < 0.001); this difference was not observed for urban participants with RA. We observed substantial differences based on sex; female participants perceived access to care to be more difficult than male participants in both urban and remote cohorts (P < 0.001). We also observed that male participants with RA reported poor access to care compared to male FDRs. Importantly, access to care in remote communities appeared to improve over the duration of the study (P = 0.01). In a logistic regression analysis, female sex, remote location, and older age were independent predictors of poor access to care. Predictors of poor access in participants with RA also included female sex, remote location, and older age.

CONCLUSION

FN peoples living in remote communities, particularly those with an established RA diagnosis, report more problems accessing health care. Sex-based inequities exist, with FN female individuals reporting greater difficulties in accessing appropriate health care, regardless of RA diagnosis. Addressing these sex-based inequities should be a high priority for improving healthcare delivery.

Implementation and evaluation of a national quality improvement initiative in cancer surgery

BACKGROUND

In 2017, the Canadian Partnership Against Cancer, a Canadian federally sponsored organisation, initiated a national multijurisdictional quality improvement (QI) initiative to maximise the use of synoptic data to drive cancer system improvements, known as the Evidence for Surgical Synoptic Quality Improvement Programme. The goal of our study was to evaluate the outcomes, determinants and learning of this nationally led initiative across six jurisdictions in Canada, integrating a mix of cancer surgery disease sites and clinicians.

METHODS

A mixed-methods evaluation (surveys, semistructured interviews and focus groups) of this initiative was focused on the ability of each jurisdiction to use synoptic reporting data to successfully implement and sustain QI projects to beyond the completion of the initiative and the lessons learnt in the process. Resources provided to the jurisdictions included operational funding, training in QI methodology, national forums, expert coaches, and ad hoc monitoring and support. The programme emphasised foundational concepts of the QI process including data literacy, audit and feedback reports, communities of practice (CoP) and positive deviance methodology.

RESULTS

101 CoP meetings were held and 337 clinicians received feedback reports. There were 23 projects, and 22 of 23 (95%) showed improvements with 15 of 23 (65%) achieving the proposed targets. Enablers of effective data utilisation/feedback reports for QI included the need for clinicians to trust the data, have comparative data for feedback, and the engagement of both data scientists and clinicians in designing feedback reports. Enablers of sustainability of QI within each jurisdiction included QI training for clinicians, the ability to continue CoP meetings, executive and broad stakeholder engagement, and the ability to use pre-existing organisational infrastructures and processes. Barriers to continue QI work included lack of funding for core team members, lack of automated data collection processes and lack of clinician incentives (financial and other).

CONCLUSION

Success and sustainability in data-driven QI in cancer surgery require skills in QI methodology, data literacy and feedback, dedicated supportive personnel and an environment that promotes the process of collective learning and shared accountability. Building these capabilities in jurisdictional teams, tailoring interventions to facility contexts and strong leadership engagement will create the capacity for continued success in QI for cancer surgery.

"We're sinking": a qualitative interview-based study on stakeholder perceptions of structural and process limitations to the Canadian healthcare system

BACKGROUND

Despite longstanding efforts and calls for reform, Canada's incremental approach to healthcare changes has left the country lagging behind other OECD nations. Reform to the Canadian healthcare system is essential to develop a higher performing system. This study sought to gain a deeper understanding of the views of Canadian stakeholders on structural and process deficiencies and strategies to improve the Canadian healthcare system substantially and meaningfully.

METHODS

We conducted individual, ~ 45-minute, semi-structured virtual interviews from May 2022 to August 2022. Using existing contacts and snowball sampling, we targeted one man and one woman from five regions in Canada across four stakeholder groups: (1) public citizens; (2) healthcare leaders; (3) academics; and (4) political decision makers. Interviews centered on participants' perceptions of the state of the current healthcare system, including areas where major improvements are required, and strategies to achieve suggested enhancements; Donabedian's Model (i.e., structure, process, outcomes) was the guiding conceptual framework. Interviews were audio-recorded, transcribed verbatim, and de-identified, and inductive thematic analysis was performed independently and in duplicate according to published methods.

RESULTS

The data from 31 interviews with 13 (41.9%) public citizens, 10 (32.3%) healthcare leaders, 4 (12.9%) academics, and 4 (12.9%) political decision makers resulted in three themes related to the structure of the healthcare system (1. system reactivity; 2. linkage with the Canadian identity; and 3. political and funding structures), three themes related to healthcare processes (1. staffing shortages; 2. inefficient care; and 3. inconsistent care), and three strategies to improve short- and long-term population health outcomes (1. delineating roles and revising incentives; 2. enhanced health literacy; 3. interdisciplinary and patient-centred care).

CONCLUSION

Canadians in our sample identified important structural and process limitations to the Canadian healthcare system. Meaningful reforms are needed and will require addressing the link between the Canadian identity and our healthcare system to facilitate effective development and implementation of strategies to improve population health outcomes.

Predictors of Physician Follow-Up Care Among Patients Affected by an Incident Mental Disorder Episode in Quebec (Canada)

OBJECTIVES

This study identified predictors of prompt (1+ outpatient physician consultations/within 30 days), adequate (3+/90 days) and continuous (5+/365 days) follow-up care from general practitioners (GPs) or psychiatrists among patients with an incident mental disorder (MD) episode.

METHODS

Study data were extracted from the Quebec Integrated Chronic Disease Surveillance System (QICDSS), which covers 98% of the population eligible for health-care services under the Quebec (Canada) Health Insurance Plan. This observational epidemiological study investigating the QICDSS from 1 April 1997 to 31 March 2020, is based on a 23-year patient cohort including 12+ years old patients with an incident MD episode (n = 2,670,133). Risk ratios were calculated using Robust Poisson regressions to measure patient sociodemographic and clinical characteristics, and prior service use, which predicted patients being more or less likely to receive prompt, adequate, or continuous follow-up care after their last incident MD episode, controlling for previous MD episodes, co-occurring disorders, and years of entry into the cohort.

RESULTS

A minority of patients, and fewer over time, received physician follow-up care after an incident MD episode. Women; patients aged 18-64; with depressive or bipolar disorders, co-occurring MDs-substance-related disorders (SRDs) or physical illnesses; those receiving previous GP follow-up care, especially in family medicine groups; patients with higher prior continuity of GP care; and previous high users of emergency departments were more likely to receive follow-up care. Patients living outside the Montreal metropolitan area; those without prior MDs; patients with anxiety, attention deficit hyperactivity, personality, schizophrenia and other psychotic disorders, or SRDs were less likely to receive follow-up care.

CONCLUSION

This study shows that vulnerable patients with complex clinical characteristics and those with better previous GP care were more likely to receive prompt, adequate or continuous follow-up care after an incident MD episode. Overall, physician follow-up care should be greatly improved.

Cancer Survivors Living in Rural Settings: A Qualitative Exploration of Concerns, Positive Experiences and Suggestions for Improvements in Survivorship Care

In Canada, the number of cancer survivors continues to increase. It is important to understand what continues to present difficulties after the completion of treatment from their perspectives. Various factors may present barriers to accessing help for the challenges they experience following treatment. Living rurally may be one such factor. This study was undertaken to explore the major challenges, positive experiences and suggestions for improvement in survivorship care from rural-dwelling Canadian cancer survivors one to three years following treatment. A qualitative descriptive analysis was conducted on written responses to open-ended questions from a national cross-sectional survey. A total of 4646 individuals living in rural areas responded to the survey. Fifty percent (2327) were male, and 2296 (49.4%) were female; 69 respondents were 18 to 29 years (1.5%); 1638 (35.3%) were 30 to 64 years; and 2926 (63.0%) were 65 years or older. The most frequently identified major challenges (n = 5448) were reduced physical capacity and the effects of treatment. Positive experiences included family and friend support and positive self-care practices. The suggestions for improvements focused on the need for better communication and information about self-care, side effect management, and programs and services, with more programs available locally for practical and emotional support.

A systematic review of participatory approaches to empower health workers in low- and middle-income countries, highlighting Health Workers for Change

This systematic review assesses participatory approaches to motivating positive change among health workers in low- and middle-income countries (LMICs). The mistreatment of clients at health centres has been extensively documented, causing stress among clients, health complications and even avoidance of health centres altogether. Health workers, too, face challenges, including medicine shortages, task shifting, inadequate training and a lack of managerial support. Solutions are urgently needed to realise global commitments to quality primary healthcare, country ownership and universal health coverage. This review searched 1243 titles and abstracts, of which 32 were extracted for full text review using a published critical assessment tool. Eight papers were retained for final review, all using a single methodology, 'Health Workers for Change' (HWFC). The intervention was adapted to diverse geographical and health settings. Nine indicators from the included studies were assessed, eliciting many common findings and documenting an overall positive impact of the HWFC approach. Health workers acknowledged their negative behaviour towards clients, often as a way of coping with their own unmet needs. In most settings they developed action plans to address these issues. Recommendations are made on mainstreaming HWFC into health systems in LMICs and its potential application to alleviating stress and burnout from COVID-19.

Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury

Introduction

The rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions.

Purpose

We employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions.

Methods

This study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews.

Results

There were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives.

Conclusion

This study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.

Quality Measures in Systemic Sclerosis

Quality improvement is an emerging field, that applies principles of improvement science and utilizes measurement methods with the aim of improving patient care. Systemic sclerosis (SSc) is a systemic autoimmune rheumatic disease associated with increased healthcare burden, cost, morbidity, and mortality. Gaps in delivering care to patients with SSc have been consistently observed. In this article, we introduce the discipline of quality improvement and its use of quality measures. We summarize and comparatively evaluate three sets of quality measures that have been proposed to evaluate the quality of care of patients with SSc. Finally, we highlight the areas of unmet needs and indicate future directions for quality improvement and quality measures in SSc.

"I Had Bills to Pay": a Mixed-Methods Study on the Role of Income on Care Transitions in a Public-Payer Healthcare System

BACKGROUND

Income disparities may affect patients' care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited.

OBJECTIVE

To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities.

DESIGN

Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial.

PARTICIPANTS

Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals.

MAIN MEASURES

The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted.

KEY RESULTS

Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0-3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health.

CONCLUSIONS

There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Use of Performance Data by Mid-Level Hospital Managers in Ontario: Results of a Province-Wide Survey and a Comparison with Hospital Managers in Europe

This paper provides insights into the use of performance data by middle managerial staff in Ontario hospitals in 2019 and compares the results to a study conducted in Europe in the same year. A total of 236 managers working in 61 hospitals across Ontario provided responses to the survey. Compared to their European colleagues, Ontario respondents self-assessed using significantly more performance data for managerial decision making. The use of performance data in Ontario was mostly motivated by external accountability requirements, followed by internal quality improvement efforts. Ontario managers also reported accessibility, appropriateness and timeliness of data and human resources and engagement as the biggest barriers to further performance data utilization. Comparative studies, such as the one this paper is based on, provide the foundation for drawing lessons across jurisdictions. This paper also affirms the importance of hospital middle management in moving from quality assurance to quality improvement efforts and developing sustainable learning healthcare organizations and systems.

On embedding assessments of self-regulated learning into licensure activities in the health professions: a call to action

How well have healthcare professionals and trainees been prepared for the inevitable demands for new learning that will arise in their future? Given the rapidity with which 'core healthcare knowledge' changes, medical educators have a responsibility to audit whether trainees have developed the capacity to effectively self-regulate their learning. Trainees who engage in effective self-regulated learning (SRL) skillfully monitor and control their cognition, motivation, behaviour, and environment to adaptively meet demands for new learning. However, medical curricula rarely assess trainees' capacity to engage in these strategic processes. In this position paper, we argue for a paradigm shift toward assessing SRL more deliberately in undergraduate and postgraduate programs, as well as in associated licensing activities. Specifically, we explore evidence supporting an innovative blend of principles from the science on SRL, and on preparation for future learning (PFL) assessments. We propose recommendations for how program designers, curriculum developers, and assessment leads in undergraduate and postgraduate training programs, and in licensing bodies can work together to develop integrated assessments that measure how and how well trainees engage in SRL. Claims about lifelong learning in health professions education have gone unmatched by responsive curricular changes for far too long. Further neglecting these important competencies represents a disservice to medical trainees and a potential risk to the future patients they will care for.

Shared decision-making in Canada: Update on integration of evidence in health decisions and patient-centred care government mandates

In Canada, government mandates for patient-centred care (PCC) vary across the 10 provinces and three territories. Although basic medical and hospital services are provided for all, health care options for patients also depend on having private insurance. Thus, the current design of the Canadian healthcare system has several implications for PCC and shared decision-making (SDM). Since 2007, this is our fourth update on SDM in Canada. The aim of this paper is to provide an update on the current state of SDM and patient and public involvement in Canada. Overall, we still observed the difficulty of implementing any sort of national strategy partly because of the decentralized nature of the healthcare system. Second, national professional education programs are complicated by licensure and scope of practice variations across jurisdictions. Third, there are variations in the availability of different options covered by universal healthcare. Canada has experienced some favorable development as PCC is now explicitly articulated in the policies of most provinces and territories and there are increased efforts to give patients more access to their electronic health records. However, patient and public engagement (PPE) reform in health programs and governance remains an exception, and continuing centralization of governance structures may reduce their responsiveness to patient priorities. In a 2018 survey, 47.2% of respondents reported that they were not told by their health professional that they had a choice about treatment. Nonetheless, decision aids and decision coaching are increasingly available for health-related decisions and the Ottawa Hospital Research Institute's decision aid inventory has ensured continued leadership in this area. Diverse jurisdictions are starting to embed decision aids into care pathways, with some decision aids being included in clinical practice guidelines. The COVID-19 pandemic may have had a negative impact on SDM by removing decision choices due to emergency public health mandates, but stimulated new research and decision aids. Canada continues to assign health research funding to SDM and PCC, and a program dedicated to patient-oriented research is central to this effort. Guides and frameworks are increasingly available for planning and evaluating PPE. Finally, various initiatives are attempting to involve and empower Indigenous peoples through PPE and SDM.

Prioritizing the healthcare access concerns of Canadians with MS

Background

Canadians with MS are high users of healthcare services, yet they report multiple unmet needs, high disease burden, and low satisfaction with care. Engaging patients in healthcare planning can lead to improvements in access and care. There is currently limited evidence that has harnessed the perspectives of Canadians with MS.

Objective

To identify and prioritize the healthcare access concerns of Canadians with MS.

Methods

A cross-sectional online survey informed by the Concerns Report Methodology was used to address the objective. Participants were recruited through multiple methods. Descriptive statistics were used to identify the main barriers to healthcare providers, and concerns report methods were used to calculate needs indexes to prioritize concerns of participants.

Results

324 Canadians with MS participated in the study between November 18, 2019 and March 27, 2020. The most pressing healthcare access concerns of Canadians with MS were related to availability of healthcare providers with MS knowledge and affordability of services that aim to improve wellness.

Conclusion

These findings provide healthcare planners with prioritized access concerns of Canadians with MS, which can be used to guide strategic planning to improve the quality of life of these individuals.

National Thoracic Surgery Standards Implementation: Barriers, Enablers, and Opportunities

Background: Diagnosis and surgical treatment decision making for thoracic cancers is complex. Moreover, there is demonstrated variability in how each province in Canada delivers cancer care, resulting in disparities in patient outcomes. Recently, the Canadian Partnership Against Cancer (CPAC) published pan-Canadian evidence-based standards for the care of thoracic surgery cancer patients. This study was undertaken to assess the degree to which these standards were currently met in practice and to further understand the determinants to their implementation nationally. Methods: This study was undertaken in two parts: (1) a national survey of thoracic surgeons to assess the perceived extent of implementation of these standards in their institution and province; and (2) formation of a focus group with a representative sample of thoracic surgeons across Canada in a qualitative study to understand the determinants of successful standards implementation. Results: 37 surgeons (33% response rate) participated in the survey; 78% were from academic hospitals. The top categories of standards that were under-implemented included (a) quality assurance processes, data collection and clinician audit and feedback, and (b) ongoing regional planning and workload assessments for thoracic surgeons, and (c) pathology turnaround time target of two weeks and the use of a standardized synoptic pathology report format. Enablers, barriers, and opportunities for standards implementation contextualized the discussion within the focus group. Conclusion: Study results demonstrated variation in the implementation of surgery standards across Canada and identified the determinants to the delivery of high quality surgical care. Future work will need to include the promotion and development of quality improvement strategies and effective resource allocation that is aligned with the implementation of thoracic cancer surgery standards in order to improve patient outcomes.

Blockchain, Interoperability, and Self-Sovereign Identity: Trust Me, It's My Data

No abstract available.  

Psychotherapy in Psychiatry: Fighting Alternative Facts

In the Canadian province of Ontario, the Ministry of Health and Long-Term Care is proposing to impose arbitrary limits on access to psychotherapy provided by physicians. This column presents and debunks 3 myths associated with this ill-conceived proposal: (1) that long-term psychotherapy costs the health care system too much money, making it necessary for the government to curb this spending; (2) that long-term psychotherapy is a non-evidence-based treatment being needlessly spent on the worried well; and (3) that we need to focus on quick treatments, not long ones.

Pushing the envelope: Advancing Canadian healthcare payment models through evaluation

When health systems aim to improve, two key considerations tend to be front and centre: cost and quality. On the cost side, health spending in Canada continues to rise. On the quality side, improvement is needed across the country. As the primary funder of healthcare, governments' historical role has focused on managing costs through their powers to set budgets, decide who gets paid, and how. Increasingly, governments are recognizing that the ways in which they choose to pay providers and organizations can also have an impact on the quality of care provided. Using Ontario as an example, we present a Canadian vision for modernizing how healthcare is organized and reimbursed and for using evidence and evaluation as the backbone for iterating new models. Realizing this vision will move Canada closer to international leadership in delivering high-quality, affordable care.