Navigating the narrowing effect of public discourse for a healthier future

This article explores the concerning phenomenon of the narrowing effect in public discourse, particularly in the context of healthcare and Medicare. It discusses the challenges posed by this narrowing effect, the impact of cognitive biases, and the ethical dilemmas faced by healthcare providers and organizations when patients take their concerns public. The article also emphasizes the importance of responsible leadership and offers navigation for overcoming the narrowing of public discourse.

Local Health Integration Networks: Build on their purpose

This article provides a high-level overview on the creation of Local Health Integration Networks (LHINs) and illustrates the complexities involved in their implementation. To understand regional structures such as LHINs, one must understand the context in which design and execution takes place. The article ends with a commentary on how Ontario is performing post-LHINs and discusses next steps.

The owners have a right to be heard: Patient voice in design and performance improvement

The Canadian taxpayer is an owner of the healthcare system and the owners have a right to be heard. This article encourages leaders both formal and informal to create cultures that promote ASKing questions to test assumptions held, LISTENing to hear the patient voice, and TALKing with patients and families to create new conversations and narratives. Looking at the label, "healthcare system" what's your contribution to creating health, how will you dedicate yourself to caring about the healthcare consumer and care provider, and what will be your role in creating a new and improved system? An implied question at the foundation of the article is this: Is the difference between managing and leading a difference of empathy?

A call for a new connectivity

"Twisting the Lion's Tail" is a valuable and timely contribution to the literature on the need to break down silo thinking and acting. If we stay within a narrow silo by suggesting that researchers generate knowledge, practitioners use the knowledge and then researchers evaluate the results, we will not get to the system thinking view articulated in the lead paper. The author hopes his observations presented in this commentary add to the conversation.

What are you prepared to see?

A hospital system is made up of interconnecting circles of complex activity; however, we are conditioned to see and think in straight lines. What we see depends on what we are prepared to see. This article asks the question: What do you see in terms of patient safety and quality of care?

Previous-day hypohydration impairs skill performance in elite female field hockey players

The purpose of this study was to determine the effects of 2% hypohydration on skill performance in elite female field hockey players following intermittent exercise in the heat. Eight elite female field hockey players performed 50 min of a field hockey-specific intermittent treadmill running protocol (FHITP) in hot environmental conditions (33 °C, 60% relative humidity) in different hydration states: euhydrated (EUH) and hypohydrated by 2% body mass (HYPO). Hydration status was manipulated via a period (121±10 min) of passive hyperthermia (40 °C, 75% relative humidity) and controlled fluid intake 1 day preceding testing. Ad libitum fluid intake was permitted throughout both trials. Field hockey skill tests were performed pre- and post-FHITP. Skill performance time increased (P=0.029) in the HYPO trial compared with the EUH trial, which may be attributed to an increase in penalty time (P=0.024). Decision-making time increased (P=0.008) in the HYPO trial and was significantly impaired compared with EUH (P=0.016) pre-FHITP. Ad libitum drinking appeared to be sufficient to maintain decision-making performance as no interaction effects were evident post-FHITP. Players who commence match-play in a state of hypohydration may be susceptible to decrements in skill and decision-making performance.

The times they are a-changing: what worked and what we learned in deploying Ontario's Wait Time Information System

How many days would you be comfortable waiting if you needed cancer surgery? What would you do if someone, not as medically urgent, was able to receive an MRI or CT scan before you? Would you want to know if you could wait less time for treatment at another location or with another clinician? These are some of the dilemmas facing patients and our health system when dealing with the issue of wait times. To address these pressing concerns, in the fall of 2004, Ontario launched its Wait Time Strategy. Two years later, Collins-Nakai et al. (2006) reported that Ontario had moved "from being a laggard to a leader" with respect to wait times. This article summarizes Ontario's work to date to improve access to care, including reviewing the need, action taken and the emerging results. Much can be learned and leveraged from the experiences described in this article and throughout this issue. They can serve as an important starting point for further discussion, improvement and action, for initiatives big and small, by all types of organizations and jurisdictions.

Evaluating outcomes in Ontario's Wait Time Strategy: Part 4

It is widely recognized that Ontario's Wait Time Strategy is a significant change management initiative. But has the province achieved the goal that it set out for itself in November 2004? This article answers this question, beginning with a brief overview of the major inputs or foundational building blocks of the strategy, followed by a detailed analysis of the major outputs or outcomes of the strategy to date.

The pivotal role of critical care and surgical efficiencies in supporting Ontario's Wait Time Strategy: Part 3

As part of its Wait Time Strategy, the Ontario Ministry of Health and Long-Term Care provided significant amounts of money to perform more cases with the understanding that improving access by reducing wait times is not just a matter of increasing funding. Rather, fundamental system and practice change is required to sustain improvements in the long term.

Expert panels and ontario's wait time strategy: part 2

Expert panels have been widely used in healthcare as a way of bringing knowledgeable people together to examine issues and identify solutions in well-defined areas. Various terms have been used to describe these groups of experts such as "consensus panels," "blue ribbon panels" and "expert committees or panels." Regardless of the term used, panels of healthcare experts have a history of providing invaluable advice to policy- and decision-makers.

Ontario's wait time strategy: part 1

Ontario's Wait Time Strategy was designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas-cancer surgery, cardiac revascularization procedures (cardiac surgery, percutaneous coronary intervention, diagnostic catheterization), cataract surgery, hip and knee total joint replacements and MRI and CT scans. These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services.

Developing a culture to sustain Ontario's Wait Time Strategy

Ontario's Wait Time Strategy--a significant change management initiative--is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans). These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006. Change management initiatives are initially successful because of the significant time, attention and resources that are dedicated to the start-up effort. Many initiatives lose their momentum and impact and ultimately fail in the long run since it is difficult to sustain this level of intensity. The probability of success increases if a culture is developed to sustain the initiative into the future. A pivotal element for this sustained culture is accountability for achieving results. If Ontario is to reduce waits for quality healthcare services over the long term, it must shift from a paradigm where no one--or only a few--are accountable for achieving a particular set of results to one where a wide range of players is accountable for achieving a broad range of results. This includes explicit accountabilities of the public, healthcare providers (including physicians, other healthcare providers, professional associations and regulatory bodies), government and Local Health Integration Networks. Tools required to support these accountabilities include developing leaders, aligning incentives to reinforce what needs to be achieved, and developing information systems to provide the data needed to make decisions, and manage and improve performance.

Making performance reports work

Public performance reporting is an increasingly common health policy tool to support accountability and quality improvement but there are few formal evaluations of this trend. In this review, we suggest that performance reporting may be an effective way to support improvements in performance when it is directed towards groups of providers rather than individuals and that there is enough evidence to support the use and further development of public performance reporting. However, the true impact of performance reporting depends on the policy context around reporting including clarity of strategy, incentives, and support for performance improvement.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

Faculty attitudes towards medical communication and their perceptions of students' communication skills training at Dalhousie University

SETTING

Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.

OBJECTIVES

(1) To assess the attitudes of full-time clinical faculty members towards medical communication using the newly developed Attitudes Towards Medical Communication Scale; (2) to determine faculty members' perceptions of communications training for students and residents.

METHODS

An anonymous self-completion survey was sent to 233 full-time clinical faculty members. The questionnaire asked about faculty attitudes towards medical communication, and assessed faculty members' views of student and resident training in communication.

RESULTS

Faculty scored highly in the Attitudes Towards Medical Communication Scale, with a mean score of 51.5 (SD 4.1) out of a possible 60. In univariate analysis, rating of personal enjoyment of teaching, rating of the importance of teaching, and having attended at least one faculty communications workshop in the previous 5 years were significantly associated with higher scale scores. When these factors were assessed using linear regression, only having attended a workshop and higher rating of the importance of teaching remained significant. Faculty assessed student training in communications skills poorly overall. When assessing seven specific communications areas, more than 20% rated this training as poor for six of the areas for third- and fourth-year students and for five of the areas for residents.

CONCLUSIONS

Clinical faculty at Dalhousie have very positive attitudes towards medical communication, and more highly positive attitudes are found in those who have attended a communications workshop. Despite this evidence that faculty appreciate the importance of medical communication skills, many assessed students' training in this curriculum area as poor.

Differences in medical students' attitudes and self-efficacy regarding patient-doctor communication

To examine students' attitudes and self-efficacy regarding patient-doctor communication across levels of training, a questionnaire was administered to three classes (n = 203 students). Students' year of study, prior experience, and sex influenced their attitudes and self-efficacy regarding patient-doctor communication.

Th2 responses induced by epicutaneous or inhalational protein exposure are differentially dependent on IL-4

Atopic individuals are predisposed to mounting vigorous Th2-type immune responses to environmental allergens. To determine the factors responsible, animal models that closely mimic natural modes of allergen exposure should prove most informative. Therefore, we investigated the role of IL-4, a known Th2-promoting cytokine, in generation of Th2 responses after exposure of either the skin or airway to soluble protein. Compared with wild-type (WT) mice, IL-4-deficient (IL-4(-/-)) mice showed markedly impaired Th2 activation after primary exposure to inhaled ovalbumin (OVA), with decreased OVA-specific IgG1 and IgE, and significantly fewer eosinophils in bronchoalveolar lavage (BAL) fluid after airway challenge. In contrast, IL-4(-/-) mice initially exposed to epicutaneous (e.c.) OVA mounted Th2 responses equivalent to responses in WT mice, with high numbers of eosinophils in BAL fluid. Because Th2 responses were not induced by e.c. OVA exposure in Stat6(-/-) mice (mice lacking signal transducer and activator of transcription 6), the role of IL-13 was tested. In vivo depletion of IL-13 prevented Th2 responses induced by e.c. OVA exposure in IL-4(-/-) mice. These data demonstrate a marked difference in the IL-4 dependence of Th2 responses generated at two anatomic sites of natural allergen encounter and identify the skin as a particularly potent site for Th2 sensitization.

Th2-induced airway mucus production is dependent on IL-4Ralpha, but not on eosinophils

Mucus hyperproduction in asthma results from airway inflammation and contributes to clinical symptoms, airway obstruction, and mortality. In human asthmatics and in animal models, excess mucus production correlates with airway eosinophilia. We previously described a system in which TCR transgenic CD4 Th2 cells generated in vitro were transferred into recipient mice and activated in the respiratory tract with inhaled Ag. Th2 cells stimulated airway eosinophilia and a marked increase in mucus production, while mice that received Th1 cells exhibited airway inflammation without eosinophilia or mucus. Mucus could be induced by IL-4-/- Th2 cells at comparable levels to mucus induced by IL-4+/+ Th2 cells. In the current studies we dissect further the mechanisms of Th2-induced mucus production. When IL-4-/- Th2 cells are transferred into IL-4Ralpha-/- mice, mucus is not induced, and BAL eosinophilia is absent. These data suggest that in the absence of IL-4, IL-13 may be critical for Th2-induced mucus production and eosinophilia. To determine whether eosinophils are important in mucus production, IL-5-/- Th2 cells were transferred into IL-5-/- recipients. Eosinophilia was abolished, yet mucus staining in the epithelium persisted. These studies show definitively that IL-5, eosinophils, or mast cells are not essential, but signaling through IL-4Ralpha is critically important in Th2 cell stimulation of mucus production.

Watson syndrome: is it a subtype of type 1 neurofibromatosis?

Over 20 years ago, Watson described three families with a condition characterised by pulmonary valvular stenosis, café au lait patches, and dull intelligence. Short stature is an additional feature of this autosomal dominant condition. A fourth family with Watson syndrome has since been reported. We have had the opportunity to review members of three of these four families. The clinical phenotype of Watson syndrome has been expanded to include relative macrocephaly and Lisch nodules in the majority of affected subjects, and neurofibromas in one-third of family members. Because the additional clinical findings enhance the similarity between Watson syndrome and neurofibromatosis 1, molecular linkage studies have been performed using probes flanking the NF1 gene on chromosome 17. Probe HHH202 showed the tightest linkage to Watson syndrome with a maximum lod score of 3.59 at phi = 0.0 (95% confidence limits of phi = 0.0-0.15). This suggests either that Watson syndrome and neurofibromatosis 1 are allelic, or that there is a series of contiguous genes for pulmonary stenosis, neurocutaneous anomalies, short stature, and mental retardation on 17q.