Client satisfaction in support of service planning within a regulatory framework: experience of a research hospital

Research Operations at UHN provide services to a large, complex client research community with varying needs. This requires complex coordination and continual refining of service and resource targets to meet client, government and external stakeholder requirements. The UHN Research Operations model focuses on six key enablers: client education, service team expertise, direct communication, process improvement, quality assurance, and, systems and tools. Service departments that have deployed these enablers experience improved client satisfaction.

Positron emission tomography in the investigation of pediatric inflammatory bowel disease

BACKGROUND

Endoscopic and radiologic studies are frequently required in inflammatory bowel disease (IBD) to determine disease activity, extent of disease, and delineating disease type. Positron emission tomography (PET) using fluorine-18-fluoro-deoxyglucose to identify metabolically active tissues may offer a simple noninvasive alternative to conventional studies in identification and localization of active intestinal inflammation in children with IBD. The aim of this study was to assess the value of PET in identifying active intestinal inflammation compared with conventional endoscopic and radiologic studies, including small bowel follow-through and colonoscopy.

METHODS

Sixty-five children were enrolled in the study. This included 55 children (mean age, 13.3 yr; range, 7-18 yr; 20 girls) with newly diagnosed IBD (37) or symptoms suggestive of recurrent disease (18) and 10 children with recurrent abdominal pain (mean age, 12.7 yr; range, 8-15 yr; 7 girls) who were studied with PET, and the results were compared with small bowel follow-through with pneumocolon and/or colonoscopy. Thirty-eight patients had Crohn's disease (17 ileal, 12 ileocolic, 5 pancolonic, 3 left-sided disease, 1 right-sided disease), and 17 had ulcerative colitis (15 pan-colitis, 2 left-sided colitis). Mean time interval between PET and other studies was 30 +/- 17.6 days.

RESULTS

PET correctly identified active inflammatory disease in 80% of children with IBD (81.5% with Crohn's disease; 76.4% with ulcerative colitis) and correctly showed no evidence of inflammation in children with recurrent abdominal pain. Gluorine-18-fluoro-deoxyglucose accumulated at sites that corresponded with active disease at colonoscopy in 83.8% of patients and with small bowel follow-through with pneumocolon 75.0% of the time.

CONCLUSION

This study suggests that PET offers a noninvasive tool for identifying and localizing active intestinal inflammation in children with IBD. PET may not be able to replace conventional studies; however, it may be useful when conventional studies cannot be performed or fail to be completed.

Prospective comparison of small bowel meal with pneumocolon versus ileo-colonoscopy for the diagnosis of ileal Crohn's disease

BACKGROUND AND AIMS

Both endoscopy and barium radiography are used routinely to diagnose terminal ileal (TI) Crohn's disease (CD). A prospective study was undertaken to compare ileoscopy with biopsy to small bowel meal with pneumocolon (SBMP) in patients with suspected TI CD.

METHODS

A cohort of outpatients investigated for diarrhea with features of TI disease underwent SBMP followed by colonoscopy with ileal intubation and biopsy within 21 days. All results were reported in a standardized, sequential format to assign SBMP TI diagnoses by the duty radiologist and by dual reading with consensus, ileoscopy by the attending endoscopist, and ileoscopy with biopsy by a blinded panel of endoscopists and pathologists. Reference standard TI diagnoses were determined by a consensus panel with full access to medical records.

RESULTS

Among 120 subjects, the reference standard TI diagnosis was normal in 47 (39.1%), lymphoid nodular hyperplasia (LNH) in 24 (20.0%), CD in 48 (40.0%), and NSAID enteropathy in 1 (0.9%). Colonoscopy provided TI images and/or biopsies in 97 cases (80.8%), while SBMP provided TI images in 119 (99.1%). When ileoscopy with biopsy succeeded, its accuracy was similar to SBMP with dual reading (89.7%vs 89.9%, p = NS) but superior to SBMP if interpreted only by the duty radiologist (80.0%, p < 0.05). Biopsy improved the accuracy of ileoscopy, while dual reading improved that of SBMP. Both ileoscopy with biopsy and SBMP with dual reading are highly accurate for diagnosing TI CD. Choice of initial test should reflect local expertise and availability, and the likelihood of associated disease in the proximal small bowel or colon.

Alternative medicine use by Canadian ambulatory gastroenterology patients: secular trend or epidemic?

OBJECTIVES

To assess the prevalence and determinants of alternative medicine (AM) use in gastroenterology outpatients and those with inflammatory bowel disease (IBD).

METHODS

An 80-item questionnaire, addressing symptoms, general health, quality of life, and AM use, was administered and analyzed using logistic regression.

RESULTS

52.5% of 341 participants used AM in the previous year. Most commonly used were herbal medicine (45.2% of users; 95% CI 35.4-52.5%), chiropractor (40.7%; 95% Cl 31.4-48.0%), and massage therapy (22.9%; 95% CI 15.9-29.1%). Reasons prompting AM use were ineffective medical therapy (39.5%; 95% CI 30.4-46.8%), a greater sense of self-control (29.1%; 95% CI 21.2-35.7%), agreement with personal beliefs (19.5%; 95% CI 13.1-25.4%), and conventional drug adverse-effects (17.3%; 95% CI 11.2-22.9%). AM use was predicted as follows: (1) higher education (odds ratio (OR) 2.10; 95% CI 1.22-3.60), (2) comorbid medical conditions (OR 1.80; 95% CI 1.08-3.00), 3) poor mental component summary score of the SF-12 health survey (OR 1.04; 95% CI 1.01-1.07), and (4) higher annual income (OR 1.17; 95% CI 1.001-1.36), but was not related to response to conventional medical therapy. AM practitioners had instructed 8.6% to change prescription medications. AM usage for gastrointestinal disease was greater in patients with IBD (44.6% vs 10.0%; p < 0.05), who were more likely to cite adverse drug effects as a reason for AM use (28.9 vs 14.4%; p = 0.03).

CONCLUSIONS

AM was used by 52.5% of gastroenterology outpatients and its use was greater in those with a higher level of education, comorbid conditions, poorer mental health-related quality of life, and higher income. Drug-related side effects also led to increased AM use.

Patient web-resource interest and internet readiness in pediatric inflammatory bowel disease

OBJECTIVE

The internet has been touted as a cost-effective method of providing valuable patient education and support resources. However, little is known of the level of internet interest in or access to web-based resources of most chronically ill populations generally, and pediatric populations in particular. Web-based patient resources could be especially applicable to the pediatric inflammatory bowel disease (IBD) population given the potential appeal of an anonymous forum for this group.

METHODS

Tertiary-care clinic patients aged 8-18 years and diagnosed with IBD were surveyed by mail. chi and/or analysis of variance were used to compare demographic data from nonresponders and responders and for subgroup analyses.

RESULTS

Of 162 eligible patients, 63 (38.9%) completed the survey. Responders did not differ significantly from nonresponders by age, sex, or distribution of disease. Overall, 98.4% of those surveyed had internet access, with 61.9% having access at school. Ninety-five percent had used the internet, while 91% expressed interest in visiting a pediatric IBD website for general IBD information (83%), for support (73%), to pose questions (78%) or read (73%) or respond (60%) to questions, or to chat with others (46%). Despite expressed interest, far fewer had ever used the internet as an IBD information (52.4%) or support (9.5%) resource. Similarly, although 15.8% anticipated visiting a pediatric IBD site weekly, only 1.5% had done so in the week of the survey.

CONCLUSIONS

Reported levels of interest in web-based patient resources are high among pediatric IBD patients, yet use may be infrequent.

Use and misuse of cost-effectiveness terminology in the gastroenterology literature: a systematic review

OBJECTIVES

The increased popularity of economic analyses for evaluating medical interventions has given rise to concern about the rigor with which economic constructs and terminology are used. True cost-effectiveness analysis considers both the costs and outcomes of alternative interventions. A systematic review of the gastroenterology literature was undertaken to evaluate how appropriately cost-effectiveness is assessed.

METHODS

A structured MEDLINE search identified all studies published in major gastroenterology journals between 1980 and 1998 that claimed in their abstracts to have assessed the cost-effectiveness of an intervention. Blinded copies of eligible studies were assessed by two independent reviewers who used standard criteria to evaluate the use of economic terminology and key economic constructs. Discrepancies were resolved by consensus. Studies met a "broad criterion" for appropriateness by evaluating both costs and effects and a "strict criterion" by demonstrating dominance of one strategy or considering both incremental costs and incremental effects.

RESULTS

Of 110 eligible studies, 77 (70.0%) met the broad criterion and 62 (56.4%) met the strict criterion for appropriateness. This did not seem to vary with either journal impact factor or publication year. Only eight of 18 studies reporting an incremental cost-effectiveness ratio compared its value to an external standard. Few studies explicitly stated their analytic perspective, and a minority of those with time horizons longer than 1 yr had discounted future costs or effects.

CONCLUSIONS

Although most studies seem to use cost-effectiveness terminology well, there remains room to improve the rigor with which economic terminology and constructs are applied.

e-Health? Clinical information network interest and impediments in a community paediatric setting

BACKGROUND

Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities.

OBJECTIVE

To examine Ontario's community care paediatricians' electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN).

DESIGN

Cross-sectional, interviewer-facilitated, structured survey.

POPULATION STUDIED

Paediatricians providing community care in the Central West Ontario Health Region.

MAIN RESULTS

Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners.

CONCLUSIONS

Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.

Health information provided by retail health food outlets

Alternative health practices have become increasingly popular in recent years. Many patients visit specific complementary practitioners, while others attempt to educate themselves, trusting advice from employees at local health food stores or the Internet. Thirty-two retail health food stores were surveyed on the nature of the information provided by their staff. A research assistant visited the stores and presented as the mother of a child in whom Crohn's disease had been diagnosed. Seventy-two per cent (23 of 32) of store employees offered advice, such as to take nutritional and herbal supplements. Of the 23 stores where recommendations were made, 15 (65%) based their recommendation on a source of information. Fourteen of the 15 stores using information sources used the same reference book. This had a significant impact on the recommendations; the use of nutritional supplements was favoured. In conclusion, retail health food stores are not as inconsistent as hypothesized, although there are many variances in the types of supplements recommended for the same chronic disease.