Recommandations pour des soins préventifs pour promouvoir l’équité en matière de santé

Contexte:

Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d’observer des disparités évitables en matière de santé au Canada. L’équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l’équité en matière de santé par la priorisation des interventions efficaces à l’intention des groupes défavorisés.

Méthodes:

La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d’un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d’autres études pertinentes sur l’efficacité du dépistage et de la prise en charge. Nous avons utilisé l’approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d’experts en contenu avant d’être distribuées à des intervenants à l’échelle nationale pour approbation.

Recommandations:

Nous avons formulé 15 recommandations concernant le dépistage et d’autres soins préventifs et 1 recommandation de nature politique visant à améliorer l’accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l’âge de 45 ans et pour l’évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l’autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l’interféron γ pour l’infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d’accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées.

Interprétation:

Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s’ils veulent promouvoir l’équité en matière de santé partout au Canada.

Access to a regular primary care physician among young people with early psychosis in Ontario, Canada

AIM

Access to a primary care physician in early psychosis facilitates help-seeking and engagement with psychiatric treatment. We examined access to a regular primary care physician in people with early psychosis, compared to the general population, and explored factors associated with access.

METHODS

Using linked health administrative data from Ontario (Canada), we identified people aged 14-35 years with a first diagnosis of nonaffective psychotic disorder (n = 39 449; 2005-2015). We matched cases to four randomly selected general population controls based on age, sex, neighbourhood, and index date (n = 157 796). We used modified Poisson regression to estimate prevalence ratios (PR) for access to a regular primary care physician in the year prior to first diagnosis of psychotic disorder, and the sociodemographic and clinical factors associated with access.

RESULTS

A larger proportion of people with early psychosis had a regular primary care physician, relative to the general population (89% vs. 68%; PR = 1.30, 95%CI = 1.30-1.31). However, this was accounted for by a higher prevalence of comorbidities among people with psychosis, and this association was no longer present after adjustment (PR = 0.97, 95%CI = 0.97, 0.98). People with early psychosis who were older, male, refugees and those residing in lower income or high residential instability neighbourhoods were less likely to have a regular primary care physician.

CONCLUSION

Approximately one in ten young people with early psychosis in Ontario lack access to a regular primary care physician. Strategies to improve primary care physician access are needed for management of physical comorbidities and to ensure continuity of care.

Preventive care recommendations to promote health equity

BACKGROUND

Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages.

METHODS

The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders.

RECOMMENDATIONS

We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-γ release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages.

INTERPRETATION

Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada.

Sex differences in the clinical presentation of early psychosis in a primary care setting

Primary care is an important part of the help-seeking pathway for young people experiencing early psychosis, but sex differences in clinical presentation in these settings are unexplored. We aimed to identify sex differences in clinical presentation to primary care services in the 1-year period prior to a first diagnosis of psychotic disorder. We identified first-onset cases of non-affective psychotic disorder over a 10-year period (2005-2015) using health administrative data linked with electronic medical records (EMRs) from primary care (n = 465). Detailed information on encounters in the year prior to first diagnosis was abstracted, including psychiatric symptoms, other relevant behaviours, and diagnoses recorded by the family physician (FP). We used modified Poisson regression models to examine sex differences in the signs, symptoms, and diagnoses recorded by the FP, adjusting for various clinical and sociodemographic factors. Positive symptoms (PR = 0.76, 95%CI: 0.58, 0.98) and substance use (PR = 0.54, 95%CI: 0.40, 0.72) were less prevalent in the medical records of women. Visits by women were more likely to be assigned a diagnosis of depression or anxiety (PR = 1.18, 95%CI: 1.00, 1.38), personality disorder (PR = 5.49, 95%CI: 1.22, 24.62), psychological distress (PR = 11.29, 95%CI: 1.23, 103.91), and other mental or behavioral disorders (PR = 3.49, 95%CI: 1.14, 10.66) and less likely to be assigned a diagnosis of addiction (PR = 0.33, 95%CI: 0.13, 0.87). We identified evidence of sex differences in the clinical presentation of early psychosis and recorded diagnoses in the primary care EMR. Further research is needed to better understand sex differences in clinical presentation in the primary care context, which can facilitate better understanding, detection, and intervention for first-episode psychotic disorders.

Patient and Physician Factors Associated with First Diagnosis of Non-affective Psychotic Disorder in Primary Care

Primary care physicians play a central role in pathways to care for first-episode psychosis, and their increased involvement in early detection could improve service-related outcomes. The aim of this study was to estimate the proportion of psychosis first diagnosed in primary care, and identify associated patient and physician factors. We used linked health administrative data to construct a retrospective cohort of people aged 14-35 years with a first diagnosis of non-affective psychosis in Ontario, Canada between 2005-2015. We restricted the sample to patients with help-seeking contacts for mental health reasons in primary care in the six months prior to first diagnosis of psychotic disorder. We used modified Poisson regression models to examine patient and physician factors associated with a first diagnosis of psychosis in primary care. Among people with early psychosis (n = 39,449), 63% had help-seeking contacts in primary care within six months prior to first diagnosis. Of those patients, 47% were diagnosed in primary care and 53% in secondary/tertiary care. Patients factors associated with lower likelihood of diagnosis in primary care included male sex, younger age, immigrant status, and comorbid psychosocial conditions. Physician factors associated with lower likelihood of diagnosis in primary care included solo practice model, urban practice setting, international medical education, and longer time since graduation. Our findings indicate that primary care is an important contact for help-seeking and diagnosis for a large proportion of people with early psychosis. For physicians less likely to diagnose psychosis in primary care, targeted resources and interventions could be provided to support them in caring for patients with early psychosis.

Preparation and evaluation of a hyaluronate-collagen film for preventing post-surgical adhesion

Post-surgical adhesion occurs when fibrous strands of scar tissue form, leading to the abnormal joining of anatomical structures. Patients undergoing abdominal surgery are at risk of the complications associated with intraperitoneal adhesions. Hyaluronic acid (HA) is a biocompatible, biodegradable and non-toxic natural polymer, which is gaining popularity as a barrier agent for preventing post-surgical adhesions. As HA is water-soluble and rapidly degraded in vivo, chemical modification is required to produce a non-soluble sheet that might be used to prevent tissue adhesion. We developed a range of biocompatible cross-linked HA-collagen composites and then evaluated them in a rat model of post-surgical adhesion. The results showed that cross-linked HA-collagen was almost totally resistant to hyaluronidase digestion. HA-collagen membranes induced minimal tissue reactions and were bioresorbed within 14 days post-surgery. These results suggest that cross-linked HA-collagen membrane may be a valuable anti-adhesion material to prevent post-surgical intraperitoneal adhesion.

Catecholamine-sensitive adenylate cyclase of caudate nucleus and cerebral cortex. Effects of guanine nucleotides

1. GTP and GMP-P(NH)P (guanyl-5'-yl imidodiphosphate) were observed to increase the stimulation of neural adenylate cyclase by dopamine (3,4-dihydroxyphenethylamine) and noradrenaline. 2. GMP-P(NH)P had a biphasic effect on the enzyme activity. 3. Preincubation of membranes with GMP-P(NH)P activated the enzyme by a process dependent on time and temperature. Catecholamines increased the speed and the extent of this activation. 4. Membrane fractions contained high- and low-affinity sites for GMP-P(NH)P binding: this binding was due to protein(s) of the membrane preparations. 5. Low-affinity-site binding of GMP-P(NH)P appeared to be related to the stimulatory effect on the adenylate cyclase activity.

Comparative adenylate cyclase activities in homogenate and plasma membrane fractions of Morris hepatoma 5123tc (h)

Homogenate and plasma membrane fractions of Morris hepatoma 5123tc (h) and rat liver were studied with regard to their relative basal activties of adenylate cyclase and to the comparative responsiveness of this enzyme to glucagon, sodium fluoride, epinephrine, prostaglandin E1, and insulin. The basal adenylate cyclase activities of the hepatoma fractions were found to be similar to those of liver at an adenosine 5'triphosphate concentration of 3.2 mM; if the substrate affinity (Km adenosine 5'-triphosphate) of the tumor enzyme is comparable to that of liver, these findings suggest that the reduced basal cyclic adenosine 3':5'-monophosphate levels found to occur in hepatoma 5123tc (h) probably are not due to a decreased basal rate of formation of this cyclic nucleotide. Glucagon (5.6 muM) significantly stimulated adenylate cyclase in both fractions of hepatoma and livers; however, the responsiveness of the tumor enzyme to this hormone was substantially lower than the responsiveness of liver for both homogenate and plasma membrane preparations; i.e., activities were enhanced 18-fold (relative to the basal activity)for liver homogenate compared with only a 6-fold increase for tumor. With the plasma membrane preparations, glucagon increased the activities 5- and 3.5-fold in liver and hepatoma, respectively. Sodium fluoride (10mM), in contrast to glucagon, increased the adenylate cyclase activity to approximately the same extent (about 10-fold) in the liver and hepatoma preparations. Epinephrine (100 muM) enhanced the liver and hepatoma homogenate activites 3- to 4-fold and the hepatoma plasma membrane activities 2-fold; however, the liver plasma membrane activites were not increased. Prostaglandin E1 (56.6 MUM) significantly increased adenylate cyclase activites of liver and hepatoma homogenates (i.e., 1.5- and 3-fold, respectively) but not of the plasma membrane preparations. Insulin (0.7 muM) did not significantly alter adenylate cyclase activities in any of the preparations.