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Rationale: Implementation of strengths model case management is increasing internationally. However, few studies have focused on its implementation process, and none have specifically addressed the implementation experience of direct‐service practitioners. Objective: This paper presents factors that facilitate and impede the successful implementation of the strengths model, with a specific focus on practitioners who deliver the intervention directly to service recipients. Method: To address this objective, a qualitative study of seven mental health agencies that implemented the model was conducted, involving a combination of participant observations and qualitative semistructured interviews with case managers, team supervisors, and senior managers. Qualitative data were analyzed using open coding followed by axial coding. Finally, the findings were aligned with an adapted Consolidated Framework for Implementation Research. Results: Implementation of the strengths model involved a significant change in practice for case management practitioners. The results confirm that at the beginning of implementation, the strengths model was perceived as complex and not always adaptable to on‐the‐ground realities. With time, and with support from management, ongoing training and supervision sessions, and reflection and discussion, practitioners regained feelings of competence and resistance to the model diminished. The use of the model's structured team‐based supervision tools was fundamental to supporting the implementation process by enabling an interactive and concrete training approach. Conclusions: The more an approach leads to changes in daily practice and is perceived as complex, the more concrete support is needed during implementation. This article highlights the importance of attending to a practitioner's sense of personal effectiveness and competence in the adoption of new practices. [ABSTRACT FROM AUTHOR]

Rationale Intersectoral action (ISA) has been at the forefront of public health policy discussions since the 1970s. ISA incorporates a broader perspective of public health issues and coordinates efforts to address the social, political, economic and environmental contexts from which health determinants operate and are created. Despite being forwarded as a useful way to address and treat complex or 'wicked' problems, such policy issues are still often addressed within, rather than across, disciplinary silos and ISA has been documented to fail more often than it succeeds. Aims and objectives This paper contributes to an understanding of ISA by outlining and applying critical systems heuristics (CSH) theory and methods. Methods CSH theory and methods are described and discussed before applying them to the example of addressing climate change and health equity through public health practice. Results CSH thinking provides useful tools to engage stakeholders, question relations of power that may exist between collaborating partners, and move beyond power inequalities that guide ISA initiatives. Conclusions CSH is a compelling framing that can improve an understanding of the collaborative relationships that are a prerequisite for engaging in ISA to address complex or 'wicked' policy problems such as climate change. [ABSTRACT FROM AUTHOR]

This paper examines the sources of practice variations and definitions of unwarranted variation, as derived from the literature. The literature suggests variables/factors related to patient health needs, doctor 'practice style' and environmental constraints/opportunities as sources of practice variations. However, this list is likely to be incomplete because of significant unexplained variation in each study. Furthermore, it is unclear which factors are sources of unwarranted variation because the reviewed studies do not clearly discriminate between those variations that are unwarranted and those that are not. It is also unclear if context plays a role in determining if and when a factor is unwarranted. The literature contains few frameworks of what constitutes unwarranted variation. Among those offered, more information is needed regarding the scientific basis for including the selected factors, and how to operationalize the framework provided a particular one is chosen. A clear and consistent framework for unwarranted variation, and a clear indication how each component factor could be measured and integrated can help investigators determine which variables should be included in their studies, such that the sources of unwarranted variations may be identified. A better understanding of the role of patient preference as a potential source of practice variations is also required. [ABSTRACT FROM AUTHOR]

Environmental illness (EI) still remains something of an enigma, despite attempts to squeeze it into the increasingly flexible framework of the biomedical model or label it as ‘psychogenic’. Consistently, environmentally ill bodies fail to respond to conventional medical tests, with the emergence of ambiguous, indecipherable or negative results. During a series of in-depth interviews in Canada, both patients and environmental health practitioners advocated the need for an alternative paradigm from which to view EI. They also spoke of the complex nature of the illness, a conundrum that is currently being explored at the Nova Scotia Environmental Health Centre through an alternative epistemological framework: complexity theory. In this paper, I present a tentative proposal, based on the juxtaposition of theoretical insights from this new science to discourses emanating from patients and doctors. Specifically, I argue that the diverse symptoms of EI can be comprehended through a study of complexity theory, a conception that has positive implications for treatment. [ABSTRACT FROM AUTHOR]

Introduction National guidelines for prevention of cardiovascular disease make different recommendations in relation to screening and treating patients with aspirin, antihypertensive treatment and statins. The resource cost and health implications of these differences are quantified in this paper. Data sources Guidelines were obtained from Australia, New Zealand, Canada, UK and USA. Effectiveness data were obtained from published sources, costs and a model population of 2000 patients from US sources. Method The resource costs and health effects of screening and treating a standard population of 2000 persons were determined for each of the five national guidelines. Costs and effects were calculated over a 5-year time horizon and cost-effectiveness determined cost per cardiovascular event prevented. Results Cost per cardiovascular event prevented is lowest in older patients and very high under 35. The New Zealand guidelines are more cost-effective of the national guidelines, however, they would be more effective if they incorporated US recommendations on the use of aspirin. Further antihypertensive treatment is the least cost-effective of the interventions considered. Discussion Cardiovascular disease prevention guidelines should focus on older rather than younger patients. Treatment eligibility should be informed more by risk than by individual risk factor status. Guidelines should put greater emphasis on the use of aspirin and initial antihypertensive treatment than on achieving blood pressure targets. Conclusion In order to justify their recommendations guidelines should quantify the resource implications in relation to the health benefits. [ABSTRACT FROM AUTHOR]

AbstractThe purpose of this paper is to synthesize and critically evaluate the current literature that explains the use and non-use of formal community-based long-term care services by caregivers of persons with dementia. There are four issues related to formal community service use by caregivers: reluctance to initiate formal services; under-utilization of available services; delayed utilization of services; and inappropriate utilization of services. Despite substantial research efforts to understand these issues, the reasons for low rates of community service use by this population remains unclear. Common methodological problems and limitations in the underlying theoretical assumptions in the literature, as they relate to caregivers of persons with dementia, have limited the usefulness of the current research for informing practice and policy. A conflict-theory model of decision-making is proposed as an alternative theoretical framework for understanding the particularity and complexity of the decision-making process leading up to the initiation of formal service use. Utilization of formal services is a result of a complex and subjective decision-making process that is unrelated to objective circumstances. The proposed conflict theory model of decision-making can inform policy and practice regarding the development of appropriate, timely and individualized interventions to facilitate the use of formal services by caregivers of persons with dementia. [ABSTRACT FROM AUTHOR]

Medically trained health professionals have been central to the development of policy responses to the coronavirus 2019 (COVID‐19) crisis. In their multiple roles—as clinicians, public health leaders, members of scientific advisory boards, and also as media pundits and health professionals—they have helped shape discourses of science‐based policy options during the first 2 years of the pandemic. In particular, health professionals as a collective voice insisted on the necessity of society‐wide measures of social control to curb the morbidity and mortality of the virus. These measures, in turn, informed the political and moral imagination of the political class, the media and the larger public. Yet, as emerging evidence suggests, measures of social control posed a serious and long‐term risk for health equity. In this discussion piece on the first 2 years of COVID‐related public health directives, we interrogate the tensions that advocating for extensive and protracted measures of social control can pose to the social contract between medicine and society, health equity and democracy. To illustrate these tensions, we discuss the public fallout between vocal members of the OSAT, an ad hoc biomedical‐led organization, and the Government of Ontario in light of the disagreement on the scope of 'stay home' orders to manage the third wave of the pandemic in the Spring of 2021 and, more recently, the mass protest against mass‐scale public health measures in Ottawa, Canada. We argue that while decision making under emergency conditions is a difficult task, the legitimacy of the social contract between medicine and society depends on medical experts' judicious exercise of public health ethics principles. We offer a set of recommendations for building a more collaborative response to future health crises. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Healthcare practitioners often note system‐level barriers to empathy between patients and practitioners. These include burnout‐inducing administrative workloads, unfriendly meeting times, burdensome protocols, lack of wellbeing spaces, and undervaluing empathy as a core part of an institution's mission. The need for empathy in healthcare has been magnified with the current SARS‐COV‐2 outbreak which has limited the expression of interpersonal empathy due to rigid isolation protocols and the use of personal protective equipment. Method: This study—the first of its kind that we are aware of—outlines the details of a facilitated workshop run with the leadership of a tertiary level pediatric center in Canada. The workshop used a modified nominal group technique to discuss and prioritize actions to enhance empathy into the hospital system. Results: Inter‐professional and inter‐disciplinary group of healthcare leader participants agreed on several immediately actionable steps, including embedding patient satisfaction with care measures as standard, and streamlining booking appointments. A roadmap was created to implement the other priorities. Conclusion: A systematic approach to infusing empathy into the structure of our healthcare system is much needed. Furthermore, inter‐professional and inter‐disciplinary educational workshops was well‐received as a way to facilitate discussion and drive change. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Physician consultations are a limited resource. Anesthesiologists provide anaesthesia during surgery and procedures, prepare patients for surgery in preoperative clinics, and provide postoperative care. This study sought to evaluate current consultation usage patterns, with an aim to determine possible opportunities for efficiency. Method: A retrospective comprehensive population‐based cohort study was performed, evaluating all hospitals in the Canadian province of Ontario from 2002 to 2018. The main outcome measures were American Society of Anesthesiologists (ASA) classification of the patients, and whether the patients underwent surgery within 3 months following the anaesthesia consultation. Results: A cohort of 2,023,499 patients, and a total of 2,920,100 preoperative anaesthesia consultations was obtained. The number of consults per year doubled between 2003 (112,983/year) and 2017 (246,427/year), despite a less than 40% increase in practicing Canadian Anesthesiologists over this same timeframe. Each year, an average of 19.3% of the consults (range: 17.7–20.5%) were for patients that did not progress to having surgery. Of those that did have surgery following the anaesthesia consult, 37.2% were ASA Classification I or II. The most common surgical procedures (percent of total) following anaesthesia consult were: Knee arthroplasty (9.5%), hip arthroplasty (5.8%), cataract extraction (4.1%), repair of muscle of chest/abdomen (3.3%), hysterectomy (2.8%), and cholecystectomy (2.7%). Conclusions: This study reveals data on utilization and trends over time of preoperative anaesthesia consultations. Potential opportunities for optimization were found, including patients who did not proceed to surgery, and healthier patients undergoing low to moderate risk surgery. [ABSTRACT FROM AUTHOR]

Discusses issues related to the selection of doctors and admission of medical students in Canada. Academic requirements; Diagnostic skills; Relationships with patients.

Background: Occupational therapy (OT) and physical therapy (PT) programs in Canada have moved to graduate‐level entry education to address graduates' readiness for evidence‐based practice (EBP). Whether rehabilitation professionals with advanced training in EBP are meeting their responsibilities as evidence‐based professionals upon entry into practice and the factors that influence the use of evidence is unclear. The aim of this study was to examine the individual and organizational factors associated with the use of EBP and supporting evidence‐based activities among graduates of professional OT and PT master's programs. Methods: A cross‐sectional design using a survey of recent graduates of the 29 OT and PT programs in Canada. The survey measured six constructs supportive of EBP (ie, knowledge, attitudes, confidence, organizational resources, actual use of EBP, and evidence‐based activities). Analyses consisted of descriptive statistics to characterize the sample and the different variables and ordinal multivariate regression analysis. Results: 257 graduates (15%) completed the survey. Attitudes towards EBP was positively associated both with evidence‐based activities (odds ratio = 1.36 with a 95% CI: 1.22 to 1.52) and use of EBP (odds ratio = 1.23 with a 95% CI: 1.12 to 1.36); greater confidence was related to greater use of EBP (OR = 1.12, 95% CI: 1.01 to 1.24); and working in a private practice setting was found to be related to performing more evidence‐based activities (odds ratio = 3.15, 95% CI: 1.40 to 7.12). Conclusions: Despite a greater focus on EBP knowledge in these curricula across Canada, knowledge was not related to EBP use nor evidence‐based activities upon entry into practice. On the other hand, attitudes, confidence and working in private practice were. University programs should consider curricular strategies that increase the use of EBP, provide opportunities to engage in evidence‐based activities with an emphasis on promoting the development of positive attitudes towards EBP and increasing learners' confidence in their ability to be evidence‐based professionals. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Guidelines recommend inviting family members of intensive care unit (ICU) patients to rounds. We aimed to create a toolkit to support family participation in ICU bedside rounds, based upon evidence from research and in collaboration with ICU family member representatives and healthcare providers. Methods: Ethnographic observations of rounds and interviews and focus groups with family members and ICU healthcare providers were analyzed for key themes, barriers and facilitators of participation, and suggestions. A full day workshop with family representatives and providers (physicians, nurses, social workers, and unit managers) from a diverse range of adult ICUs in Western Canada, including several community ICUs and a majority of large, urban ICUs enabled the collaborative development of key toolkit elements. Results: We have developed an evidence‐informed approach to patient‐and‐family‐centered rounds that highlights the importance of six key elements foundational to patient and family centered rounds: Invitation, Orientation, Engagement, Summary, Questions, and Communication Follow‐Up. We describe strategies, techniques, and templates to optimize these elements and interactions so that communication is more meaningful, and to facilitate the ability of family members to adopt a meaningful role as contributing members of the care team. Conclusion: There is consensus on general strategies for facilitating family participation in rounds and meaningful communication between family and the healthcare team during rounds as an important element of the continuum of communication in the ICU. The incorporation of these elements should be standardized, though tailored to user needs. [ABSTRACT FROM AUTHOR]

Rationale: High data quality is essential to ensure the validity of clinical and research inferences based on it. However, these data quality assessments are often missing even though these data are used in daily practice and research. Aims and objectives: Our objective was to evaluate the data quality of our high‐resolution electronic database (HRDB) implemented in our paediatric intensive care unit (PICU). Methods We conducted a prospective validation study of a HRDB in a 32‐bed paediatric medical, surgical, and cardiac PICU in a tertiary care freestanding maternal‐child health centre in Canada. All patients admitted to the PICU with at least one vital sign monitored using a cardiorespiratory monitor connected to the central monitoring station. Results: Between June 2017 and August 2018, data from 295 patient days were recorded from medical devices and 4645 data points were video recorded and compared to the corresponding data collected in the HRDB. Statistical analysis showed an excellent overall correlation (R2 = 1), accuracy (100%), agreement (bias = 0, limits of agreement = 0), completeness (2% missing data), and reliability (ICC = 1) between recorded and collected data within clinically significant pre‐defined limits of agreement. Divergent points could all be explained. Conclusions: This prospective validation of a representative sample showed an excellent overall data quality. [ABSTRACT FROM AUTHOR]

The authors reflect on the significance of the emergence of virtual emergency department (ED) care during the COVID-19 pandemic. Fourteen regionally coordinated, virtual urgent care initiatives in Ontario received funding from the Ontario Ministry of Health in 2020. Research show the presence of demand and varied complaints and acuity scores for virtual ED care. They emphasize the need to focus on improving virtual ED care to benefit patient outcome.

Rationale: Competency‐based education (CBE) is currently being implemented across Canadian postgraduate medical education programmes through Competence by Design (CBD).1 Queen's University received permission to initiate CBE in all programmes simultaneously starting in 2017; an institutional initiative termed Competency‐based medical education (CBME).2 We describe our initial experiences to highlight perceptions and barriers and facilitate implementation at other centers. Methods: Anonymous online surveys were administered to faculty and residents transitioning to CBE (138 respondents) including (a) Queen's programme leaders (Programme Directors and CBME Leads) [n = 27], (b) Queen's residents [n = 102], and (c) Canadian neurology programme directors [n = 9] and were analysed using descriptive and inferential statistical techniques. Results: Perceptions were favourable (x = 3.55/5, SD = 0.71) and 81.6% perceived CBE enhanced training; however, perceptions were more favourable among faculty. Queen's programme leaders indicated that CBE did not improve their ability to provide negative feedback. Queen's residents did not perceive improved quality of feedback. National Canadian neurology programme directors did not perceive that their institutions had adequately prepared them. There was variability in barriers perceived across groups. Queen's programme leaders were concerned about resident initiative. Queen's residents felt that assessment selection and faculty responsiveness to feedback were barriers. Canadian neurology programme directors were concerned about access to information technology. Recommendations Our results indicate that faculty were concerned about the reluctance of residents to actively participate in CBE, while residents were hesitant to assume such a role because of lack of familiarity and perceived benefit. This discrepancy indicates attention should be devoted to (a) institutional administrative/educational supports, (b) faculty development around feedback/assessment, and (c) resident development to foster ownership of their learning and familiarity with CBE. [ABSTRACT FROM AUTHOR]

Objective: The main purpose of our study was to subjectively assess the quality of a paediatric intensive care unit (PICU) database according to the Directory of Clinical Databases (DoCDat) criteria. Design and setting: A survey was conducted between April 1 and June 15, 2018, among the Sainte Justine PICU research group. Population: Every member of this group whose research activity required the use of the database and/or who was involved in the development/validation of the database. Interventions: None. Measurements and main results: All 10 research team members (one Information Technology specialist, one junior medical student, and eight clinician researchers) who used the high‐resolution database fulfilled the survey (100% response rate). The median quality level of the Sainte Justine PICU database across all the 10 criteria was 3 (2‐4), rated on a 1 (worst) to 4 (best) numeric scale. When compared with previously assessed databases through the DoCDat criteria, we found that the Sainte Justine PICU database performance was similar. Conclusions: The PICU high‐resolution database appeared of good quality when subjectively assessed by the DoCDat criteria. Further validation procedures are mandatory. We suggest that data quality assessment and validation procedures should be reported when creating a new database. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: The patient‐centred medical home (PCMH) is an innovative approach to health care reform. Despite a well‐established process for recognizing PCMH practices, fidelity to, and/or adaptation of, the PCMH model can limit health care and population health improvements. This study explored the connection between fidelity/adaptation to the PCMH model with implementation successes and challenges through the experiences of family and internal medicine PCMH physicians. Methods: Interviews were conducted at two academic PCMH clinics with faculty and resident physicians. Data were transcribed and coded on the basis of an a priori code list. Together, the authors reviewed text and furthered the analysis process to reach final interpretation of the data. Results: Ten faculty and nine resident physicians from the Family Care Centre (FCC; n = 11) and the Internal Medicine Clinic (IMC; n = 8) were interviewed. Both FCC and IMC physicians spoke positively about their clinic's adherence to the PCMH model of enhanced access to care, coordinated/integrated care, and improvements in quality and safety through data collection and documentation. However, physicians highlighted inadequate staffing and clinic hours. FCC physicians also discussed the challenge of providing high‐quality care amidst differences in coverage between payers. Conclusion: There remains significant variability in PCMH characteristics across the United States and Canada. This qualitative analysis uncovered factors contributing to fidelity/adaptation to the PCMH model in two academic PCMH clinics. For the PCMH to achieve the Triple Aim promise of improved patient health and experience at a reduced cost, policy must support fidelity to core elements of the PCMH. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Clinical practice guidelines (CPGs) endeavour to incorporate the best available research evidence together with the clinically informed opinions of leading experts in order to guide clinical practice when dealing with a given condition. There has been increased interest in CPGs that are evidence based and that promote best practice, a central component of which is incorporating the best available research predicated on strong study designs. Despite this soaring interest, there remains heterogeneity in the methodological quality of many CPGs, which may have an effect on the quality of services that clinicians offer. In light of this, this study examined the quality of the methodology used to develop two CPGs of the Canadian Psychiatric Association (CPA). Method: The CPA's guidelines for the management of anxiety disorders (2006) and for the treatment of depressive disorders (2001) were assessed by trained raters using the Appraisal of Guidelines for Research and Evaluation II Instrument scale. Results: The blind ratings of three trained raters demonstrated that the anxiety and depression CPGs had a number of strengths and important weaknesses. Conclusion: Implications for the development of future CPGs on anxiety and depression, including recommendations to improve guideline quality in psychiatry in particular, are discussed. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Over the past two decades, research informing good clinical practices related to intimate partner violence (IPV) has been plentiful, yet partner violence screening remains challenging to translate into action. In spite of the documented efficacy of routine screening for women of reproductive age and the availability of validated screening instruments, many IPV screening programmes lack the components necessary for success. In Toronto, a multidisciplinary team of researchers and clinicians is using the tools of implementation science to scale up an evidence‐based IPV screening and response programme in an urban orthopaedic clinic where prior screening attempts have been ineffective. Methods: Using the Active Implementation Framework as a guide, researchers collected data across multiple sources to inform the first stage of implementation. Analysis focused on identifying the characteristics of the clinic that support or hinder implementation of new processes, evidence‐based screening practices that fit with the clinic, and characteristics of a strong implementation team. Results: Through this process, researchers and clinicians uncovered organizational strengths and weaknesses related to IPV screening that may not have been identified previously. The need to incorporate technology into our screening processes became apparent, as did the importance of shared communication and colearning between clinicians and researchers. Conclusions: The benefits of investing in the preparatory phases of implementation are discussed. Without undertaking the process of gathering and analysing data, examining the factors that support effective and sustainable implementation, and investing in the creation of a strong implementation team, it is likely that decisions about our screening approaches would have resulted in a less‐effective and sustainable process. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Local health administrators implemented chronic obstructive pulmonary disease and heart failure admission order sets to increase guideline adherence. We explored the impact of these order sets on workflows and guideline adherence in the internal medicine specialty in two Canadian teaching hospitals. Methods: A mixed methods study combined shadowing care providers (250 h), meeting observation and interviews (11 h), and patient medical chart audits for heart failure (n = 120) and chronic obstructive pulmonary disease (n = 120) patients. The chart audits analysed details of the admission process and 14 guideline elements associated with heart failure (nine) and chronic obstructive pulmonary disease (five). Results: A subset (10/14) of the evaluated guideline elements were included in the heart failure or chronic obstructive pulmonary disease order sets. Order set use significantly increased adherence to some (4/10) of these elements. However, our qualitative work uncovered a perception that use of these two order sets increased order duplication. Our chart audits supported this perception. Order set use increased order duplication for heart failure (92% vs 43%) and chronic obstructive pulmonary disease (75% vs 43%). Conclusion: It is unclear whether, for these two hospitals, the gains brought by implementation of chronic obstructive pulmonary disease and heart failure admission order sets were worth their associated organisational shortcomings. Problems with order set implementation appeared to stem from poor integration with pre‐existing complex organisational systems. Health administrators and clinicians interested in implementing order sets within their own hospitals need to remain cognizant of how these tools will fit into existing systems and practices. [ABSTRACT FROM AUTHOR]

Objectives: After patients are discharged from the emergency department (ED), follow‐up of test results focuses on abnormal values. In the elderly, non‐specific symptoms can result in an incorrect diagnosis of urinary tract infection (UTI). This study compared the outcomes of patients discharged from the ED with a diagnosis of UTI based on urine culture results. Methods: We conducted a retrospective cohort study using linked health databases and chart review of a random sample of elderly patients (age > 65 years) discharged from the Ottawa Hospital ED between 2006 and 2014 with a diagnosis of UTI. Patients were categorized based on whether urine cultures were positive and bacterial sensitivity to prescribed antibiotics. Primary outcome was return to ED, admission to hospital, or death within 30 days. Results: A total of 1001 patients were included in the study (401 culture‐negative; 474 culture‐positive antibiotic‐sensitive; 126 culture positive antibiotic‐insensitive). Patients were elderly (mean age 80 years, SD 7.6) with a high prevalence of dementia (18.0%). Almost a third of patients (n = 313, 31.3%) experienced an outcome. Compared to culture‐positive antibiotic‐sensitive patients, culture negative patients (adjOR 1.45, 95% CI 1.07‐1.97) and culture‐positive antibiotic‐insensitive patients (adjOR 1.49, 95% CI 0.90‐2.14) were significantly more likely to experience an outcome (P = 0.04). Conclusions: Patients discharged from the ED with a diagnosis of UTI have an increased risk of return to ED, urgent readmission or death if the uropathogen is insensitive to the prescribed antibiotic or if the culture is negative. Patients diagnosed with UTI with a negative culture may need further assessment. [ABSTRACT FROM AUTHOR]

Abstract: For older adults with osteoporosis, a fall resulting in hip fracture is a life‐changing event from which only one‐third fully recover. Current best evidence argues strongly for elderly patients to bear weight on their repaired hip fracture immediately after their surgery to maximize their chances of full or nearly full recovery. Patient stakeholders in Canada have argued that some surgeons fail to issue “weight‐bearing‐as‐tolerated” (WBAT) orders in all eligible cases, protecting their bony repair but contributing to increased mortality and long‐term disability rates. In collaboration with a national stakeholder organization, Bone and Joint Canada, we interviewed 20 orthopedic surgeons across Canada who perform hip fracture repair surgery, with the aim of understanding their attitudes and behavior toward patient management regarding weight bearing. Qualitative content analysis, in which themes are identified and agreed by multiple coders, suggested that both patient characteristics and surgeon factors influence surgeons' postoperative weight‐bearing orders. While almost all respondents agreed that weight bearing as tolerated is indeed therapeutic for most hip fracture repair or replacement patients, surgeons also described certain patient characteristics that would diminish the value of immediate weight bearing, including poor bone quality and certain types of fracture pattern. Surgeon factors that affect postoperative mobilization orders include choice of construct, previous experience of construct failure, and lack of local audit data regarding past weight‐bearing decisions and patient outcomes. Thus, although familiar with best practice guidelines, surgeons also have “rules to break the rules.” In an era when “good” medicine leans toward science rather than art, the role of individual experience in decision making with regard to hip fracture care continues to be important and would benefit from being discussed openly. [ABSTRACT FROM AUTHOR]

Rationale: Venous thromboembolic disease is a source of significant morbidity in hospitalized patients. The American College of Chest Physicians published the ninth edition of antithrombotic therapy and prevention guidelines (AT9) in 2012, addressing thromboprophylaxis in hospitalized patients. A notable difference from previous guidelines was utilization of risk assessment models for thrombosis and bleeding to classify patients into risk categories. Aim: This study's objective was to evaluate thromboprophylaxis adherence to AT9 guidelines in a population of patients at the Centre intégré universitaire de santé et de service sociaux de l'Estrie – Centre hospitalier universitaire de Sherbrooke. Method: A cross‐sectional study at the Centre intégré universitaire de santé et de service sociaux de l'Estrie – Centre hospitalier universitaire de Sherbrooke was performed between June and December 2012. Patients' risk factors for thrombosis and bleeding, and thromboprophylaxis use were documented. The Padua and Caprini models were used to determine thrombotic risk, and the International Medical Prevention Registry on Venous Thromboembolism bleeding risk score was used for bleeding risk. Results: A total of 290 patients were included for analysis. Overall, 200 patients (70%) received some form of thromboprophylaxis. However, according to AT9 guidelines, only 162 patients (55.9%) received recommended prophylaxis, 91 (31.4%) had overuse of prophylaxis and 37 (12.7%) had underuse of prophylaxis. Appropriate prophylaxis use was higher in surgical (61.8%) than in medical (46.7%) patients. Conclusions: There was a high rate of inappropriate thromboembolic prophylaxis in our centre according to AT9 guidelines, mostly from overuse of prophylaxis. Utilization of risk assessment models in AT9 guidelines adds to the complexity of physician's decisions to prescribe thromboprophylaxis and needs further validation. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Invasive lobular breast cancer ( ILC) has distinct features that present challenges for management. We surveyed doctors regarding management approaches, opinions on quality of evidence supporting their practice, and future research needs. Methods An online questionnaire was developed and circulated to breast cancer surgical, radiation and medical oncologists. Results The questionnaire was completed by 88/428 doctors (20.6%); 22/56 (39.3%) surgeons, 21/64 (32.8%) radiation oncologists and 45/308 (14.6%) medical oncologists. The majority (65%) of surgeons were comfortable treating ILC patients using the same surgical management as patients with invasive ductal cancers ( IDC). Furthermore, 25% would perform a similar surgery but would obtain larger gross margins. There was equipoise for radiation oncologists regarding whether or not ILC was an independent risk factor for local-regional recurrence after either breast-conserving surgery or mastectomy. Of those radiation oncologists who believe ILC is an independent risk factor for recurrence after mastectomy, 44.4% would offer radiation in the absence of usual indications. Medical oncologists approached systemic therapy for ILC patients similarly to those with comparable IDCs. Areas identified as most controversial and requiring future research were preoperative magnetic resonance imaging, radiotherapy post-mastectomy and the responsiveness of ILC to adjuvant chemotherapy compared with endocrine therapy. Conclusions There is a variation in doctors' beliefs, management and opinions regarding the quality of evidence for the management of ILC. Clinical trials specifically assessing the management of ILC are required to guide clinical practice. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide. Methods Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed. Results A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice- Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice- Based Surveys collected the most information on organizational attributes. Conclusions There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Based on input from 400 stakeholders over 6 years, the 2011 Program Evaluation Standards represents an in-depth analysis of values, meaning and measurement and their relationships in programme evaluation. Evaluation quality is achieved by balancing five attributes: utility, feasibility, propriety, accuracy and evaluation accountability. These attributes are used to organize 30 standards, 200 strategies and 197 hazards. Method In response to a call from the authors of the standards, we have used them to guide our meta-evaluation of Mc Gill's undergraduate physicianship programme. Results Our findings show how the standards illuminate the tensions, dilemmas and hazards inherent in all stages of programme evaluation studies and offer helpful strategies for designing and conducting high-quality evaluation studies. Conclusions Based on our experience, the third edition needs to be used as a reference document in all stages of evaluations of medical education programmes. [ABSTRACT FROM AUTHOR]

Introduction Clinical practice guidelines ( CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated aims of these CPGs and the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial ( RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Medication-prescribing errors with adverse drug events impose substantial harms on patients and health systems. Medication errors resulting in preventable adverse drug events most commonly occur at the ordering stage. Electronic prescribing may prevent such errors but its impact has not been rigorously evaluated. Methods We conducted a pragmatic cluster randomized controlled trial in academic hospital ambulatory clinics to evaluate the effects of a commercially available electronic prescribing software system on total prescription error ratio. Secondary outcomes included the number of callbacks for clarification from community pharmacies to physicians' clinics. Results Twenty-six physicians used the electronic prescribing system, writing 1980 prescriptions during 44 intervention weeks when the electronic prescribing system was available (7.6% of these were electronic, the remainder handwritten) and 973 prescriptions during 22 control weeks while the system was switched off (1.4% electronic, prescribed in the previous intervention week, but issued with delay). The total prescription error rate was 118/1980 (6.0%) in intervention weeks and 57/973 (5.9%) in control weeks ( P = 0.91). During the intervention period more callbacks requesting clarification were made to clinic administrators ( n = 83, 1.89 per week) than during control weeks ( n = 32, 1.45 per week; P < 0.001). Conclusion Implementation of the electronic prescribing system had no impact on total prescription error, and increased the callback rate. In spite of intensive user support, few prescriptions in intervention weeks were made using the electronic system. Given the costs, training requirements, workflow redesigns and regulatory hurdles, additional evaluations of outpatient prescribing on clinically important outcomes are needed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Diabetes mellitus is a growing health and economic burden. Identification of patients with unrecognized diabetes, or those at high risk for diabetes, provides an opportunity for timely intervention. This study assessed the accuracy of using electronic health care data to identify patients with undiagnosed diabetes. Methods The study was conducted at a tertiary-care teaching facility in Ottawa, Canada. The study cohort was a stratified random sample of hospitalizations between 1 January 2003 and 31 December 2008. We used diagnostic codes, pharmacy orders and serum glucose tests to classify patients into six groups: 'recognized diabetes' (a diabetes diagnostic code or any diabetes medication), 'probable diabetes' (maximum glucose ≥ 11.1 mmol L−1), 'possible diabetes' (maximum glucose between 7.8 and 11.1 mmol L−1), 'unlikely diabetes' (maximum glucose between 6.0 and 7.8 mmol L−1), 'no diabetes' (maximum glucose < 6.0 mmol L−1) and 'unknown diabetes status' (no glucose test). We compared this electronic classification to a reference standard chart review performed by a blinded abstractor. Results A total of 500 hospitalizations were included. The prevalence of each diabetes group was: recognized - 17%; probable - 4%; possible - 15%; unlikely - 20%; none - 15%; and unknown - 29%. Our electronic algorithm correctly classified 88.8% (95% confidence interval 85.7-91.3) of hospitalizations (weighted-Kappa = 0.885; 95% confidence interval 0.851-0.919). The sensitivity, specificity and positive predictive values of our algorithm for 'known diabetes' was 0.842, 0.988 and 0.941, respectively. For patients at a 'high risk for diabetes' (maximum glucose > 7.8 mmol L−1), the corresponding values were 0.921, 0.971 and 0.872. Conclusions Patients with diagnosed and undiagnosed diabetes can be accurately identified using electronic health care data. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Value-based pricing has recently been discussed by international bodies as a means to estimate a drug price that is linked to the benefits it offers patients and society. The World Health Organization (WHO) has recommended using three times a country's per capita gross domestic product (GDP) as the threshold for economic value. Using the WHO criteria, pharmacoeconomic modelling was used to illustrate the application of value-based price towards bevacizumab, a relatively new drug that provides a 1.4-month survival benefit to patients with metastatic colorectal cancer (mCRC). Methods A decision model was developed to simulate outcomes in mCRC patients receiving chemotherapy ± bevacizumab. Clinical data were obtained from randomized trials and costs from Canadian cancer centres. Utility estimates were determined by interviewing 24 oncology nurses and pharmacists. A price per dose of bevacizumab was then estimated using a target threshold of $CAD117 000 per quality adjusted life year gained, which is three times the Canadian per capita GDP. Results For a 1.4-month survival benefit, a price of $CAD830 per dose would be considered cost-effective from the Canadian public health care perspective. If the drug were able to improve patient quality of life or survival from 1.4 to 3 months, the drug price could increase to $CAD1560 and $CAD2180 and still be considered cost-effective. Discussion The use of the WHO criteria for estimating a value-based price is feasible, but a balance between what patients/governments can afford to pay and the commercial viability of the product in the reference country would be required. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Following increased interest in having inter-professional (IP) health care teams engage patients in decision making, we developed a conceptual model for an IP approach to shared decision making (SDM) in primary care. We assessed the validity of the model with stakeholders in Canada. Methods In 15 individual interviews and 7 group interviews with 79 stakeholders, we asked them to: (1) propose changes to the IP-SDM model; (2) identify barriers and facilitators to the model's implementation in clinical practice; and (3) assess the model using a theory appraisal questionnaire. We performed a thematic analysis of the transcripts and a descriptive analysis of the questionnaires. Results Stakeholders suggested placing the patient at its centre; extending the concept of family to include significant others; clarifying outcomes; highlighting the concept of time; merging the micro, meso and macro levels in one figure; and recognizing the influence of the environment and emotions. The most common barriers identified were time constraints, insufficient resources and an imbalance of power among health professionals. The most common facilitators were education and training in inter-professionalism and SDM, motivation to achieve an IP approach to SDM, and mutual knowledge and understanding of disciplinary roles. Most stakeholders considered that the concepts and relationships between the concepts were clear and rated the model as logical, testable, having clear schematic representation, and being relevant to inter-professional collaboration, SDM and primary care. Conclusions Stakeholders validated the new IP-SDM model for primary care settings and proposed few modifications. Future research should assess if the model helps implement SDM in IP clinical practice. [ABSTRACT FROM AUTHOR]

Rationale Self-efficacy beliefs may provide a means to influence health care professionals' (HCPs) engagement in evidence-based practice (EBP) but no standardized measure of this construct exists. Objectives To create and evaluate the validity and comprehensibility of a scale measuring belief in ability to implement EBP, known as EBP self-efficacy, among HCPs. Methods Items describing the steps of EBP outlined in the literature were generated. Fourteen content experts reviewed the scale for face and content validity. A purposive sample of 10 HCPs from medicine, nursing, physical and occupational therapy and speech language pathology provided feedback on the clarity and meaning of scale wording in telephone interviews. Results Progressive refinement yielded an 11-item self-report scale. Each item describes an activity that is part of the process of implementing EBP, such as formulating a question to guide a literature search and asking your patient or client about his/her needs, values and treatment preferences. To complete the scale, HCPs rate their level of confidence on an 11-point scale ranging from 0% (no confidence) to 100% (completely confident) in their ability to perform each activity. Item-level responses are averaged to obtain a summary score that can range from 0% to 100%. Conclusion The newly created scale, named the EPIC (evidence-based practice confidence) scale, provides an opportunity to evaluate HCPs' beliefs in their ability to implement EBP and the effects of interventions on these beliefs. Psychometric evaluation of the test-retest reliability and construct validity of the scale is necessary prior to its widespread use. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Teratology Information Services (TIS) provide health care professionals and the public with information regarding the safety and/or risk of exposures during pregnancy and lactation, mainly via telephone consultations. An international comparison of clinical practices at TIS has never been conducted. The survey objective was to compare international TIS to North American TIS, with an aim to identify strengths and challenges that can lead to service improvement. Methods Twenty-two international TIS were approached for participation during an international conference. TIS were surveyed on information in six categories: services, staffing, operations, data collection, knowledge transfer activities and additional information. Data were summarized using descriptive statistics. Statistical tests were conducted using SPSS®. Results Sixteen TIS from 12 countries participated. Survey results were compared with previously reported results from a similar survey of North American TIS (16 US, two Canadian). TIS exist in a variety of departments and settings, but most commonly are in university hospitals. Pregnant women were the most commonly counselled group worldwide. International TIS spent significantly more time fielding inquiries regarding medications, while North American TIS had a wider variety of inquiry categories. All TIS could improve budget tracking. Conclusions Overall, service practices and goals were similar, although international TIS conducted more follow-up with service users than North American TIS. This report offers TIS the first ever opportunity to compare practices. Increased dialogue between TIS encourages sharing of best practices and improves the ability of these important public health programmes to support women and health care providers. [ABSTRACT FROM AUTHOR]

Context Four maternity/obstetrical care organizations, representing women, midwives, obstetricians and family doctors conducted interdisciplinary policy research under auspices of four key stakeholder groups. These projects teams and key stakeholders subsequently collaborated to develop consensus on strategies for improved maternity services in Ontario. Objectives The objective of this study is to evaluate a 2-day research synthesis and consensus building conference to answer policy questions in relation to new models of interdisciplinary maternity care organizations in different settings in Ontario. Methods The evaluation consisted of a scan of individual project activities and findings as were presented to an invited audience of key stakeholders at the consensus conference. This involved: participant observation with key informant consultation; a survey of attendees; pattern processing and sense making of project materials, consensus statements derived at the conference in the light of participant observation and survey material as pertaining to a complex system. The development of a systems framework for maternity care policy in Ontario was based on secondary analysis of the material. Findings Conference participants were united on the importance of investment in maternity care for Ontario and the impending workforce crisis if adaptation of the workforce did not take place. The conference participants proposed reforming the current system that was seen as too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. However, not one model of interdisciplinary maternity/obstetrical care was endorsed. Consistency and coherence of models (rather than central standardization) through self-organization based on local needs was strongly endorsed. An understanding of primary maternity care models as subsystems of networked providers in complex health organizations and a wider social system emerged. The patterns identified were incorporated into a complexity framework to assist sense making to inform policy. Discussion Coherence around core values, holism and synthesis with responsiveness to local needs and key stakeholders were themes that emerged consistent with complex adaptive systems principles. Respecting historical provider relationships and local history provided a background for change recognizing that systems evolve in part from where they have been. The building of functioning relationships was central through education and improved communication with ongoing feedback loops (positive and negative). Information systems and a flexible improved central and local organization of maternity services was endorsed. Education and improved communication through ongoing feedback loops (positive and negative) were central to building functioning relationships. Also, coordinated central organization with a flexible and adaptive local organization of maternity services was endorsed by participants. Conclusions This evaluation used an approach comprising scoping, pattern processing and sense making. While the projects produced considerable typical research evidence, the key policy questions could not be addressed by this alone, and a process of synthesis and consensus building with stakeholder engagement was applied. An adaptive system with local needs driving a relationship based network of interdisciplinary groupings or teams with both bottom up and central leadership. A complexity framework enhanced sense making for the system approaches and understandings that emerged. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Clinical trials are integral to progress in cancer management. While doctors’ attitudes to clinical trials have been documented, there is little or no literature on the perception of trials from the perspective of other clinicians who treat trial patients. The purpose of this phenomenological study was to explore nurses’ and radiation therapists’ (RTs) perceptions of clinical trials in their cancer centre. Methods This study was conducted in a Canadian cancer centre where over 50 clinical trials actively recruit patients at any one time. Nurses and RTs were interviewed to explore their perceptions of clinical trials. Results The following themes emerged from the analysis: (1) nurses and RTs perceived a variety of ethical concerns associated with clinical trials; (2) treating patients enrolled in clinical trials was perceived to add to the workload of RTs; (3) nurses and RTs did not perceive meaningful involvement in clinical trials as an option; and (4) the additional workload and ethical concerns associated with trials were off-set by the view that patients’ interests outweighed those of nurses and RTs. Discussion Nurses and RTs should be invited to provide input regarding trial procedures and be acknowledged for their work associated with clinical trials. [ABSTRACT FROM AUTHOR]

Abstract The Canadian Medical Association (CMA) maintains a database of clinical practice guidelines (CPGs) developed or endorsed by Canadian organizations. The study purpose was to describe how these guidelines were developed, disseminated and evaluated. A survey was mailed to the developer of each CPG registered in the CMA Infobase between June 1996 and December 1999. Data were received for 730 unique guidelines (response rate of 70%) developed by 75 organizations. Of these, 72% were developed by committees that had a formal process for selecting their members. The scientific literature was reviewed for all of the guidelines, a computerized search undertaken for 88% and the search strategy included 34% of CPG documents. An attempt was made to grade the quality of the evidence underpinning 54% of the guidelines. For most guidelines, consensus about values or judgements was reached by expert opinion through open discussion (78% of guidelines). The most common strategies used to disseminate the guidelines were direct mailing of guidelines to members of the developing organization (80% of all guidelines), publishing guidelines in newsletters/journals (76%), direct mailing to others (73%), electronic dissemination (62%), educational or continuing medical education activities (50%), and providing information about guidelines to patients/consumers (47%). Overall, 5% of the guidelines have been evaluated to determine their impact on health outcomes. During the 5-year study period (1994–99), the more recent guidelines were more likely to use multidisciplinary development panels, report the literature search strategies and grade the quality of the evidence. The CPG development process in Canada is becoming more rigorous and reproducible, but there is still considerable room for improvement. In addition to encouraging Canadian guideline developers to use more rigorous and transparent methods, considerably more attention must be focused on using and identifying... [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims and objectives An Achilles’ heel of Canadian Medicare is long waits for elective services. The Western Canada Waiting List (WCWL) project is a collaboration of 19 partner organizations committed to addressing this issue and influencing the way waiting lists are structured and managed. The focus of the WCWL project has been to develop and refine practical tools for prioritizing patients on scheduled waiting lists. Methods Scoring tools for priority setting were developed through extensive clinical input and highly iterative exchange by clinical panels constituted in five clinical areas: cataract surgery; general surgery procedures; hip and knee replacement; magnetic resonance imaging (MRI) scanning, and children's mental health. Several stages of empirical work were conducted to formulate and refine criteria and to assess and improve their reliability and validity. To assess the acceptability and usability of the priority-setting tools and to identify issues pertaining to implementation, key personnel in the seven regional health authorities (RHAs) participated in structured interviews. Public opinion focus groups were conducted in the seven western cities. Results Point-count scoring systems were constructed in each of the clinical areas. Participating clinicians confirmed that the tools offered face validity and that the scoring systems appeared practical for implementation and use in clinical settings. Reliability was strongest for the general surgery and hip and knee criteria, and weakest for the diagnostic MRI criteria. Public opinion focus groups endorsed wholeheartedly the application of point-count priority measures. Regional health authorities were generally supportive, though cautiously optimistic towards implementation. Conclusions While the WCWL project has not ‘solved’ the problem of waiting lists and times, having a standardized, reliable means of assigning priority for services is an important step... [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims and objectives This randomized controlled trial was designed to evaluate the 2-year costs and effects of a proactive, public health nursing case management approach compared with a self-directed approach for 129 single parents (98% were mothers) on social assistance in a Canadian setting. A total of 43% of these parents had a major depressive disorder and 38% had two or three other health conditions at baseline. Methods Study participants were recruited over a 12 month period and randomized into two groups: one receiving proactive public health nursing and one which did not. Results At 2 years, 69 single parents with 123 children receiving proactive public health nursing (compared with 60 parents with 91 children who did not receive public health nursing services) showed a slightly greater reduction in dysthymia and slightly higher social adjustment. There was no difference between the public health and control groups in total per parent annual cost of health and support services. However, costs were averted due to a 12% difference in non-use of social assistance in the previous 12 months for parents in the public health nursing group. This translates into an annual cost saving of $240 000 (Canadian) of costs averted within 1 year for every 100 parents. Conclusions In the context of a system of national health and social insurance, this study supports the fact that it is no more costly to proactively service this population of parents on social assistance. [ABSTRACT FROM AUTHOR]

A series of 12 studies (five historic cohort and seven randomized trials) examined clients in community settings in Southern Ontario suffering from a variety of chronic physical and mental health conditions. These studies are appraised using a framework for evaluating possible outcomes of economic evaluation. In the 12 studies, sample composition and size varied. Each study was designed to quantify the well-being outcomes and expenditures associated with different community-based approaches to care provided in the context of a system of national health insurance. As a collective, these studies represent increasing methodological rigour. Multiple-perspective client well-being outcome measures were used. In two studies, caregiver burden also was analysed. A common approach to quantification and evaluation of expenditures for service consumption was used in all 12 studies. The nature of community-based health services (health vs. disease care orientation) was found to have direct and measurable impact on total expenditures for health service utilization and client well-being outcomes. In most cases, a recurring pattern of equal or better client outcomes, yet lower expenditures for use of community based health services, was associated with well-integrated health oriented services. Integrated services aimed at factors which determine health are superior when compared to individual, fragmented, disease oriented, and focused approaches to care. The main lessons from the 12 studies are that it is as or more effective and as or less expensive to offer complete, proactive, community health services to persons living with chronic circumstance than to provide focused, on-demand, piecemeal services. Complete services would have a psychosocial and mental health focus included with the physical care approach. Furthermore, people with coexisting risk factors (age, living arrangements, mental distress and problem-solving ability) are the ones who most benefit at lower expense... [ABSTRACT FROM AUTHOR]

The topic, evidence-based decision making, may be seen from many perspectives and levels of policy consideration. Canada has been actively pursuing policy macro-level directions for health information and evidence-based decision making through the National Forum on Health and the Advisory Council on Health Infostructure, together with changes in the federal health ministry, Health Canada, and other important national health organizations such as the Canadian Institute for Health Information. It remains to be determined how these initiatives will fundamentally influence a culture of evidence-based decision making and health information availability and quality for the average Canadian. Canada has, nonetheless, recognized that our health care delivery system has fallen behind in terms of using information management and technology to enable and facilitate the ever-growing information needs of the system. Policy direction provided by the National Forum on Health and the Advisory Council on Health Information offer an agenda for action and strategic direction drawn from two broadly based, highly iterative processes. [ABSTRACT FROM AUTHOR]