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Malnutrition in medical and surgical inpatients is an on-going problem. More-2-Eat (M2E) Phase 1 demonstrated that improved detection and treatment of hospital malnutrition could be embedded into routine practice using an intensive researcher-facilitated implementation process. Yet, spreading and sustaining new practices in diverse hospital cultures with minimal researcher support is unknown.To demonstrate that a scalable model of implementation can increase three key nutrition practices (admission screening; Subjective Global Assessment (SGA); and medication pass (MedPass) of oral nutritional supplement) in diverse acute care hospitals to detect and treat malnutrition in medical and surgical patients.Ten hospitals participated in this pretest post-test time series implementation study from across Canada, including 21 medical or surgical units (Phase 1 original units (n = 4), Phase 1 hospital new units (n = 9), Phase 2 new hospitals and units (n = 8)). The scalable implementation model included: training champions on implementation strategies and providing them with education resources for teams; creating a self-directed audit and feedback process; and providing mentorship. Standardized audits of all patients on the study unit on an audit day were completed bi-monthly to track nutrition care activities since admission. Bivariate comparisons were performed by time period (initial, mid-term and final audits). Run-charts depicted the trajectory of change and qualitatively compared to Phase 1.5158 patient charts were audited over the course of 18-months. Admission nutrition screening rates increased from 50% to 84% (p 0.0001). New Phase 1 units more readily implemented screening than Phase 2 sites, and the original Phase 1 units generally sustained screening practices from Phase 1. SGA was a sustained practice at Phase 1 hospitals including in new Phase 1 units. The new Phase 2 units improved completion of SGA but did not reach the levels of Phase 1 units (original or new). MedPass almost doubled over the time periods (7%-13% of all patients p 0.007). Other care practices significantly increased (e.g. volunteer mealtime assistance).Nutrition-care activities significantly increased in diverse hospital units with this scalable model. This heralds the transition from implementation research to sustained changes in routine practice. Screening, SGA, and MedPass can all be implemented, improve nutrition care for all patients, spread within an organization, and for the most part, sustained (and in the case of original Phase 1 units, for over 3 years) with champion leadership.

Summary Background Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical nutrition care. Aim This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates. Methods 1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates. Results Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (−0.28 per time period; 95% CI -0.44, −0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes. Discussion Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition. Trial registration Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.

BACKGROUND Decreased physical functioning is associated with malnutrition and common in acute care patients; determining loss of function is often considered part of a comprehensive nutrition assessment. Handgrip strength (HGS) and 5-meter timed walk (5m) are functional measures used in a variety of settings. This analysis sought to determine which functional measure could be added to a hospital nutrition assessment, based on its feasibility and capacity to discriminate patient subgroups. METHODS Eligible medical patients (no delirium/dementia, admitted from community; n = 1250), recruited from 5 hospitals that participated in a previous multisite action research study, provided data on demographics, HGS, 5m, nutrition status, perceived disability, and other characteristics. RESULTS Significantly more patients (z = 17.39, P < .00001) were able to complete HGS than 5m (92% versus 43%, respectively). Median HGS was 28.0 kg for men and 14.7 kg for women. Of patients who completed the 5m, mean completion time was 8.98 seconds (median, 6.79 seconds, SD = 6.59). 5m and HGS scores were significantly worse with patient-perceived disability (z = -9.56, t = 10.69, respectively; P < .0001; 95% confidence interval [CI], [7.33, 10.63]; [1.76, 3.18]). HGS was associated with nutrition status (t = 4.13, P < .001; 95% CI [2.02, 5.67]), although it showed poor validity as a single nutrition indicator. CONCLUSIONS These data indicate that HGS is a more useful functional measure than 5m when added to a hospital nutrition assessment. Determination of HGS cutpoints to identify low strength in acute care patients will promote its use.

Summary Background Handgrip strength (HGS) is a practical measure of strength and physical function that can be used to identify frailty among hospitalized patients, but its utility in this setting is unclear. To be considered useful, any functional measure needs to provide pertinent information on the patient and predict relevant outcomes such as health-care utilization (e.g., length of stay (LOS)) and patient-reported quality of life (QOL). The purpose of this study was to determine if HGS predicted LOS and QOL. A second aim was to examine the best sensitivity (SE) and specificity (SP) for predicting length of stay (>7 or >13 days) using previously published cut-points for HGS. Methodology HGS was measured on 1136 medical patients shortly after admission with a Lafayette dynamometer. QOL was assessed with the self-reported SF-12 completed with an interviewer during hospitalization and 30- days after discharge via telephone. Physical (PCS) and mental (MCS) component scores of SF-12 were calculated. A variety of covariates were assessed (e.g., nutritional status). Multivariate analyses stratified by sex were completed. Results The mean LOS was 12.71 days (median = 8.00; SD = 13.20), 12.88 days (SD = 13.82) for males, and 12.58 days (SD = 12.68) for females. Lower admission HGS scores were associated with longer LOS (male X2 = 7.85, p Conclusion Admission HGS adds predictive value for both LOS and physical components of QOL and is worth pursuing in practice to identify potential frailty and the need for proactive steps to mitigate further functional decline during hospitalization. However, HGS cut-points for LOS specific to acute care patients need to be defined and tested.

In-hospital malnutrition and inadequate food intake have been associated with negative outcomes (e.g., prolonged length of stay, readmission, mortality, and increased hospital costs). Studies examining the factors associated with low food intake in hospital, commonly defined as the consumption of ≤50% of meals, have produced mixed results. We examined the correlates of food intake including patient socioeconomic, demographic, and health characteristics, institutional factors, and common clinical strategies in 1129 medical patients from 5 Canadian hospitals. Low food intake was found in 35% of patients (41% of females and 29% of males) (p < 0.001). In multivariate analyses, sex, socioeconomic status, demographics, and diagnoses were not significantly related to food intake. Patients assessed as malnourished (subjective global assessment (SGA) B/C) (odds ratio (OR), 2.41; p = 0.003) or as not at risk of malnutrition (OR, 1.67; p = 0.040) were more likely to have low intake when compared with those assessed as well nourished (SGA A). Patient reports of mealtime challenges (OR, 2.70; p < 0.001) and barriers to food intake (OR, 1.11; p = 0.008) were positively related to low intake throughout the study sample. Higher 12-Item Short Form Health Survey Mental Component Summary scores were related to better food intake (OR, 0.98; p < 0.001). Clinical strategies such as between-meal snacks lowered the likelihood of low food intake (OR, 0.55; p = 0.037), whereas a group of “other strategies” increased the odds (OR, 2.77; p = 0.001). These results offer a better understanding of the correlates of in-hospital low food intake. The conclusion discusses some avenues for improving food intake in the clinical setting, such as better mealtime monitoring and a reduction in barriers to food intake.

Many international medical graduates (IMGs) are unable to find residency positions in Canada. A growing proportion are “Canadians studying abroad” (CSAs) trying to return to Canada. We examine the characteristics and practice intentions of residents in Canada: IMGs excluding CSAs, CSAs, and Canadian medical school graduates (CMGs). CSAs and CMGs appear to be similar, but IMGs do not in key instances. IMGs are substantially less likely to state that they intend to practise where they trained or in Canada, controlling for characteristics. This adds support to previous findings indicating that regions relying on IMGs to provide health care may experience ongoing challenges.

Many patients leave hospital in poor nutritional states, yet little is known about the post-discharge nutrition care in which patients are engaged. This study describes the nutrition-care activities 30-days post-discharge reported by patients and what covariates are associated with these activities. Quasi-randomly selected patients recruited from 5 medical units across Canada (n = 513) consented to 30-days post-discharge data collection with 48.5% (n = 249) completing the telephone interview. Use of nutrition care post-discharge was reported and bivariate analysis completed with relevant covariates for the two most frequently reported activities, following recommendations post-discharge or use of oral nutritional supplements (ONS). A total of 42% (n = 110) received nutrition recommendations at hospital discharge, with 65% (n = 71/110) of these participants following those recommendations; 26.5% (n = 66) were taking ONS after hospitalization. Participants who followed recommendations were more likely to report following a special diet (p = 0.002), different from before their hospitalization (p = 0.008), compared to those who received recommendations, but reported not following them. Patients taking ONS were more likely to be at nutrition risk (p < 0.0001), malnourished (p = 0.0006), taking ONS in hospital (p = 0.01), had a lower HGS (p = 0.0013; males only), and less likely to believe they were eating enough to meet their body’s needs (p = 0.005). This analysis provides new insights on nutrition-care post-discharge.

Staff play key roles in the prevention, detection, and treatment of hospital malnutrition. Understanding staff knowledge, attitudes, and practices (KAP) is important for developing and evaluating change management strategies.The More-2-Eat project improved nutrition care in 5 Canadian hospitals by implementing the Integrated Nutrition Pathway for Acute Care (INPAC). To understand staff views before (T1) and after 1 year of implementation (T2), a reliable KAP questionnaire, based on INPAC, was administered. T2 included questions about involvement in implementation. The mean difference between T2 and T1 responses was calculated, and t tests were used for comparisons.The questionnaire was completed at T1 (n = 189) and T2 (n = 147) (unpaired); 57 staff completed both questionnaires (paired). A significant increase in total score was seen in unpaired results at T2 (from 93.6/128 [range, 51-124] to 99.5/128 [range, 54-119]; t = 5.97, P.0001), with an increase in knowledge/attitudes (KA) (t = 2.4, P = .016) and practice (t = 3.57, P.0001) components. There were no statistically significant changes in paired responses. Seventy percent (n = 102/147) noticed positive changes in practices, 12% (n = 18) noticed positive/negative changes, 1% (n = 1) noticed negative change, and 17% (n = 25) noticed no change. Fifty-nine percent (n = 86) felt involved in the change, and these staff had higher KA and KAP scores than those who did not feel involved.Staff involvement is important in the implementation process for improving nutrition care.

There is a well documented health disparity between several European countries and the United States. This health gap remains even after controlling for socioeconomic status and risk factors. At the same time, we note that the U.S. market structure is characterized by significantly more large corporations and "super-sized" retail outlets than Europe. Because big business is hierarchical in nature and has been reported to engender urban sprawl, inferior work environments, and loss of social capital, all identified as correlates of poor health, we suggest that differences in market structure may help account for some of the unexplained differences in health across Europe and North America. Using national level data, this study explores the relationship between market structure and health. We investigate whether individuals who live in countries with proportionately more small business are healthier than those who do not. We use two measures of national health: life expectancy at birth, and age-standardized estimates of diabetes rates. Results from ordinary least squares regressions suggest that, there is a large and statistically significant association between market structure (the ratio of small to total businesses) and health, even after controlling income, public percent of health expenditure, and obesity rates. This association is robust to additional controls such as insufficient physical activity, smoking, alcohol disease, and air pollution.

Hospital malnutrition has been established as a critical, prevalent, and costly problem in many countries. Many cost studies are limited due to study population or cost data used. The aims of this study were to determine: the relationship between malnutrition and hospital costs; the influence of confounders on, and the drivers (medical or surgical patients or degree of malnutrition) of the relationship; and whether hospital reported cost data provide similar information to administrative data. To our knowledge, the last two goals have not been studied elsewhere.Univariate and multivariate analyses were performed on data from the Canadian Malnutrition Task Force prospective cohort study combined with administrative data from the Canadian Institute for Health Information. Subjective Global Assessment was used to assess the relationship between nutritional status and length of stay and hospital costs, controlling for health and demographic characteristics, for 956 patients admitted to medical and surgical wards in 18 hospitals across Canada.After controlling for patient and hospital characteristics, moderately malnourished patients' (34% of surveyed patients) hospital stays were 18% (p = 0.014) longer on average than well-nourished patients. Medical stays increased by 23% (p = 0.014), and surgical stays by 32% (p = 0.015). Costs were, on average, between 31% and 34% (p-values 0.05) higher than for well-nourished patients with similar characteristics. Severely malnourished patients (11% of surveyed patients) stayed 34% (p = 0.000) longer and had 38% (p = 0.003) higher total costs than well-nourished patients. They stayed 53% (p = 0.001) longer in medical beds and had 55% (p = 0.003) higher medical costs, on average. Trends were similar no matter the type of costing data used.Over 40% of patients were found to be malnourished (1/3 moderately and 1/10 severely). Malnourished patients had longer hospital stays and as a result cost more than well-nourished patients.

A plethora of literature links socioeconomic status (SES) to health and health care utilization. Recent anecdotal evidence indicates that Canadians believe their access to health care is diminishing. This study describes health care utilization patterns for services provided under public health insurance (physicians, specialists, and hospitals) in Canada between 1978 and 2003. The relationship between SES and utilization, controlling for health and demographic characteristics, is examined to investigate whether changes in the equity of utilization have occurred over time. Results indicate that SES inequities in utilization are apparent, appearing to be more relevant in initial contact with the system than in the number of visits. Specialists' services are particularly problematic and becoming more so over time.

OBJECTIVE: To determine the association of socio-economic (SES) factors with risk behaviours among adolescents. METHODS: A cross-sectional survey was carried out on students in four high schools in northern Nova Scotia, Canada. Associations between SES variables and substance use behaviours, having early intercourse and suicide attempt in the past year were examined using multivariate analysis (logit regression). Negative binomial regression was performed for associations of SES with a total risk score summing risk behaviours. RESULTS: Participants included 2,198 students (48% males; 52% females) ranging in age from 14 to 20 years. Almost 25% of youth smoked regularly, 19% of males smoked marijuana > or = 10 times monthly, more than 40% of males regularly drank excessively, and 10% of students > 14 years old had had intercourse before age 15. Smoking was the behaviour most often associated with lower SES in both genders. Mother's not being employed was protective against all substance use variables except driving after drinking. Living both with lone mother and in any family arrangement other than with both parents was associated with smoking, using marijuana, and early sex. Higher risk score was associated with living with a lone mother or other family arrangement. Lower risk score was associated with father having more than high school education and mother not working. INTERPRETATION: Lower socio-economic status is associated with adolescent risk behaviours. These findings point to the importance of these factors to risk-taking in youth, their relevance to social policy, and also their importance as factors to consider in targeted interventions. Language: en

In Canada's publicly funded health care system, policy is governed by the Canada Health Act whose primary objective is to “protect, promote, and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health care services without financial or other barriers” (Canada Health Act 1984, c.6, s.3). “Reasonable access,” while not explicitly defined by the Act, is generally assumed to have been achieved by the removal of the direct cost of health care at the point of delivery (Birch and Abelson 1993; Birch, Eyles, and Newbold 1993; Newbold, Eyles, and Birch 1995). A number of Canadian studies have examined access to general practitioner (GP) services in relation to income with conflicting results. While most conclude that there is no association between income and incidence of GP utilization when assessed over a 1-year period (Broyles et al. 1983; Birch, Eyles, and Newbold 1993; McIsaac, Goel, and Naylor 1997; Dunlop, Coyte, and McIsaac 2000; Finkelstein 2001), the association between income and volume of GP utilization is less clear. Several studies have reported an inverse association even after adjustment for need (Broyles et al. 1983; McIsaac, Goel, and Naylor 1997; Dunlop, Coyte, and McIsaac 2000), while others have reported no differential utilization by income level (Birch, Eyles, and Newbold 1993; Finkelstein 2001). In general, most studies that were unable to use direct measures to control for medical need found an expected inverse association between income and utilization of GP services (Roos and Mustard 1997; Kephart, Thomas, and MacLean 1998; Veugelers and Yip 2003); however, a recent study by Roos et al. (2004) observed lower than expected use of physician services among individuals from poorer neighborhoods. While the literature examining equity of access to GP services in Canada contains many studies of the relationship between income and access to physician services, comparatively little attention has been given to other potential barriers to access (Birch and Abelson 1993; Birch, Eyles, and Newbold 1993). It has been suggested that opportunity costs associated with attending medical appointments may render some individuals less likely to access care than others (Broyles et al. 1983; Birch, Eyles, and Newbold 1993). There are reasons to believe that employment-related opportunity costs may influence an individual's ability to access GP services. Because the ability to attend ambulatory medical appointments is time dependent, “time crunch” imposed by work may operate as a barrier to utilization (Boaz and Muller 1989) in that it reduces opportunities to access medical appointments (Nishiyama and Johnson 1997). Lost wages for time off work may also deter some workers from accessing care (Broyles et al. 1983; Boaz and Muller 1989). Studies of work hours and health have largely focused on the effect of long work hours on illness, injury, and health behavior (Caruso et al. 2004); however, the relationship between work hours and use of health care services has not been well studied. Only one qualitative study (Wellstood, Wilson, and Eyles 2006), and no quantitative studies were identified that have specifically assessed whether work hours act as a barrier to accessing GP services. The purpose of this study, therefore, was to examine the relationship between work hours and utilization of ambulatory GP services in order to assess the extent to which work hours may act as a barrier to access.