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PubMed1999

Do physicians assess lifestyle health risks during general medical examinations? A survey of general practitioners and obstetrician-gynecologists in Quebec.

BACKGROUND: In Canada several guidelines have been published for the screening of lifestyle health risks during general medical examinations. The authors sought to examine the extent to which such screening practices have been integrated into medical practice, to measure physicians' perceived level of difficulty in assessing these risks and to document physicians' evaluation of their formal medical training in lifestyle risk assessment. METHODS: An anonymous mail survey was conducted in 1995 in Quebec with a stratified random sample of 1086 general practitioners (GPs) and with all 241 obstetrician-gynecologists (Ob-Gyns). The authors evaluated the proportion of physicians who reported routine assessment (with 90% or more of their patients) of substance use, family violence and sexual history during general medical examinations of adult and adolescent patients; the proportion of those who find inquiring about these issues difficult; and the proportion of those who evaluated their medical training in lifestyle risk assessment as adequate or excellent. RESULTS: The overall response rate was 72.6%. Among adult patients, 82.2% of the GPs reported routinely assessing tobacco use, 67.2% alcohol consumption, 34.2% illicit drug use and 3.2% family violence; the corresponding proportions for assessment among adolescent patients were 77.1%, 61.8%, 52.9% and 5.6%. Comparatively fewer Ob-Gyns reported routinely assessing these issues (56.1%, 28.6%, 20.4% and 1.3% respectively among adults and 62.7%, 35.2%, 26.8% and 2.8% respectively among adolescents). In the area of sexual history, condom use was routinely assessed by more Ob-Gyns than GPs (47.0% v. 28.2%); however, the proportion of Ob-Gyns and GPs was equally low for assessing number of partners (24.8% and 23.1%), sexual orientation (18.8% and 16.9%) and STD risk (26.2% and 21.2%). The vast majority of GPs and Ob-Gyns reported finding it difficult to assess family violence (86.5% and 93.0%) and sexual abuse (92.7% and 92.4% respectively). Over 80% of the physicians felt that they had had adequate or excellent medical training in assessing risk behaviours for heart disease and STD risk. The proportion who felt this way about their training in screening for illicit drug use, family violence and sexual abuse ranged between 12.7% and 31.6%. INTERPRETATION: Although morbidity and mortality associated with smoking, alcohol consumption, illicit drug use, unsafe sexual practices, family violence and sexual abuse have been well documented, routine screening for these risk factors during general medical examinations has yet to be integrated into medical practice.

Adolescent↗
PubMed1999

[Respiratory resuscitation in Quebec. General aspects and implications of pneumologists in intensive care units in "New France"].

ICU set up is a complex framework in Québec. In this respect, quebecer and french systems are very different. Pulmonologists are one of the most committed sub-specialists in ICUs, either as consultant or as MD on duty. Amongst paramedics, respiratory therapists are essential members of the team. Invasive and noninvasive ventilations are commonly performed. Critical care teaching program and structures for developing and supporting clinical research activities are in place.

Cardiopulmonary Resuscitation↗
PubMedDate not supplied

Prevalence of neural tube defects in the province of Quebec, 1992.

A retrospective study of neural tube defects (NTDs) was carried out among elective terminations of pregnancies, stillbirths and live births to women residing in two regions of Quebec, in 1992. Primary data sources included the hospital administrative data system MEDECHO, stillborn and infant death certificates, and the list of patients seen at three spina bifida clinics. Hospital records were reviewed. A total of 30 NTD cases were identified. The prevalence rate was 1.41 per 1,000, indicating a three-fold reduction in frequency during the last three decades. All 17 cranial defects but only 5 of 13 spinal defects were diagnosed during pregnancy. Elective terminations were performed at an average gestation of 18 weeks (range 11 to 21 weeks). The MEDECHO file allows a complete identification of NTD cases, but diagnostic categories are not very specific and coding errors are present.

Abortion, Therapeutic↗
PubMed2000

Prevalence of anemia among James Bay Cree infants of northern Quebec.

BACKGROUND: Anemia is common among First Nation infants in Canada, often as a result of iron deficiency, which places them at risk for psychomotor impairment. Prevalence data are unavailable, and the risk factors are unknown. This study assessed the prevalence of anemia and associated risk factors among 9-month-old Cree infants in northern Quebec. METHODS: Between January 1995 and October 1998, 6 of 9 Cree villages in the James Bay region adopted a screening protocol for anemia in 9-month-old infants. Cross-sectional data were obtained from medical charts. The data for babies of very low birth weight and those with fever or infection were excluded. Among the 386 babies whose hemoglobin concentration was known, the type of milk consumed at the time of screening was known for 354. Associations between hemoglobin concentration and mean cell volume at 9 months, and milk type and weight gain since birth were analysed. RESULTS: The mean hemoglobin concentration of the 386 infants was 114.1 (standard deviation [SD] 10.6) g/L. The prevalence of anemia was 31.9% (95% confidence interval [CI] 27.2%-36.7%) with a hemoglobin cutoff value of 110 g/L, 17.6% 95% CI 13.9%-21.7%) with a cutoff value of 105 g/L, and 7.8% (95% CI 5.3%-10.9%) with a cutoff value of 100 g/L. Babies exclusively fed formula at 9 months had a higher mean hemoglobin concentration (118.5 [SD 9.9] g/L) than those exclusively fed breast milk (109.9 [SD 10.0] g/L), cow's milk (112.5 [SD 10.1] g/L) or more than one type of milk (112.0 [SD 10.8] g/L) (p < 0.05). Compared with formula, the odds ratio (OR) for anemia was 7.9 (95% CI 3.4-18.2) for breast milk, 5.0 (95% CI 2.0-12.7) for cow's milk and 5.2 (95% CI 1.9-14.6) for mixed milks. Infants fed formula and those fed cow's milk had significantly greater weight gains since birth, by 724 g and 624 g respectively, than breast-fed infants (p < 0.05). When milk type was controlled for, weight gain since birth was significantly associated with the presence of microcytic erythrocytes (OR comparing highest tertile of weight gain to lowest tertile 2.9, 95% CI 1.2-6.6). INTERPRETATION: Iron-deficiency anemia is highly prevalent among James Bay Cree infants. Measures to increase iron intake are required.

Analysis of Variance↗
PubMedDate not supplied

Comparison of midwifery care to medical care in hospitals in the Quebec pilot projects study: clinical indicators. L'Equipe dEvaluation des Projets-Pilotes Sages-Femmes.

The purpose of this study was to compare indicators of process and outcome of midwifery services provided in the Quebec pilot projects to those associated with standard hospital-based medical services. Women receiving each type of care (961 per group) were matched on the basis of socio-demographic characteristics and level of obstetrical risk. We found midwifery care to be associated with less obstetrical intervention and a reduction in selected indicators of maternal morbidity (caesarean section and severe perineal injury). For neonatal outcome indicators, midwifery care was associated with a mixture of benefits and risks: fewer babies with preterm birth and low birthweight, but a trend toward a higher stillbirth ratio and more frequent requirement for neonatal resuscitation. The study design does not permit to conclude that the associations were causal in nature. However, the high stillbirth rate observed in the group of women who were selected for midwife care raises concerns both regarding the appropriateness of the screening procedures for admission to such care and regarding the quality of care itself.

Adult↗
PubMedDate not supplied

Cost-effectiveness of midwifery services vs. medical services in Quebec. LEquipe dEvaluation des Projets-Pilotes Sages-Femmes.

This study compared the cost-effectiveness of midwife services provided in birth centres operating as pilot projects with current hospital-based medical services in the province of Quebec. One thousand midwives' clients were matched with 1,000 physicians' clients on the basis of socio-demographic characteristics and obstetrical risk. Direct costs for the prenatal, intrapartum and postpartum periods were estimated. Effectiveness was assessed on the basis of three clinical indicators and four indices related to the individualization of care as assessed by women. Results show that the costs of midwife services were barely lower than or equal to those of physician services, but cost-effectiveness ratios were to the advantage of the midwife group, except for one clinical indicator (neonatal ventilation). Overall, this study provides rational support for the process of legalizing midwifery in the province.

Birthing Centers↗
PubMedDate not supplied

Integration of midwives into the Quebec health care system. L'Equipe d'Evaluation des Projets-Pilotes Sages-Femmes.

This paper reports on one aspect of the evaluation of the midwifery pilot projects in Quebec: the identification of the professional and organizational factors, as well as the mode of integrating midwives into the maternity care system, that would promote the best outcomes and the autonomy of midwives. The research strategy involved a multiple-case study, in which each midwifery pilot project represented a case. Based on a qualitative approach, the study employed various sources of data: individual interviews and focus groups with key informants, site observations and analyses of written documents. Results show that midwives were poorly integrated into the health care system during the evaluation. Four main reasons were identified: lack of knowledge about the practice of midwifery on the part of other health care providers; deficiencies in the legal and organizational structure of the pilot projects; competition over professional territories; and gaps between the midwives' and other providers' professional cultures. Recommendations are provided to facilitate the integration of midwives into the health care system.

Attitude of Health Personnel↗
PubMed1999

Health technology assessment and the regulation of medical devices and procedures in Quebec. Synergy, collusion, or collision?

In this paper, we discuss the complex relationship between health technology assessment (HTA) and the regulation of medical devices and procedures. The relationship is first examined through a conceptual framework describing the itinerary from research to three levels of policy making: micro (standards of medical practice), meso (institutional rules), and macro (health policies). Four reports from the Quebec Health Technology Assessment Council (CETS) are used to illustrate how HTA activities can influence the regulatory mechanisms operating at each decision-making level. We then discuss the skillful balancing act required from HTA agencies to constantly negotiate the right distance from the regulatory process at which to operate. We propose that HTA agencies should not be incorporated into any regulatory, auditing, or monitoring process. Finally, the relationship between health technology assessment and health care reform is discussed. It is suggested that HTA activities will contribute most during the data-driven preparation and consolidation phases of a reform process. The fast pace of events and the political turmoil characteristic of the implementation phase provide a less receptive environment for HTA contributions.

Equipment and Supplies↗
PubMed2000

Spousal homicide and suicide in Quebec.

Domestic violence is a cause for major concern in psychiatry today, yet little is known about the amplitude and dynamics of spousal homicide and extended suicide. Within the jurisdiction of the Quebec Coroner's Office, the investigation files on all consecutive cases of deceased victims of intrafamilial violence occurring between 1991 and 1998 were reviewed. Using a validated checklist, a variety of variables were systematically collected and reviewed for descriptive analysis. Three hundred eighty-eight cases of death were studied. Of this sample, 145 cases (37.4%) concerned victims of conjugal homicide. Fifty-eight cases (40.01%) concerned victims whose homicidal spouses subsequently killed themselves. Suicidal offenders were more likely to be men, to be estranged from their spouse through separation, and, most often, to have used a firearm in the commission of the extended homicide-suicide. The majority of offenders suffered from clinical symptoms of depression. This study emphasizes the need to develop a detailed tool to assist coroners in the field and police investigators with the gathering of specific information that will be of use to clinical researchers.

Adult↗
PubMed2000

Patterns of amlodipine and felodipine use in an elderly Quebec population.

OBJECTIVES: To assess drug prescription patterns and medical resource consumption in an elderly population in Quebec receiving amlodipine or felodipine for the treatment of hypertension. PATIENTS AND METHODS: Sociodemographic, clinical and drug claim data for a random sample of hypertensive patients 65 years of age and older with at least one claim for amlodipine or felodipine between August 1, 1990 and August 31, 1997 were extracted from the Régie de l'assurance maladie du Québec (RAMQ) database. Patterns of prescription renewal, drug switch and compliance rates, and health care resource use were established for both an amlodipine and a felodipine group. Long term persistence on treatment was quantified by survival curve analysis. RESULTS: The amlodipine (5188 patients) and felodipine (2630 patients) groups were similar in terms of sex ratio (66.7% female) and age (mean 74 years). Average compliance rates for amlodipine patients (67.9%) were significantly higher than for felodipine patients (66.2%) (P<0.01), and switch rates were 5.4-fold higher in the latter group. Patients initiating treatment with felodipine had a 27% increased rate of discontinuation (relative risk 1.27) compared with the amlodipine patients. In addition, patients with at least one year of follow-up data were more likely to maintain amlodipine as part of their antihypertensive regimens than felodipine. After adjustment, medical resource consumption patterns were similar for both groups except for an increase in the number of specialist visits for the amlodipine treatment group. CONCLUSIONS: Patients who received amlodipine, either as a monotherapy or as part of a multitherapy regimen, were more compliant and persistent with their treatment than patients on felodipine. The data suggest that amlodipine may provide more effective long term hypertension control than felodipine, and that the two drugs are not therapeutically equivalent.

Aged↗
PubMed2001

Discharge prescriptions following admission for acute myocardial infarction at tertiary care and community hospitals in Quebec.

BACKGROUND: Many physicians are not adhering to the recommendations found in evidence-based guidelines for the treatment of acute myocardial infarction (AMI). Physicians who practise in tertiary care settings may show better adherence to guideline recommendations than physicians who practise in other settings. OBJECTIVE: To determine whether there is an association between the practice setting of admission for AMI and discharge prescriptions for cardiac drugs recommended in evidence-based guidelines. PATIENTS AND METHODS: Discharge prescription data from a prospective cohort of patients with AMI admitted at five tertiary care (n=250) and five community hospitals (n=331) in Quebec from December 1996 to November 1998 were examined. RESULTS: The proportions of patients who were prescribed recommended drugs at tertiary care hospitals compared with those at community hospitals were as follows: beta-blockers (78% versus 74%, respectively; 95% CI around the difference - 4% to 11%), lipid-lowering drugs (45% versus 39%, respectively; 95% CI - 2% to 15%) and angiotensin-converting enzyme (ACE) inhibitors (44% versus 57%, respectively; 95% CI - 22% to - 5%). In adjusted analyses, practice setting was not associated with the prescription of beta-blockers (odds ratio [OR] for tertiary care 1.36; 95% CI 0.82 to 2.24) or lipid-lowering drugs (OR for tertiary care 1.06; 95% CI 0.67 to 1.68). However, tertiary care admission reduced the likelihood of ACE inhibitor prescription (OR 0.50; 95% CI 0.32 to 0.77). This association may have been due to the increased likelihood of ACE inhibitor prescription for patients with hypertension at community hospitals (OR 2.13; 95% CI 1.23 to 3.67). The results also showed that older patients were less likely to be prescribed beta-blockers or lipid-lowering drugs, women were less likely to be prescribed beta-blockers and patients with diabetes mellitus were less likely to be prescribed lipid-lowering drugs (OR 0.45; 95% CI 0.23 to 0.89). CONCLUSION: No strong association was found between the practice setting of admission for AMI and discharge prescriptions for cardiac drugs recommended in evidence-based guidelines. Prescription rates for recommended drugs were high, yet results suggest that there is room for improvement with regard to patients with diabetes, women and older patients.

Adrenergic Antagonists↗
PubMedDate not supplied

Anemia and iron status in Inuit infants from northern Quebec.

The iron status and diet of Inuit infants living in northern Quebec who were part of a prospective cohort study was described. The prevalence of anemia (hemoglobin values > 2 SD below the reference mean) was 21.1% (23/109), 47.4% (55/116) and 37.7% (46/122) at 2, 6 and 12 months, respectively. The corresponding prevalence of microcytic anemia was 0.0%, 4.3% and 21.3%. At 2, 6 and 12 months, iron-deficiency anemia (serum ferritin < 10 micrograms/L coupled with anemia) was present in 1.3% (1/79), 24.4% (21/86) and 26.3% (25/95) of infants, respectively. Compared with breastfeeding, the odds ratio for iron deficiency (serum ferritin < 10 micrograms/L) for bottle-feeding with cows' milk or low iron formula was 3.02 (95% CI 1.25-7.27) at 6 months and 3.05 (95% CI 1.28-7.28) at 12 months. This study shows iron-deficiency anemia to be a problem in Inuit infants as young as 6 months old. Breastfed infants were better protected against iron deficiency than infants fed cow's milk or low-iron formula.

Anemia, Iron-Deficiency↗
PubMed2001

[Management systems of the quality of health care in Quebec hospitals].

OBJECTIVES: The aim of this study was to take stock of the development of quality management systems in the Quebec health care services. METHODS: The study relied on semi-guided interviews and on a documentary analysis. It concerned the structure and the activity of quality management in 4 Montreal university hospitals as well as on outside organizations dealing with quality of care. RESULTS: Quality management of the health care services is dealt with by council on health care accreditation and regional health and social services agencies. In hospitals, the quality of services is managed by structures created by the administration council and the top management: the piloting committee, the head of quality assurance, the executive committees and the multidisciplinary team or self-evaluation of the hospital, and development of plans for improvement. Other activities are management of complaints, users satisfaction evaluation and follow-up of indicators. CONCLUSIONS: This system of quality management of services is currently expanding. This change of paradigm leads to accepting the view of services users and to change quality management methods. Those methods have evolved from normative approach to a continuous quality improvement approach.

Consumer Behavior↗
PubMed2001

Global predictive real-time control of Quebec Urban Community's westerly sewer network.

Quebec Urban Community (QUC) has selected Global Predictive Real-Time Control (GP-RTC) as the most efficient approach to achieve environmental objectives defined by the Ministry of Environment. QUC wants to reduce combined sewer overflows (CSOs) frequency to the St Lawrence river to two events per summer period in order to reclaim the use of Jacques-Cartier Beach for recreational activities and sports of primary contact. QUC's control scheme is based on the Certainty Equivalent Control Open Loop Feedback (CEOLF) strategy which permits one to introduce, at each control period, updated measurements and meteorological predictions. A non-linear programming package is used to find the flow set points that minimise a multi-objective (cost) function, subjected to linear equality and inequality constraints representing the physical and operational constraints on the sewer network. Implementation of GP-RTC on QUC's westerly network was performed in the summer of 1999 and was operational by mid-August. Reductions in overflow volumes with GP-RTC compared to static control are attributed to the optimal use of two existing tunnels as retention facilities as well as the maximal use of the wastewater treatment plant (WWTP) capacity.

Computer Systems↗
PubMedDate not supplied

[Regulating the distribution of health professionals in Germany, Belgium, the United Kingdom, Quebec and the United states: monograph study].

The Province of Quebec and the United Kingdom have both a strong system of medical manpower regulation. Growth of the number of doctors--and consequently of health expenditures--is kept under control. Shortage of supply of health services increases the queuing process. In the two countries, the main problem is not how to curb health costs but to cope with the unmet demand. In Germany, the control of medical school intake is very weak. However, agreement of young doctors by the Sickness Fund is strictly controlled, the Fund having the right to close the list of "agreed physicians" in areas or specialties where doctor surplus is observed. In Belgium, a numerus clausus system is established very recently for medical school intake. In the USA, the health care system is traditionally regulated by the market forces. The strong increase of health expenditures during the recent decades has shifted the power from the medical profession to the paying bodies (HMO, MCO...) who are now supporting the emergence of new health personnels, less costly.

Belgium↗
PubMed1975

The Quebec health care system: its implication for medical education.

Since November 1, 1970, doctors in Quebec have been operating under a government-controlled compulsory and universal "fee-for-service" insurance plan. After a review of some characteristics of the new system, the author describes the impact of this social legislation on physicians' lives, control of health delivery costs, and various policy issues. He examines the implications of these changes for medical education. A qualitatively different kind of physician must be able to deal comfortably and effectively with a reality which includes: (a) the concept of "global medicine" and its social implications, (b) greater external control of costs and increased public concern with quality, (c) a new concept of the role of the hospital and its integration within the system, and (d) the concept of team care. Possible changes associated with the new system include a reevaluation of the criteria for a good clerkship, an acquisition of a new perspective on community health ecology, and a need to become an efficient team-worker.

Community Participation↗
PubMed2001

[Regionalization of rehabilitation services. Survey of users of a Quebec center].

OBJECTIVE: To understand the situation of and difficulties encountered by users of a supraregional rehabilitation institute when they are transferred from the institute to facilities in their own regions, and to discover how they address these difficulties. DESIGN: Qualitative descriptive study. SETTING: Regions in Quebec served by a physical rehabilitation institute (Institut de réadaptation en déficience physique de Québec). PARTICIPANTS: Thirty-nine people who used services at the institute and then sought rehabilitation in their own regions. METHOD: Telephone survey using a validated questionnaire with both open-ended and closed questions. MAIN FINDINGS: About 69% of users had difficulty obtaining adequate follow up in their regions; the regions lacked professionals with expertise; more efficient methods of communication are required; and physicians' role in providing continuity of care needs to be recognized. CONCLUSION: Providing continuity of care on a regional basis is a formidable challenge for the entire health and social services network, but ways of meeting this challenge are within reach.

Adolescent↗
PubMed2001

Completed suicides among the Inuit of northern Quebec, 1982-1996: a case-control study.

BACKGROUND: The rate of completed suicide among Inuit in Canada has been alarmingly high in recent years, and the suicide rate among Inuit in northern Quebec has increased since 1982. Our objectives were to describe the characteristics of Inuit people who died by suicide in Nunavik between 1982 and 1996, and to identify the antecedents and correlates of completed suicide. METHODS: We carried out a case-control study of 71 people who died by suicide between 1982 and 1996 and 71 population-based living control subjects matched for sex, community of residence and age within 1 year. Comprehensive medical charts were reviewed for data on sociodemographic characteristics, medical and psychiatric history, childhood separations and family history, and use of health care services. RESULTS: Most of the case subjects were single males aged 15 to 24 years. The two principal means of suicide were hanging (in 39 cases [54.9%]) and gunshot (in 21 cases [29.6%]). About 33% had been in contact with medical personnel in the month before their death. The case subjects were significantly more likely than the control subjects to have received a lifetime psychiatric diagnosis (one or more of depression, personality disorder or conduct disorder) (odds ratio [OR] 4.3 [95% confidence interval (CI) 1.2-15.2]) and to have had a history of psychiatric symptoms, disorder (including solvent sniffing) or treatment (OR 3.5 [95% CI 1.4-8.7]). The case subjects had experienced more severe types of nonpsychiatric illnesses and injuries than the control subjects (p = 0.04). The case subjects had more lifetime contacts with health care services than the control subjects (p = 0.01) and were more likely than the control subjects to have had contact with health care services in the year before death of the case subject (p = 0.03), even when psychiatric diagnoses were controlled for in conditional regression analysis (OR 1.02 [95% CI 1.01-1.04] and 5.0 [95% CI 1.07-23.7] respectively). INTERPRETATION: Since case subjects had frequent contact with health care services, frontline medical personnel may be in a position to identify people at risk for suicide.

Adolescent↗