Care In Quebec Research Articles

Specialized Adult Congenital Heart Care Saves Lives

For more than half a century, growing numbers of practitioners and clinician-scientists have created systems for and practiced healthcare delivery within centers of expertise for young and older adults with congenital heart disease (CHD). To date, this has been driven largely by energy, enthusiasm, and shared mission without supportive data demonstrating the benefit of such adult CHD (ACHD) care programs in the lives of patients and families served by this developing field. Now, for the first time, Mylotte and colleagues1 present in this issue of Circulation good evidence that there is a survival advantage to ACHD patients being cared for by ACHD specialists. This confirms what those working in this field had long assumed and hoped but to date could not substantiate. Article see p 1804 The authors used their own extensively validated, province-wide, administrative longitudinal database that has been highly effective in demonstrating the demography and epidemiology of ACHD care in Quebec, Canada, as a model for North America. Their study included data from 1990 to 2005. They performed an elegant combination of time-series analysis together with case-control studies that included year-dependent survival and center-dependent survival so as to determine mortality trends within a highly monitored and geographically stable group of adults with CHD. A number of important findings emerged. Specialized ACHD care was independently associated with reduced mortality. Among patients who died, just under half died of cardiovascular diseases. Other causes of death included neoplasms (≈18%), respiratory disease (≈9%), and diseases of other systems …

Introducing Volume 6 of London Journal of Primary Caer: community-oriented integrated care.

Introducing Volume 6 of London Journal of Primary Caer: community-oriented integrated care.

Abstract 82: Comparison of Outcomes by Type of Treatment for Patients with ST-Elevation Myocardial Infarction (STEMI) who presented to Hospitals without Percutaneous Coronary Intervention (PCI) Facilities in Quebec, Canada

BACKGROUND: Guidelines recommend that STEMI patients who present to non-PCI centers generally be treated with fibrinolysis instead of untimely transfer for primary PCI (i.e., first medical contact [FMC] to device ≥120 min). Little real-world evidence exists for this recommendation since transfer patients are often excluded from clinical registries. A provincial field evaluation of the whole system of STEMI care in Quebec (Canada) provided the opportunity to compare the effectiveness of different treatment modalities, including, importantly, inter-hospital transfer for primary PCI. METHODS: All STEMI patients who presented to non-PCI hospitals during two 6-month periods in 2006-7 and 2008-9 were identified (N=2623) and followed up to one year. Detailed information on patient risk factors and treatment delays was extracted from medical charts. We used a multivariate Cox proportional hazards model with time-dependent treatment modelling to assess the hazard ratio of death for 5 treatment modalities: on-site fibrinolysis without later transfer to a PCI center; on-site fibrinolysis with subsequent transfer; timely transfer for primary PCI; untimely transfer for primary PCI; no reperfusion therapy. RESULTS: Median FMC-to-device delay for transfer primary PCI patients was 131 min (interquartile range, IQR: 107-166) and only 29% had timely treatment. Median door-to-needle delay was 30 min (IQR: 20-48) with 70% being transferred, after fibrinolysis, to a PCI center (81% subsequently received PCI). Median time to transfer after fibrinolysis was 17.8 hours (IQR: 3.3-77.3). Compared with untimely transfer for primary PCI, the adjusted hazard ratio was 0.29 (95% CI: 0.15-0.56) for timely primary PCI transfer, 0.52 (95% CI: 0.29-0.95) for fibrinolysis with subsequent transfer, 1.18 (95% CI: 0.75-1.84) for fibrinolysis alone and 1.74 (95% CI: 1.31-2.31) for no reperfusion therapy. CONCLUSION: Timely treatment delay is associated with improved STEMI survival. These results also provide real-world evidence to support the guideline recommendation to prioritize on-site treatment with fibrinolysis (with consideration of subsequent transfer to a PCI center) over untimely transfer for primary PCI. Transfer to a PCI center after fibrinolysis mostly occurred the following day, suggesting that transfer need not necessarily be immediate.

Réformer le Financement des Services de Garde au Québec: Oui, mais Comment? (Reforming the Financing of Child Care in Quebec: Yes, but How?)

With a possible Quebec election fast approaching, funding for child care (and public services in general) may rise to the top of the policy agenda. In the study Reforming the Financing of Child Care in Quebec: Yes, but How? the authors analyze the impact of two proposals on the issue, and propose a third option for consideration. The third option would abolish direct subsidies and replace them with offsetting provincial tax credit for childcare expenses. This reform would achieve several objectives simultaneously. First, it would make the size of government assistance more transparent to families. Second, it would allow more effective selection and management of childcare costs. Thirdly, it would protect the income of poorer families (including single parents) and encourage mothers to participate in the labour force. Finally, this reform would increase significantly the participation of federal funding of child care in Quebec.

O3‐07‐02: Current change in Alzheimer's disease care in Quebec: From the proposed action plan to innovative approaches in family medicine groups (FMGs)

O3‐07‐02: Current change in Alzheimer's disease care in Quebec: From the proposed action plan to innovative approaches in family medicine groups (FMGs)

Abstract 195: The Importance Of Assessing Inter-regional Systems Of Healthcare In Patients With ST-Elevation Myocardial Infarction (STEMI): Examples From A Systematic Field Evaluation

BACKGROUND: INESSS is a government-funded independent body that aids in evidence-based policy-making. Its cardiology evaluation unit recently completed a second systematic province-wide field evaluation of STEMI care in Quebec during a 6-month period in 2008-2009 in collaboration with a committee of clinical experts. The main objectives were to improve STEMI care by: 1) providing individual feedback to hospitals; and 2) identifying problems related to systems of STEMI care through analysis of inter-regional data. METHODS: At least 3 clinicians and 2 administrators of each of the 80 participating hospitals received a portrait of STEMI care for the province, their region and their hospital. Individual report cards ranked the healthcare region and the hospital for 14 measures of care. For the inter-regional analyses, we examined characteristics of existing networks of STEMI care such as the corridors of service for transfers for primary percutaneous coronary intervention (PPCI). RESULTS: At the provincial level, 82% of treated patients (n=1608) received PPCI. The majority (61%, n=987) were transferred from a non-tertiary centre with a median door-in door-out delay of 51 minutes (min) (10-90th percentile: 26-135) and a median door-to-device delay of 112 min (75-209). Notably, the 2 healthcare regions with the greatest number of STEMI patients had among the lowest proportions of patients treated (whether with PPCI or fibrinolysis) within recommended delays (39% and 32%, respectively). One of these regions had 9 community hospitals and a single PPCI center that did not have cardiac surgery-on-site (SOS) while the other region had 11 community hospitals and 6 PCI centers (1 no SOS and 5 SOS). In the latter region, >60% of STEMI patients had a direct admission PPCI but 3/6 centers had a median door-to-device time >90 min and there was a large variation in center volume. Only 22% of STEMI patients transferred for PPCI had a door-to device ≤90 min and choice of PPCI center was often not geographically optimal. Two PPCI centers received <5 transfers for PPCI. In the region with a single noSOS PPCI center, 76% of patients were transferred for PPCI but this center treated only 20% of these patients, 80% being sent to one of 4 PPCI centers in neighbouring regions. Only 19% of the transferred patients were treated ≤90 min, the median delay being 111 min (82-181). Sub-optimal utilization of the noSOS PPCI center in this region was also indicated by the low prevalence of direct admission PPCI (21%) compared with 2 other regions that had a single PPCI center (42% and 48%, respectively). CONCLUSIONS: Our province-wide evaluation of STEMI care indicates that it is important to examine systems of care as well as in-hospital processes. In 2 poorly-performing but high-output regions of Quebec, transfer for PPCI was the predominant choice of treatment of the community hospitals despite long delays. Moreover, recourse to certain PPCI centers appeared to be sub-optimal for both direct admission PPCI and transfer for PPCI. Thus, to improve systems of STEMI care, healthcare organizers must identify ways to optimize both choice of reperfusion strategy and corridors of service.

Resettlement challenges faced by refugee claimant families in Montreal: lack of access to child care

ABSTRACTAdult refugee claimants experience several well‐documented post‐migratory challenges. Little is known about the resettlement process for refugee claimant families with children. This study reports on 75 open‐ended, in‐depth interviews with refugee claimant families in Montreal about their resettlement challenges and their proposed solutions to them. These interviews were conducted with 33 dyads and triads of children and parents attending a paediatric hospital. Experiences accessing formal and informal child care in Montreal were addressed. Subsequently, a comparative policy analysis was conducted on residency eligibility criteria for child care subsidization. Twenty‐eight out of 39 parents (73%) report a lack of informal or formal child care and 15 out of 33 families (39%) propose improving access to formal child care services. They describe a lack of informal child care as a result of reduced social networks, and affordability as a barrier to formal child care services. Refugee claimants are not eligible for subsidized child care in Quebec. A comparative policy analysis within Canada and comparable countries reveals that this situation is not unique to Quebec. However, most provinces and European countries offer child care subsidies to refugee claimants. Refugee claimants should qualify for child care subsidies. Social workers and community organizations should consider their clients' child care needs in designing programmes and services.

Primary Care Reform: Can Quebec’s Family Medicine Group Model Benefit from the Experience of Ontario’s Family Health Teams?

Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.

‘Professional Techs’: Machines, Technical Skills and Professional Aspirations in Hearing Prosthetics and Respiratory Care in Quebec, 1950-1990

In the sociology of professions, working with machines is often seen as an obstacle to professional aspirations. This is especially true in healthcare, where a sharp distinction between professionals and technicians has prevailed since the early 20th century. However, only a few studies have documented the meaning of machines and technical skills for healthcare technicians. The purpose of this article is to show how and why two groups of such technicians, hearing prosthetists and respiratory technicians, actually tried to reconcile the use of machines with professionalization projects. It concludes with considerations about what these stories tell us about the history of technical work, about the transformations of the healthcare work environment in the second half of 20th century, and about the place of technical skills in the system of professions.

What a difference a decade makes: Counting the benefits of investment in early childhood development in Quebec

What a difference a decade makes: Counting the benefits of investment in early childhood development in Quebec

Prior Victimization and Sexual and Contraceptive Self-Efficacy Among Adolescent Females Under Child Protective Services Care

Adolescent females under Child Protective Services care in Quebec, Canada (n = 328) completed a questionnaire designed to explore associations between prior victimization (childhood sexual abuse and four forms of dating violence) and four dimensions of sexual and contraceptive self-efficacy. Five MANCOVAs were performed. In each model, a victimization index served as the independent variable, four Contraceptive Self-Efficacy subscales as dependant variables, and age, age at first sexual intercourse, and lifetime number of sexual partners as covariates. Childhood sexual abuse was negatively associated with adolescent's perceived ability to communicate about her sexuality and contraceptive practices. Sexual coercion in dating relationships was negatively associated with the adolescent's perceived ability to communicate about her sexuality and contraception, her perceived control over her sexual activity, and her perceived control over her use of contraceptives in passionate situations. Sexual victimization was found to impair important aspects of adolescent females' sexual and contraceptive self-efficacy.

Child Care in Quebec

Five cycles of data from the Canadian National Longitudinal Survey of Children and Youth (1994/5–2002/3) were used to examine patterns of child care use in Quebec and the rest of Canada to explore the impact of Quebec’s implementation of universal child care. Rates of overall use as well as use of regulated (child care centre, family child care) and non-regulated care (sitter, nanny, relative, family child care) were examined for preschoolers aged 0–5 years in Quebec as compared to the other provinces and by family household income. Chi-square tests were used to examine significance of differences. Since the implementation of Quebec’s child care program, Quebec demonstrated substantial increases in child care use, particularly in the use of regulated care (from 10% prior to program compared to 30% by 2002) whereas the use of unregulated care did not demonstrate a significant increase in Quebec as compared to the other provinces (1994 to 2002). Furthermore, the use of regulated care by low-income families was greater in Quebec than elsewhere in Canada, although the greatest increase in use of regulated care was for children from high-income families. Findings suggest that since the introduction of Quebec’s universal child care program, there was an increase in the use of regulated child care for families of preschoolaged children in the province, although by 2002 Quebec had not achieved the coverage of universal child care programs attained by many European countries.

Towards Excellence in Asthma Management: Final Report of an Eight-Year Program Aimed at Reducing Care Gaps in Asthma Management in Quebec

Asthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or 'care gaps', in which all stakeholders of the health care system (including patients) are involved, was proposed. Several projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma-related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician-patient cohort, confirming the many care gaps in asthma management. Third, two series of peer-reviewed outcome studies, targeting high-risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed. Key observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners. Disease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.

On the Road and on their Own: Autonomy and giving in home health care in Quebec

The reorganization of health care in Quebec, as in the rest of Canada, has helped reinforce inequities based on gender, race, ethnic status, etc. in employment in this field. Home health care workers in Quebec, called auxiliaires, are mostly women, frequently immigrants, and often immigrant women of colour. Their jobs are low status and badly paid, yet auxiliaires express a high degree of attachment to the work and find it highly rewarding. We suggest this is largely due to the worker's mobility and physical distance from the institutions that employ them; this allows them considerable autonomy and gives them the freedom to provide service beyond the requirements of the job. Drawing on recent analyses of Mauss' notion of the gift, as well as Tronto and others, we look at ‘giving’ in home health care, and its implications for the workers. En el camino y estar solo: Autonomía y Regalando en el cuidado de salud en casa en Quebec La reorganización del sistema de salud en Québec, como en el resto de Canadá, ha ayudado reiterar las inigualdades de género, raíz, etnicidad, etcétera, en el empleo de salud. La mayoría de los trabajadores de salud en Québec—que se llaman ‘auxiliaires’—son mujeres y muchas veces inmigrantes y además, mujeres inmigrantes de color. Su trabajo se considera como estatus inferior y tiene salario bajo, sin embargo ‘auxiliaires’ declaran un apego significativo al trabajo y lo encuentran gratificante. Sugerimos que el apego y gratificación se resultan de la movilidad de las trabajadoras y sus distantes físicos de la institución; ésta situación las permite una autonomía considerable y como consecuencia tienen ellas la libertad para proveer asistencia por encima de los requisitos del trabajo. Usando unos análisis recientes de la noción del regalo de Gauss, además de Tronto y otros, examinamos ‘regalar’ en el cuidado de salud en casa y las implicaciones para las trabajadoras.

Universal Child Care, Maternal Labor Supply, and Family Well‐Being

We analyze the introduction of highly subsidized, universally accessible child care in Quebec, addressing the impact on child care utilization, maternal labor supply, and family well‐being. We find strong evidence of a shift into new child care use, although some crowding out of existing arrangements is evident. Maternal labor supply increases significantly. Finally, the evidence suggests that children are worse off by measures ranging from aggression to motor and social skills to illness. We also uncover evidence that the new child care program led to more hostile, less consistent parenting, worse parental health, and lower‐quality parental relationships.

On reading a government document: When will we finally achieve the true organization of paediatric care in Quebec?

At the end of fall 2004, the Association of Pediatricians received a request to express its opinion on the organization of mental care as put forward by the Ministere de la Sante et des Services sociaux (MSSS). Finally! Our opinion was being asked, which had to be a first, and, in addition, it was our opinion on the organization of a very sensitive area that is affecting us more and more closely. We said to ourselves that this was real progress, even though the document was more than 60 pages long and arrived on December 22 by e-mail. We had to believe that MSSS employees did not celebrate Christmas and, obviously, did not pull extra duty during that period! However, that was incidental because, for once, someone thought that paediatricians could contribute something in this area. There was no question of missing the opportunity we were being given. Our opinion had to be produced by the end of January 2005 and presented to a committee, headed up by a psychiatrist. Because the invitation came from Dr Michel Bureau of the MSSS, we believed that our opinion would have a definite impact. So, to work! After the first read-through, we thought that perhaps we had gone a bit too quickly because there wasn’t a single mention of paediatricians in the text – not one word. We read it again, and again, and then had to face the truth: the text distinguished itself by a total lack of recognition of what paediatricians do for the mental health of children in Quebec. First-line care is mentioned – detecting adjustment difficulties that can be assessed and treated by the Centres locaux de services communautaires experts. Second-line care will be the purview of general practitioners trained in psychiatry and supported by it and, finally, there is the referral to child psychiatry, which results from this second line only, to the exclusion of any other caregiver!

Less money, less care: How nurses in long‐term care allocate hours of needed care in a context of chronic shortage

The average funding of long-term care in Quebec, Canada, currently covers < 70% of the care hours required, which means that 30% of needs are unmet. The aims of this study were to understand how nurses, when they are in a position to do so, assign care hours, which needs are unmet by care dimensions and whether dimensions with unmet needs vary with client profiles. One-hundred-and-four nurses working in long-term care facilities participated in the study. They filled out individual questionnaires containing three case studies in the form of vignettes. When obliged to cut 30% of the care hours, the nurses ensured that treatment and diagnostic methods were done as prescribed and that vital feeding and elimination functions were preserved. However, they made the choice to cut some mobility and personal-care activities and, especially, communication with patients, families and other professionals. In this, they partly follow the theoretical care prioritization approach of Lefebvre and Dupuis, who take into account the degree of discomfort caused by the situation, the problem's place in Maslow's hierarchy of needs and the availability of a solution. Thus, although the choices made by the nurses follow a logical pattern, they could result in medium-term deterioration in the functional autonomy of their older patients. The overall consequences of these decisions are discussed.

Implementation of a trauma care system: evolution through evaluation.

The regionalization of trauma services has been implemented in many health care systems and communities over the past 10 to 20 years. As these trauma systems mature and evolve, changes are made to improve the care and efficiency of the system. Trauma care regionalization was introduced in Quebec in 1993. This study looked at the evolution of trauma care in Quebec over the past 13 years, from the preregionalization era to the present. A retrospective review scientifically evaluated a trauma system, the implementation of evidence-based changes, and the efficacy of these changes. Various changes have been made in the Quebec trauma system since the introduction of regionalization. These changes have led to an incremental decrease in mortality caused by severe trauma from 51.8% in 1992 to 8.6% in 2002. A trauma system is fluid and constantly evolving. Research and constant reevaluation are necessary for continuous evaluation of the system and improvement of its outcomes and efficiency.

Are mental health services for children distributed according to needs?

The purpose of this study was twofold: 1) to determine whether publicly funded mental health services and resources available in 4 large regions in the province of Quebec were distributed according to the mental health needs of children aged 6 to 14 years and 2) to assess whether the variations in mental health services and resources across the 4 regions had changed over a 5-year period. Indicators of need according to the child's parent (presence of mental disorder, measure of adaptation, and perception of need for help) from an epidemiologic survey of 2400 noninstitutionalized children were compared with both in-school and community professional resources and with physician and hospital services in 1992-1993. Resource and service data were also collected for 1997-1998. Resource and service data came from professional colleges and government administrative databases. No significant regional differences were found for need indicators, but there were large discrepancies in mental health resources and services in 1992-1993. Differences in professional resources were largest for special education teachers in the school system and for psychiatrists in the community. The regional differences in resources and services were as large in 1997-1998 as they were in 1992-1993. Despite universal health care in Quebec and a government mental health policy stressing equity of access, the available mental health resources for children aged 6 to 14 years are not distributed across regions according to needs. More evidence-based planning is required, specifically using epidemiologic survey data, to match resources to needs and to monitor changes over time.

La transformation du rôle des instances régionales dans le système de santé au Québec -Le cas de Montréal-Centre

&lt;i&gt;The Transformation of the Role of Regional Authorities in the Quebec Health Service. The Case of Regional Government Control in Montreal-Centre &lt;/i&gt; The System of health care in Quebec has undergone important changes since its reform in 1991. The reform was carried out within a legislative framework and with regard to particular political and administrative traditions. With the objective of curbing expenditure on health care, securing equal access to services and maintaining the political means for redistribution of collective resources, the reform is an attempt at compromise between a technocratie desire to maintain control over the System and a discourse of decentralisation.