Saskatoon Health Region Research Articles

A retrospective study on incidence, diagnosis, and clinical outcome of gastric-type endocervical adenocarcinoma in a single institution

BackgroundGastric-type endocervical adenocarcinoma is rare but the most common subtype of cervical adenocarcinoma not associated with human papillomavirus. It is more aggressive with a shorter five-year survival rate compared to human papillomavirus-associated usual type endocervical adenocarcinoma. The objectives of our study were to determine the incidence and clinical-pathological characteristics of Gastric-type endocervical adenocarcinoma in a single institution.MethodsTwenty four cases of invasive cervical adenocarcinoma were identified between January 2000 and December 2015, from the Saskatoon Health Region pathology database using International Endocervical Adenocarcinoma Criteria and Classification to retrospectively classify endocervical adenocarcinoma. Immunohistochemistry was performed with antibodies for Gastric mucin-6 (MUC-6), p16INK4a, cyclin-dependent kinase inhibitor 2A (p16), p53 protein (p53), estrogen and progesterone receptors. Clinical and pathological data was retrieved from pathology reports and charts. Statistical analysis was performed using Mann-Whitney U test and Chi-Square test.ResultsUsing the International Endocervical Adenocarcinoma Criteria and Classification criteria, 19 cases (79.2%) were classified as human papillomavirus-associated usual type endocervical adenocarcinoma, and five cases (20.8%) as Gastric-type endocervical adenocarcinoma. In our study 40% of Gastric-type endocervical adenocarcinoma cases presented at stage III compared to none of the usual type endocervical carcinoma cases. All the Gastric-type endocervical adenocarcinoma cases were positive for MUC-6, and negative for p16. 60% Gastric-type endocervical adenocarcinoma cases demonstrated mutant type p53 staining. In contrast, 84.2% of human papillomavirus-associated usual type endocervical adenocarcinoma cases showed block like nuclear and cytoplasmic positivity with p16 antibodies. The Gastric-type endocervical adenocarcinoma group had significantly shorter median survival time than human papillomavirus-associated usual type endocervical adenocarcinoma group, Gastric-type endocervical adenocarcinoma is 22 months compared to human papillomavirus-associated usual type endocervical adenocarcinoma at 118 months (p = 0.043).ConclusionsIn this study, Gastric-type endocervical adenocarcinoma accounted for 20.8% of all cervical adenocarcinoma with higher stage at presentation and shorter overall survival. Criteria proposed by International Endocervical Adenocarcinoma Criteria and Classification (IECC) are simple and reproducible in differentiating between, HPV- associated (HPVA) and non HPV associated (NHPVA) endocervical adenocarcinoma. Although none of the IHC assays is specific for GAS, but p16, MUC-6, ER, PR and p53 may further aid in confirming GAS and to differentiate it from benign and malignant mimics.

Clinical microbiology laboratories and COVID-19: an interview with Joseph Blondeau.

This interview was conducted by Atiya Henry, Commissioning Editor of Future Microbiology.Joseph M Blondeau, MSc, PhD, RSM(CCM), SM(AAM), SM(ASCP), FCCP is a Clinical Microbiologist and Head of Clinical Microbiology at Royal University Hospital (Saskatoon Health Region) and the University of Saskatchewan in Saskatoon, Canada. He is also the Provincial Clinical Lead for Microbiology in Saskatchewan, Canada. He holds a Masters of Sciences in Microbiology from Dalhousie University (1985) and a Doctor of Philosophy in Medical Microbiology from the University of Manitoba (1989). Following completion of his PhD, he completed a 1 and a half year post-doctoral training in an infectious diseases research laboratory at Dalhousie University and following which he completed a 2 year post-doctoral residency training program in Clinical Microbiology, also at Dalhousie University. He holds appointments as a Clinical Associate Professor of Pathology, Adjunct Professor of Microbiology and Immunology and Clinical Associate Professor of Ophthalmology. He teaches to undergraduate and graduate students in the areas of microbiology, infectious diseases, antimicrobial agents and pharmacology. Dr Blondeau’s main research interests are in the area of antimicrobial agents and antimicrobial resistance, clinical microbiology and clinical outcomes associated with antimicrobial therapy in both human and veterinary medicine.

Impact of an emergency department opioid prescribing guideline on emergency physician behaviour and incidence of overdose in the Saskatoon Health Region: a retrospective pre-post implementation analysis.

Background:Deaths related to opioid overdoses are increasing in North America, with the emergency department being identified as a potential contributor toward this epidemic. Our goal was to determine whether a departmental guideline for the prescribing of restricted medications resulted in a reduction in opioids prescribed in a Canadian setting, with a secondary objective of determining the impact on local overdose frequency.Methods:We conducted a retrospective analysis of the prescribing habits of emergency department physicians in 3 hospitals in the Saskatoon Health Region, Saskatchewan, before (Nov. 1, 2015, to Apr. 30, 2016) and after (Nov. 1, 2016, to Apr. 30, 2017) implementation of a guideline in September 2016 for the prescribing of restricted medications. We quantified opioids prescribed per hour worked and per patient seen. We performed Student paired 2-tailed t tests for both individual drug formulations and the combined total morphine equivalents.Results:Thirty-two emergency department physicians were included. We found a decrease of 31.1% in opioids prescribed, from 10.36 morphine milligram equivalents (MME) per patient seen to 7.14 MME per patient seen (absolute change −3.22 MME, 95% confidence interval −4.81 to −1.63 MME). Over the same period, we found no change in prehospital naloxone use and a modest increase in the amount of naloxone dispensed by emergency department pharmacies. There was no decrease in the number of overdoses after guideline implementation.Interpretation:Implementation of a guideline for the prescribing of restricted medications in a Canadian emergency department setting was associated with a decrease in the quantity of opioids prescribed but not in the number of overdoses. This finding suggests that the emergency department is unlikely the source of opioids used in acute overdose, although emergency department opioid prescriptions cannot be ruled out as a risk factor for opioid use disorder.

Emergency department referrals from a provincial medical call centre: Is it more than just 1-800-go-to-emerg?

HealthLine is Saskatchewan's provincial 24-hour health information and support telephone line. A proportion of HealthLine's callers are referred to the emergency department (ED) for further assessment. The purpose of this study was to gain insight into the appropriateness of these referrals and assess whether they increased the burden on an already strained ED system. A list of callers referred from HealthLine to Saskatoon EDs from January 1, 2014, to March 31, 2014 was obtained. This list was cross-referenced with Saskatoon Health Region registration data to determine which of those callers had been registered in one of the three Saskatoon EDs within 48 hours of the original call. During the 90-day time period in question, 707/3,938 (17.9%) of callers were referred by HealthLine to the ED. Out of those referred, 601 were identifiable and 358 attended the ED. Hospital charts were pulled for full data extraction and analysis of the 276 who met inclusion criteria. Of those who presented to the ED and met inclusion criteria, 60% had investigations performed while 66% received some form of treatment. The overall admission rate for the patient population studied was 12.0% v. 16% for non-referred patients. Referred pediatric patients had fewer investigations and treatments with a lower admission rate compared with the adult patients. The Saskatchewan HealthLine is doing an effective job at directing callers both to and away from EDs in Saskatoon and not overburdening our local EDs with unnecessary referrals.

Qualitative exploration of the education and skill needs of community pharmacists in Saskatoon concerning substance use disorder.

Identifying the skills and educational needs of community pharmacists concerning addiction is critical to improving the services provided for people who suffer from addiction disease (PWSAD). Eleven one-to-one semi-structured interviews were conducted with community pharmacists practising in the Saskatoon Health Region, Canada. The interviews were recorded and transcribed verbatim and verified with the participants. Thematic analysis was employed to analyze the transcripts. Four major themes were identified: 1) effect of the work setting on pharmacists' encounters with PWSAD, 2) pharmacists' knowledge of key aspects of addiction, 3) level of support within the health care system, and 4) educational and training needs. Participants indicated that a lack of knowledge and training were major hindrances to improving the quality of the services provided to people who suffer from addiction disease. Additional practicum experience at the undergraduate level and interprofessional interactive educational sessions at the continuing educational level were key recommendations emerging from the study.

Saskatoon Urban Hospital Frozen Plasma Utilization and Appropriateness Audit

Plasma is a blood component frequently used in inappropriate clinical contexts. A 2013 frozen plasma utilization audit in Ontario found that 52% of orders for plasma were inappropriate, while plasma requested for appropriate indications was frequently under-dosed (less than 10 mL/kg administered). Local trends of plasma utilization have not previously been audited. We hypothesized that hospital sites within the former Saskatoon Health Region would have similar rates of inappropriate plasma transfusion and under-dosing as reported by other recent Canadian audits.This retrospective, quality improvement audit was completed evaluating transfused units of fresh frozen plasma and frozen plasma (collectively known as plasma), given between January and September 2017 at the two largest tertiary care hospitals in Saskatoon, Saskatchewan - Royal University Hospital (RUH) and St. Paul's Hospital (SPH). Data collected included: patient demographics, indication for plasma transfusion, plasma dose, coagulation parameters pre- and post-transfusion, specialty of ordering physician, location of transfusion, and concurrent vitamin K use.Appropriateness of plasma utilization was judged according to the Ontario Clinical Practice Recommendations for the Use of Frozen Plasma. Appropriate indications for plasma transfusion included: massive hemorrhage, intraoperative coagulopathy during cardiac surgery, and patients with active bleeding or need for invasive procedures with laboratory evidence of coagulopathy (INR [International Normalized Ratio] ≥ 1.5). Inappropriate indications for plasma transfusion included: correction of laboratory evidence of coagulopathy in the absence of bleeding or need for invasive procedures, reversal of warfarin when Prothrombin Complex Concentrate (PCC) was available, reversal of other anticoagulants, and an INR of 1.5 or less or for whom the INR was unknown. Plasma transfusion to patients with INR of 1.5 or less or with an unknown INR was not considered inappropriate in cases of massive hemorrhage. According to the predefined criteria, each plasma transfusion during our study period was individually reviewed and classified as appropriate or inappropriate.A total of 270 adult and pediatric patients received plasma transfusion during our study period. Patients receiving plasma for therapeutic plasma exchange were excluded. Final analysis included 244 patients, representing 392 transfusion events and 891 units of plasma. Among adult patients at RUH and SPH, 50.5% of plasma transfusions were judged to be inappropriate. The most common inappropriate indication in adult patients (26.5%) was plasma transfusion to patients with an INR of 1.5 or less, or for whom INR was not measured (6.3%). Despite availability of PCC, 5% of plasma orders for adults were for the reversal of warfarin. The average plasma dose ordered for adults was 2 units per transfusion event, which is unlikely to be an appropriate dose for an average sized adult. In adult patients, transfusion of plasma was requested primarily by: critical care physicians (28.6%), cardiac surgeons (16.0%), and general internists (15.3%). Among pediatric patients at RUH, 79.8% of plasma transfusions were judged to be inappropriate, with the most common inappropriate request in pediatric patients (38.5%) cited as hemodynamic support without coagulopathy or massive hemorrhage.Our study demonstrated that the rate of inappropriate plasma transfusion at two major Saskatoon urban hospital sites was similar to that recently published in Ontario. It is reassuring that plasma transfusion for warfarin reversal was found to be only 5%, suggesting broad awareness of PCC availability. Plasma transfused to adults was found to frequently be under-dosed, suggesting patients are being exposed to the potential risks of plasma transfusion with limited clinical benefit. These results highlight plasma transfusion utilization and appropriateness as an area of educational need among both adult and pediatric clinicians. Implementation of strategies including local clinical practice guidelines for plasma transfusion, plasma order screening by the transfusion medicine laboratory, or a plasma transfusion order set may optimize plasma utilization and enhance patient safety by reducing unnecessary patient exposure to plasma transfusion. DisclosuresNo relevant conflicts of interest to declare.

INCREASING BURDEN OF INFECTIVE ENDOCARDITIS IN SASKATOON HEALTH REGION

Infective Endocarditis (IE) is associated with significant morbidity and mortality. Recent studies suggested a very gradual increase in overall IE hospitalizations in Canada, of approximately 0.7 admissions per 10 million per month. However, we suspect that the burden of IE in Saskatchewan has increased more significantly over the past decade. In this study, we aim to quantify the burden of IE in the Saskatoon Health Region (SHR) over the past 10 years. We performed a retrospective analysis of all IE admissions between January 2006 and July 2017. In total, 621 individuals, representing 901 IE admissions, were identified. Over the period of our study, there was a dramatic increase in the total number of IE admissions (Figure 1, R2=0.871, p<0.0001). Even when controlled for changes in overall hospital admissions, this increase was highly significant (R2=0.781, p=0.0003). Inpatient length of stay on average was 23 days per admission (CI=21.6-24.4, p=0.05). Women represented 53% (CI=49.3-55.9%, p=0.05) of total admissions, much higher than previously reported national average. The in-hospital mortality rate was 21% (CI=17.9-24.5%, p=0.05). There was a trend towards higher mortality for men compared to women (24% vs 18% p=0.0676). Our study identifies an alarming increase in IE admissions over the past decade in the Saskatoon Health Region. This is significantly different from previously published Canadian data, and may be related to the prevalence of IVDU in our region. Furthermore, the proportion of female admissions is also significantly different from established literature, and deserves further investigation.

Can mental health related hospital visits be relied upon for suicide prevention?

IntroductionEven among people with mental disorders, relatively few die of suicide. However, a large proportion of people dying from suicide have seen a physician in the year before death. This raises the question whether focusing on hospital visits for suicide-related outcomes is a viable suicide prevention strategy.&#x0D; Objectives and ApproachOur objective was to examine whether a hospital visit for a mental disorder or prior suicide attempt preceded suicide death. We requested Saskatchewan’s provincial coroner for records of people dying of suicide in the Saskatoon Health Region catchment area for the years 2012 to 2016. The coroner’s list was linked with hospital and community mental health databases. Patient charts and medical abstracts in both settings were reviewed for risk factors.&#x0D; ResultsThere were 143 suicide deaths in the time period and the yearly incidence was higher in Saskatoon as compared with the national average. Only 38 percent were seen previously in any Saskatoon hospital for a mental disorder (11 percent for a self-harm diagnosis). The chart review confirmed several known psychological and social risk factors. Having a history of depression or psychosis and alcohol and/or drug use were common. Many decedents also had disadvantaged socio-economic backgrounds characterized by vulnerable housing and being on social assistance.&#x0D; Conclusion/ImplicationsWith only 38 percent of decedents being seen in hospital, community-based mental health care and data are important for suicide prevention. Suicide prevention efforts can be aided by facilitating the linkage of community and medical records to better track patients as they move between care settings.

Self-documentary in the emergency department: Perspectives on patients recording their own procedures.

Patients often bring their smartphones to the emergency department (ED) and want to record their procedures. There was no clear ED recording policy in the Saskatoon Health Region nor is there in the new Saskatchewan Health Authority. With limited literature on the subject, clinicians currently make the decision to allow/deny the request to record independently. The purpose of this study was to examine and compare patient and clinician perspectives concerning patients recording, in general, and recording their own procedures in the ED. Surveys were developed for patients and clinicians with respect to history and opinions about recording/being recorded. ED physicians and nurses, and patients&gt;17 years old who entered the ED with a laceration requiring stitches were recruited to participate; 110 patients and 156 staff responded. There was a significant difference between the proportion of patients (61.7% [66/107]) and clinicians (28.1% [41/146]) who believed that patients should be allowed to video record their procedure. There was also a significant difference between clinicians and patients with regard to audio recording, but not "selfies" (pictures). However, with no current policy, 47.8% (66/138) of clinicians said that they would allow videos if asked, with caveats about staff and patient privacy, prior consent, and procedure/patient care. Contrary to patients' views, clinicians were not in favour of allowing audio or video recordings in the ED. Concerns around consent, staff and patient privacy, and legal issues warrant the development of a detailed policy if the decision is made in favour of recording.

Evaluation of an enhanced recovery protocol on patients having radical cystectomy for bladder cancer.

Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care protocols that are designed to shorten recovery time and reduce complication rates.1,2 An ERAS protocol was implemented in the Saskatoon Health region for radical cystectomy patients in 2013. This study evaluates the safety and efficacy of the protocol for patients having radical cystectomy for bladder cancer. Length of stay, early in-hospital complication rates, 30-day readmission rates, age, and gender were collected for patients seen for bladder cancer requiring radical cystectomy in Saskatoon between January 2007 and December 2016. Of these patients, 176 were pre-ERAS implementation (control group) and 84 were post-ERAS implementation (experimental group). The data from each variable was compared between the groups using a Z-test. There was no significant difference in age or gender of patients between the groups. Average length of stay pre-ERAS was 14.25±14.57 days, which is significantly longer than the post-ERAS average of 10.91±8.56 days (p=0.043). There was no significant difference in 30-day readmission rate (19.87% pre-ERAS vs. 19.05% post-ERAS; p=0.873) or complication rate (51.7% pre-ERAS vs. 46.4% post-ERAS; p=0.425). The implementation of an ERAS protocol for radical cystectomy reduces length of stay, with no effect on early complication rates or 30-day readmission rates. This indicates that the protocol is safe for patients when compared to previous practices and is an effective means of reducing length of stay.

P030: Role of scribes in emergency care in the Saskatoon health region

Introduction: Increasingly, hospitals are adopting electronic charting systems. Recent literature suggests that physicians are spending roughly 2:1 hours on charting as compared to actual patient care raising questions as to whether manual electronic charting is the best use of scarce physician resources. To counter these effects, some hospitals have introduced scribes into their departments. A medical scribe is a person, or paraprofessional, who specializes in charting physician-patient encounters in real time. In this pilot study, we assessed the impact of having a scribe on the mental and physical fatigue, patient and healthcare-team engagement, and overall work satisfaction of emergency physicians at an urban emergency department (St. Paul’s Hospital, Saskatoon). Methods: Three research participants (emergency physicians) were recruited to the study. Each participant completed a typing test to determine typing skills. The student researcher then provided scribe services for each participant for two shifts. The scribe charted physician-patient interactions in real time and also completed order sets, wrote orders, imaging requisitions, and prescriptions. Physicians completed surveys after each shift with the scribe as well as after 2 shifts without a scribe (for a total of 12 shifts in the study, 6 with the intervention). Physicians were asked to rate their mental and physical fatigue, enjoyment of work, and impact on patient/team engagement on a 10-point Likert scale. Results from the questionnaires were analyzed to determine individual and group mean responses. Given the small sample size, no further statistical calculations were completed. Results: Typing test results (in words per minute) were as follows: Scribe 93, Physician A 64, Physician B 40, Physician C 25. In terms of both mental and physical fatigue post shift, all 3 participants recorded being less fatigued after working shifts with a scribe. Mean group scores were as follows: mental fatigue decreased by 33%, physical fatigue decreased by 23%. Physicians work enjoyment improved by 10%. Team and patient interaction did not seem impacted by the intervention. Conclusion: It appears that regardless of typing skills, all physician participants noted a measurable benefit from having a scribe on shift. This suggests that off-loading documentation to the scribe has a positive effect on mental and physical endurance. These results warrant further investigations.

Predictors of pertussis outbreak in urban and rural municipalities of Saskatchewan, Canada.

Increased numbers of pertussis cases in September 2015 led to the declaration of an outbreak in the Saskatoon Health Region (SHR). SHR (population approximately 350,000) is a geographic area in central Saskatchewan consisting of both urban and rural municipalities. The purpose of this study was to describe the epidemiology and identify possible predictors of the outbreak. Confirmed cases of pertussis in SHR from 2010 to 2015 were extracted from the integrated Public Health Information System (iPHIS) database. Univariate and bivariate analyses and a comparison of the two outbreaks were conducted. Poisson regression modelling was used to estimate incidence rate ratios (IRRs) of factors associated with pertussis infection. Two outbreaks between 2010 and 2015. Factors associated with the 2015 outbreak were residence in rural areas (IRR = 18.67, 95% CI 11.82-29.49; 11.37, 95% CI 6.40-20.21; and 6.31, 95% CI 3.43-11.62) for Humboldt, Watrous, and Rosthern areas, respectively, compared to the City of Saskatoon, and among children 11-14years of age (IRR = 3.11, 95% CI 1.67-5.79) compared to children under 5years of age. Unvaccinated persons had increased risk (IRR = 1.60, 95% CI 1.07-2.38). Multiple interventions, including enhanced contact tracing, supplemental immunization clinics, and cocooning, were employed in the 2015 outbreak. Pertussis is a cyclical disease with outbreaks occurring every 3 to 5years. Teenagers have increased risk of disease compared to younger children, likely due to waning immunity. Rural residents had a higher incidence of disease, possibly due to clusters of conscientious objectors. Control efforts require recognition of waning immunity and unvaccinated susceptibles.

Editorial introductions

Editorial introductions

Embedding Health Equity Strategically within Healthy Built Environments to Improve Walkability ( breakout presentation )

Background Population health promotion approaches have become increasingly focused in recent years on improving walkability in built environments. Communities, health sectors and public leaders alike have recognized that factors such as transportation networks and neighbourhood design have a significant impact on the physical activity levels and health of populations. Despite this attention on healthy built environments and walkability, health equity is often not an explicit strategic focus. Description of Program Recognizing the need for frameworks to prioritize, integrate, and measure health equity within built environments, Saskatoon Health Region Population and Public Health Services (SHR) has embedded health equity within this work. Aligning population-level approaches, a health equity focus, and the overarching goal of better health for all has positive impacts on walkability and other forms of active transportation through healthy built environments. With partners, SHR carried out a Health Equity Impact Assessment of the City of Saskatoon’s Growth Plan, focussing on the areas of active transportation, public transportation and growth along major corridors. This report highlighted the potential negative impacts that can be mitigated as well as the positive impacts that can be enhanced by incorporating health equity into the planning process. Outcomes Walkability, and active transportation overall, has many benefits, including improved health. It also can be a catalyst for building social capital, supporting economic development and providing economical means of supporting people of all income levels to move around their communities. Implications In order to foster better health for all, health equity must be at the forefront within a health promotion strategy, working in partnership with municipal governments and other partners. Deliberate and explicit planning is needed in order to integrate health equity into walkability and how communities are planned and built. Public Health can act as a partner in the work alongside municipalities, to help bring this perspective to facilitate physical and social environments for all to thrive.

Patient Education on an Inpatient Rehabilitation Unit

ABSTRACTThe Saskatoon Health Region Medical Library runs a patient education program on an inpatient rehabilitation unit. The program includes an online health information guide and patient education appointments for patients, family members, and caregivers. The program was volunteer-run from 2012 to 2015 and taken over by the Medical Library in 2015. It provides access to reliable health information to an average of 180 patients and their families, caregivers and friends each year. In 2016, the Medical Library conducted a survey of patients, family members, caregivers, and staff on the program. The survey results showed good support for the program, particularly from patients and family members, and also identified a number of areas of improvement. As a result of the survey, the Medical Library has made changes to how and when the patient education appointments are scheduled and conducted, as well as increased marketing of the program to staff. The program has encountered obstacles as a result of administrative changes, such as when the appointments can be scheduled and how patients are selected, which continue to be monitored and addressed. The Medical Library and rehabilitation unit are committed to continuing and growing the program going forward.

Cybervictimization among preadolescents in a community-based sample in Canada: Prevalence and predictors.

To examine the prevalence and predictors associated with cybervictimization among preadolescents in a community-based sample from Canada. Data were drawn from a cohort of 5783 students of grades 5-8, aged 9-14 from 109 elementary schools at the Saskatoon Health Region, Saskatchewan of Canada based on the Student Health Survey in the year of 2010-2011. Multivariate logistic regression with the generalized estimating equation was used to determine the individual and contextual factors associated with self-reported cybervictimization. Of the 5783 school children, 5611 (97.0%) responded to the question regarding cybervictimization. Among those respondents, 572 (10.2%) reported being cyberbullied at least once in the past four weeks. The students most likely to be victimized by cyberbullying were girls, students in grades 7 and 8 compared with grade 5, Aboriginal students compared to non-Aboriginal students, those who had lived part of their life outside of Canada compared with those who lived all of their life in Canada, those who reported drinking alcohol in the past, those who reported very elevated depressive symptoms, those who were traditionally bullied, those who had low self-esteem, and those who had a poor relationship with their parents. School-level variation in cyberbullying victimization is negligible. School neighbour-level deprivation is not significant after adjusting for individual-level characteristics and parent-child relationship. Our findings identified important characteristics of preadolescents with higher susceptibility to cybervictimization in a Canadian setting, which can be used to develop intervention strategies for mitigating cybervictimization among the study population.

Identifying superusers of health services with mental health and addiction problems

ABSTRACT&#x0D; ObjectiveThe objective of this research is to identify people with mental health and/or addiction (MHA) problems and determine characteristics that led to them becoming a superuser of health services (i.e., the most expensive 10% of all health service users).&#x0D; ApproachIn Saskatchewan, Canada, we used hospital and physician administrative data spanning 2005 to 2014 to identify the MHA cohort. We will calculate total health care costs for each individual and assign them to one of three groups: low cost users (&lt;50th percentile), moderate cost users (50-&lt;90th percentile), and superusers (90th percentile and above). For each group, we will describe sociodemographic characteristics, disease characteristics, and use of health services, and describe their trajectory towards becoming a superuser. Predictors of becoming a superuser will be identified. A novel aspect of this research is the inclusion of sociobehavioural risk factors by linking 4 population and public health administrative datasets obtained from the Saskatoon Health Region to the provincial administrative health services data. Sociobehavioral factors are widely accepted as strongly influencing health. Each database was selected because it captures data on a sociobehavioral factor. The Oral Health Database contains data on early childhood development, including early childhood tooth decay, dental health status, and tobacco use in elementary school-aged children. The Integrated Public Health Information System contains data on self-reported ethnicity, the occurrence of an infectious notifiable disease, and behavioural and social risk factors for the notifiable disease. The Sexually Transmitted Infection (STI) Clinic Data contains data on exposure to and contraction of STIs, as well as referrals given for mental health and/or addiction services. Finally, the Street Outreach Program provides services to individuals living a high-risk lifestyle on the street. Their database contains information on self-reported ethnicity, hypodermic needle exchange, and homelessness.&#x0D; ResultsIn a province of approximately 1.1 million people, we identified 417,724 people as having at least 1 MHA diagnosis, of which two-thirds were depression and/or anxiety. Substance abuse was found in 9.4%, and schizotypal and psychotic disorders were found in 7.9%, of the MHA cohort,&#x0D; ConclusionIndividuals with severe MHA problems account for a disproportionate amount of health care costs. Identifying predictors of becoming an MHA superuser may afford an opportunity to intervene, possibly years in the future, to prevent a person from becoming a superuser. If true, this has significant implications for health care costs, wait times to access health services, and quality of life for this vulnerable population.

Restaurant inspection frequency: The RestoFreq Study.

Foodborne illness is an important contributor to morbidity and health system costs in Canada. Using number of critical hazards as a proxy for food safety, we sought to better understand how to improve food safety in restaurants. We compared the current standard of annual inspections to twice-yearly inspections among restaurants "at risk" for food safety infractions. These were restaurants that had three or more elevated-risk inspection ratings in the preceding 36 months. We conducted a two-arm randomized controlled trial between November 2012 and October 2014. The intervention was twice-yearly routine restaurant inspection compared to standard once-yearly routine inspection. Included were all restaurants within Saskatoon Health Region that were assessed as "at risk", with 73 restaurants in the intervention arm and 78 in the control arm. Independent sample t-tests were conducted between groups to compare: i) average number of critical hazards per inspection; and ii) proportion of inspections resulting in a rating indicating an elevated hazard. Over time we noted statistically significant improvements across both study arms, in number of both critical food safety hazards (decreased by 61%) and elevated-risk inspection ratings (decreased by 45%) (p &lt; 0.0001). We observed no significant differences between the two groups pre- or post-intervention. Results suggest increasing the number of annual routine inspections in high-risk restaurants was not associated with a significant difference in measures of compliance with food safety regulations. Findings of this study do not provide evidence supporting increased frequency of restaurant inspection from annually to twice annually.

Expanding patient engagement in quality improvement and health system redesign: Three Canadian case studies.

Healthcare organizations face growing pressures to increase patient-centred care and to involve patients more in organizational decisions. Yet many providers worry that such involvement requires additional time and resources and do not see patients as capable of contributing meaningfully to decisions. This article discusses three efforts in four organizations to engage patients in quality improvement efforts. McGill University Health Centre, Saskatoon Health Region, and Vancouver Coastal and Fraser Health Regions all engaged patients in quality improvement and system redesign initiatives that were successful in improving care processes, outcomes, and patient experience measures. Patient involvement in redesigning care may provide a way to demonstrate the value of patients' experiences and inputs into problem-solving, building support for their involvement in other areas. Further study of these cases and a broader survey of organizational experiences with patient involvement may help elucidate the factors that support greater patient engagement.

Planning Adolescent Mental Health Promotion Programming in Saskatoon.

We assessed associations between key demographic risk factors and the outcome of depressed mood in Saskatoon, Saskatchewan, to inform the planning and implementation of mental health promotion programming in schools. In the 2008/2009 school year, 3958 students from grades 5 through 8 from 76 elementary schools completed questions regarding depressed mood on the Student Health Survey administered by the Saskatoon Health Region. The demographic risk factors for depressed mood considered in this study included age, sex, cultural status, and neighborhood income, as well as the role of school and age cohorts or grades within schools. We found Aboriginal students were significantly more likely to report moderate/severe depressed mood than other students. We also found older female adolescents were significantly more likely to report moderate/severe depressed mood. Neighborhood income explained the largest proportion (40%) of depressed mood differences between schools. These results can inform the planning and implementation of mental health promotion programming by the health sector in Saskatoon's elementary schools, including an appropriate balance between targeted and population-based interventions that address both the distal and proximal determinants of depressed mood in adolescents.