Open Medicine

Description

  • ISSN
    1911-2092

Publications in this journal

  • Article: Inclusion of persons with mental illness in patient-centred medical homes: cross-sectional findings from Ontario, Canada
    Leah S Steele, Anna Durbin, Lyn M Sibley, Richard Glazier
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    ABSTRACT: Background: In Ontario, Canada, the patient-centred medical home is a model of primary care delivery that includes 3 model types of interest for this study: enhanced fee-for-service, blended capitation, and team-based blended capitation. All 3 models involve rostering of patients and have similar practice requirements but differ in method of physician reimbursement, with the blended capitation models incorporating adjustments for age and sex, but not case mix, of rostered patients. We evaluated the extent to which persons with mental illness were included in physicians’ total practices (as rostered and non-rostered patients) and were included on physicians’ rosters across types of medical homes in Ontario. Methods: Using population-based administrative data, we considered 3 groups of patients: those with psychotic or bipolar diagnoses, those with other mental health diagnoses, and those with no mental health diagnoses. We modelled the prevalence of mental health diagnoses and the proportion of patients with such diagnoses who were rostered across the 3 medical home model types, controlling for demographic characteristics and case mix. Results: Compared with enhanced fee-for-service practices, and relative to patients without mental illness, the proportions of patients with psychosis or bipolar disorders were not different in blended capitation and team-based blended capitation practices (rate ratio [RR] 0.91, 95% confidence interval [CI] 0.82–1.01; RR 1.06, 95% CI 0.96–1.17, respectively). However, there were fewer patients with other mental illnesses (RR 0.94, 95% CI 0.90–0.99; RR 0.89, 95% CI 0.85–0.94, respectively). Compared with expected proportions, practices based on both capitation models were significantly less likely than enhanced fee-for-service practices to roster patients with psychosis or bipolar disorders (for blended capitation, RR 0.92, 95% CI 0.90–0.93; for team-based capitation, RR 0.92, 95% CI 0.88–0.93) and also patients with other mental illnesses (for blended capitation, RR 0.94, 95% CI 0.92–0.95; for team-based capitation, RR 0.93, 95% CI 0.92–0.94). Interpretation: Persons with mental illness were under-represented in the rosters of Ontario’s capitation-based medical homes. These findings suggest a need to direct attention to the incentive structure for including patients with mental illness.
    Open Medicine 01/2013; 7(1).
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    Article: Reviewing the medical literature: five notable articles in general internal medicine from 2010 and 2011.
    Alexander A Leung, Carl van Walraven
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    ABSTRACT: Although the ongoing information explosion within medicine is indisputably beneficial, it is difficult to stay abreast of the large volume of new information being published in the peer-reviewed and grey literature. Practical strategies to organize the swelling tide of medical literature are essential for providers to recognize and incorporate new information into their practice. One strategy for managing new information is the traditional annual review, in which selected, appraised articles are presented for general consumption. Here, we present five notable articles for general internal medicine published from 1 Sept. 2010 to 31 Aug. 2011, with focused summaries of their key findings and supporting clinical vignettes to highlight their significance.
    Open Medicine 01/2012; 6(1):e17-23.
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    Article: Rare diseases: Canada's "research orphans".
    Samir Gupta
    Open Medicine 01/2012; 6(1):e23-7.
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    Article: Retention of specialist physicians in Newfoundland and Labrador.
    Patrick Fleming, Maria Mathews
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    ABSTRACT: Although specialist physicians comprise nearly half of the physician workforce in Newfoundland and Labrador (NL), relatively little is known about their retention patterns. We compared 2 cohorts of physicians who were initially licensed to practise in NL between 1993 and 1997 and between 2000 and 2004, to examine whether retention had changed over time. Additionally, we examined the retention of 4 groups of physicians in each cohort: (1) fully licensed medical graduates of Memorial University, (2) fully licensed medical graduates of other Canadian universities, (3) provisionally licensed international medical graduates (IMGs) and (4) fully licensed IMGs. Provisional licences allow physicians who have not received Canadian certification to practise while obtaining credentials. We hypothesized that fully licensed physicians (largely physicians who are locally trained) would remain in NL longer than provisionally licensed physicians (largely IMGs). Using data from the provincial medical registrar and Memorial University's office of postgraduate medical education, we used survival analysis (Cox regression) to compare the retention of the 2 cohorts and the 4 groups of physicians within each cohort. After 48 months, roughly 60% of the physicians in the 2000-04 cohort and 45% of the physicians in the 1993-97 cohort remained in NL. Medical graduates of Memorial University comprised 61/180 (33.9%) of the 2000-04 cohort and 38/211 (18.0%) of the 1993-97 cohort.Physicians in the 2000-04 cohort were 1.6 (95% confidence interval [CI] 1.23-2.08) times less likely to leave NL than physicians in the 1993-97 cohort. In the 2000-04 cohort, medical graduates of Canadian universities, provisionally licensed IMGs and fully licensed IMGs were 3.19 (95% CI 1.47-6.89), 1.85 (95% CI 1.09-3.17) and 4.39 (95% CI 1.91-10.10) times more likely to leave NL than medical graduates of Memorial University. In the 1993-97 cohort, IMGs with provisional licences were 2.16 (95% CI 1.37-3.42) times more likely to leave NL than medical graduates of Memorial University. There was no significant difference in retention between medical graduates of Memorial University and other Canadian universities or IMGs with full licences in the 1993-97 cohort. The improvement in the retention of specialist physicians in NL since the 1990s may be attributable to the increase in the relative proportion of medical graduates of Memorial University. Although provisional licensing enables IMGs to begin practice in NL, it does not lead to long-term retention.
    Open Medicine 01/2012; 6(1):e1-9.
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    Article: The effectiveness and safety of emergency department short stay units: a rapid review.
    Kristin J Konnyu, Edmund Kwok, Becky Skidmore, David Moher
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    ABSTRACT: Emergency department overcrowding is a serious and ongoing issue across Canada. Short stay units (SSUs) have emerged as a potentially useful strategy for managing overcrowding in emergency departments. Members of The Ottawa Hospital senior management team contemplating the introduction of an SSU to help alleviate emergency department overcrowding approached our rapid response service to conduct a rapid review on the safety and effectiveness of SSUs. This paper presents the process for conducting this review, its findings, and the end-user report generated for the senior management team and other stakeholders.
    Open Medicine 01/2012; 6(1):e10-6.
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    Article: Improving community health and safety in Canada through evidence-based policies on illegal drugs.
    Evan Wood, Moira McKinnon, Robert Strang, Perry R Kendall
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    ABSTRACT: Illegal drug use remains a serious threat to community health in Canada, yet there has been a remarkable discordance between scientific evidence and policy in this area, with most resources going to drug use prevention and drug law enforcement activities that have proven ineffective. Conversely, evidence-based drug treatment programs have been chronically underfunded, despite their cost-effectiveness. Similarly, various harm reduction strategies, such as needle exchange, supervised injecting programs and opioid substitution therapy, have also proven effective at reducing drug-related harm but receive limited government support. Accordingly, Canadian society would greatly benefit from reorienting its drug policies on addiction, with consideration of addiction as a health issue, rather than primarily a criminal justice issue. In this context, and in light of the simple reality that drug prohibition has not effectively reduced the availability of most illegal drugs and has instead contributed to a vast criminal enterprise and related violence, among other harms, alternatives should be prioritized for evaluation.
    Open Medicine 01/2012; 6(1):e35-40.
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    Article: Appreciating the medical literature: five notable articles in general internal medicine from 2009 and 2010.
    Alexander A Leung, William A Ghali
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    ABSTRACT: The advent of clinical trials and evidence-informed medicine has resulted in a vast wealth of medical literature. Here, we summarize five notable articles for general internal medicine published in late 2009 and in 2010, and reflect on the remarkable advances made by an increasingly prolific medical research community.
    Open Medicine 01/2011; 5(1):e49-54.
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    Article: Freedom to be altruistic: allowing for risk/knowledge ratios in decisions concerning multiple sclerosis research.
    Kenneth Arenson
    Open Medicine 01/2011; 5(1):e26-7.
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    Article: Second-line therapy in patients with type 2 diabetes inadequately controlled with metformin monotherapy: a systematic review and mixed-treatment comparison meta-analysis.
    Brendan McIntosh, Chris Cameron, Sumeet R Singh, Changhua Yu, Tarun Ahuja, Nicky J Welton, Marshall Dahl
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    ABSTRACT: Although there is general agreement that metformin should be used as first-line pharmacotherapy in patients with type 2 diabetes, uncertainty remains regarding the choice of second-line therapy once metformin is no longer effective. We conducted a systematic review and meta-analysis to assess the comparative safety and efficacy of all available classes of antihyperglycemic therapies in patients with type 2 diabetes inadequately controlled on metformin monotherapy. MEDLINE, EMBASE, BIOSIS Previews, PubMed and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials published in English from 1980 to October 2009. Additional citations were obtained from grey literature and conference proceedings and through stakeholder feedback. Two reviewers independently selected studies, extracted data and assessed risk of bias. Key outcomes of interest were hemoglobin A1c, body weight, hypoglycemia, quality of life, long-term diabetes-related complications, serious adverse drug events and mortality. Mixed-treatment comparison and pairwise meta-analyses were conducted to pool trial results, when appropriate. We identified 49 active and non-active controlled randomized trials that compared 2 or more of the following classes of antihyperglycemic agents and weight-loss agents: sulfonylureas, meglitinides, thiazolidinediones (TZDs), dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogues, insulins, alpha-glucosidase inhibitors, sibutramine and orlistat. All classes of second-line antihyperglycemic therapies achieved clinically meaningful reductions in hemoglobin A1c (0.6% to 1.0%). No significant differences were found between classes. Insulins and insulin secretagogues were associated with significantly more events of overall hypoglycemia than the other agents, but severe hypoglycemia was rarely observed. An increase in body weight was observed with the majority of second-line therapies (1.8 to 3.0 kg), the exceptions being DPP-4 inhibitors, alpha-glucosidase inhibitors and GLP-1 analogues (0.6 to -1.8 kg). There were insufficient data available for diabetes complications, mortality or quality of life. DPP-4 inhibitors and GLP-1 analogues achieved improvements in glycemic control similar to those of other second-line therapies, although they may have modest benefits in terms of weight gain and overall hypoglycemia. Further long-term trials of adequate power are required to determine whether newer drug classes differ from older agents in terms of clinically meaningful outcomes.
    Open Medicine 01/2011; 5(1):e35-48.
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    Article: Personal music players and hearing loss: are we deaf to the risks?
    Kapil Khatter
    Open Medicine 01/2011; 5(3):e137-8.
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    Article: Unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm.
    Andrea Gruneir, Irfan A Dhalla, Carl van Walraven, Hadas D Fischer, Ximena Camacho, Paula A Rochon, Geoffrey M Anderson
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    ABSTRACT: Unplanned hospital readmissions are common, expensive and often preventable. Strategies designed to reduce readmissions should target patients at high risk. The purpose of this study was to describe medical patients identified using a recently published and validated algorithm (the LACE index) as being at high risk for readmission and to examine their actual hospital readmission rates. We used population-based administrative data to identify adult medical patients discharged alive from 6 hospitals in Toronto, Canada, during 2007. A LACE index score of 10 or higher was used to identify patients at high risk for readmission. We described patient and hospitalization characteristics among both the high-risk and low-risk groups as well as the 30-day readmission rates. Of 26 045 patients, 12.6% were readmitted to hospital within 30 days and 20.9% were readmitted within 90 days of discharge. High-risk patients (LACE ≥ 10) accounted for 34.0% of the sample but 51.7% of the patients who were readmitted within 30 days. High-risk patients were readmitted with twice the frequency as other patients, had longer lengths of stay and were more likely to die during the readmission. Using a LACE index score of 10, we identified patients with a high rate of readmission who may benefit from improved post-discharge care. Our findings suggest that the LACE index is a potentially useful tool for decision-makers interested in identifying appropriate patients for post-discharge interventions.
    Open Medicine 01/2011; 5(2):e104-11.
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    Article: The characteristics of physicians disciplined by professional colleges in Canada.
    Asim Alam, Jason Klemensberg, Joshua Griesman, Chaim M Bell
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    ABSTRACT: The identification of health care professionals who are incompetent, impaired, uncaring or have criminal intent has received increasing attention in recent years. These individuals are often subject to disciplinary action by professional licensing authorities. To date, no national data exist for Canadian physicians disciplined for professional misconduct. We sought to describe the characteristics of physicians disciplined by Canadian professional licensing authorities. We constructed a database of physicians disciplined by provincial licensing authorities during the years 2000 to 2009. Comparisons were made with the general population of physicians licensed in Canada. Data on demographic characteristics, type of misconduct and penalty imposed were collected for each disciplined physician. A total of 606 identifiable physicians were disciplined by their professional college during the years 2000 to 2009. The proportion of licensed physicians who were disciplined in a given year ranged from 0.06% to 0.11%. Fifty-one of the disciplined physicians committed 64 repeat offences, accounting for a total of 113 (19%) offences. Most of the disciplined physicians were independent practitioners (99%), male (92%) and trained in Canada (67%). The most common specialties of physicians subject to disciplinary action were family medicine (62%), psychiatry (14%) and surgery (9%). For disciplined physicians, the average number of years from medical school graduation to disciplinary action was 28.9 (standard deviation [SD] = 11.3). The 3 most frequent violations were sexual misconduct (20%), failure to meet a standard of care (19%) and unprofessional conduct (16%). The 3 most frequently imposed penalties were fines (27%), suspensions (19%) and formal reprimands (18%). A small proportion of registered physicians in Canada were disciplined by their medical licensing authorities. Sexual misconduct was the most common disciplined offence. The standardization of provincial reporting along with the creation of a national database of physician offenders would facilitate more comparable public reporting as well as further research and educational initiatives.
    Open Medicine 01/2011; 5(4):e166-72.
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    Article: The effect of a biofeedback-based stress management tool on physician stress: a randomized controlled clinical trial.
    Jane B Lemaire, Jean E Wallace, Adriane M Lewin, Jill de Grood, Jeffrey P Schaefer
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    ABSTRACT: Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations. To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress. Randomized controlled trial measuring efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness. Urban tertiary care hospital. Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians' lounge and throughout the hospital. Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team. Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200). During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change -14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change -2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change -8.5, SD 7.6; p < 0.001). A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.
    Open Medicine 01/2011; 5(4):e154-63.
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    Article: Collaborative authoring: a case study of the use of a wiki as a tool to keep systematic reviews up to date.
    Jacqueline L Bender, Laura A O'Grady, Amol Deshpande, Andrea A Cortinois, Luis Saffie, Don Husereau, Alejandro R Jadad
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    ABSTRACT: Systematic reviews are recognized as the most effective means of summarizing research evidence. However, they are limited by the time and effort required to keep them up to date. Wikis present a unique opportunity to facilitate collaboration among many authors. The purpose of this study was to examine the use of a wiki as an online collaborative tool for the updating of a type of systematic review known as a scoping review. An existing peer-reviewed scoping review on asynchronous telehealth was previously published on an open, publicly available wiki. Log file analysis, user questionnaires and content analysis were used to collect descriptive and evaluative data on the use of the site from 9 June 2009 to 10 April 2010. Blog postings from referring sites were also analyzed. During the 10-month study period, there were a total of 1222 visits to the site, 3996 page views and 875 unique visitors from around the globe. Five unique visitors (0.6% of the total number of visitors) submitted a total of 6 contributions to the site: 3 contributions were made to the article itself, and 3 to the discussion pages. None of the contributions enhanced the evidence base of the scoping review. The commentary about the project in the blogosphere was positive, tempered with some skepticism. Despite the fact that wikis provide an easy-to-use, free and powerful means to edit information, fewer than 1% of visitors contributed content to the wiki. These results may be a function of limited interest in the topic area, the review methodology itself, lack of familiarity with the wiki, and the incentive structure of academic publishing. Controversial and timely topics in addition to incentives and organizational support for Web 2.0 impact metrics might motivate greater participation in online collaborative efforts to keep scientific knowledge up to date.
    Open Medicine 01/2011; 5(4):e201-8.

Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.

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