Friday, March 7, 2008

A ten-year pain resolved in 2 weeks

It was by a lucky chance that Mme Dominique Forget was delegated to cover the press conference with Health Services International in Montreal in June of 2007. She interviewed several people who had returned from Cuba healed and relieved.
For several years She had considered going to Cuba to seek treatment for her chronic back pain.
For over ten years she had to take extended absences from work when the pain was too intense. She was not able to lie down or to sit for extended periods, which lead to a chronic sleep deficit. For her it was ten difficult years as no specialist here could find the medical solution.

For her, this press conference was the spark…she decided to try the renowned orthopaedic specialists in Cuba.

Only a few hours after arriving in Cuba, the doctors diagnosed a fracture in the sacrum. As this situation had been long untreated, there was noticeable wear on the fractured parts. The doctors proceeded with a bone graft to heal the fracture. Two weeks later, she was on her way home, relieved of her pain and hopeful.
Her life now has changed. She no longer needs to take the large quantities of pain-killers, with all the unpleasant side-effects.

“My only solution was to pay to get answers to my questions, so that finally I could be taken seriously and not have them doubt the fact that I was in pain. I am not saying that all the doctors here doubted my pain. They sent me to the pain clinic where they gave me some heavy medication that allowed me to endure the pain and to be able to sleep for a few weeks. I was left with the worry, discouragement and despair. This was to be a necessary part of my life.”

“The difference with the Cubans is in the team work approach. Several doctors met to discuss my case before my orthopaedist came to tell me the results. Every day I saw the team of 6 doctors who had participated in my operation and each one of them closely followed my case. Clearly, the quality of Cuban doctors has given them a very good reputation, and I would add that there are also very good doctors here in Canada. I could have gone to a private clinic but I had lost confidence that they would find anything. After 11 years, anyone could be discouraged.”

Thursday, March 6, 2008

A Canadian Woman Determined Not to go Blind heads to Cuba

Ms. Anne Lortie collapsed in tears the day that she was advised, in a nonchalant way, that she would go blind in a few years. The only help offered was to suggest she sign up for white cane courses at the Braille Institute

She was not able to accept oncoming blindness without trying to do something. That was when she found out about treatments in Cuba for Retinosis Pigmentaria. The operation and treatments usually stop the degeneration and often permit recuperation of at least a part of lost vision.

She sent her medical history to Cuba, but after a year had received no answer.

It was in January of 2007, when she learned of Health Services International, that she sent her dossier to see if it was possible for her to obtain the “miraculous operation”.

In February of 2007, Ms Lortie’s dream came true and she embarked for Havana to have her operation and treatments.

Victory!...the degeneration is stopped…she will not go blind! More than that, she actually recovered a part of the vision that had been lost.

Ms. Lortie wants all Canadians stricken by this disease to know that they need not be afraid to receive treatments in Cuba, that Cuban doctors have a treatment for this ailment and that they are very competent.

Patients from a number of countries have shown that this treatment is not new nor unknown to the medical community. Why then this reticence, when the results speak for themselves and patients come home with joy and relief?

Ms Lortie left for Cuba in spite of negative advice and dire warnings about this treatment. She does not regret for an instant the decision to regain her eyesight and prepare for a better life.

Source : Health Services International

Wednesday, March 5, 2008

RFID technology can help save lives in health-care sector – and preserve privacy: Commissioner Cavoukian and HP Canada

Wide-sweeping developments – including potentially life-saving uses – in Radio Frequency Identification (RFID) technology for the health sector have been advancing in lock-step with concerns about the privacy implications of deploying this nascent “auto-ID” information technology.

Ontario Information and Privacy Commissioner Ann Cavoukian, Ph.D., in collaboration with Hewlett-Packard (HP) Canada, released a joint whitepaper, RFID and Privacy: Guidance for Health-Care Providers, which is aimed at cutting through the mists of uncertainty over the potential application of RFID technology in the health sector and the privacy implications of its uses.

In the U.S., for example, some health-care providers are already using RFID-based systems to track equipment, instruments and sponges used in surgery to ensure that nothing is left behind inside a patient. And some health-care providers are already using RFID-enabled labels to track specimens and laboratory results to ensure that they are not misplaced, as well as tracing pharmaceutical products to ensure that the correct medication and dosage is being administered. More than 400 U.S. hospitals are currently using RFID-based, baby-and-mother matching systems to prevent mix-ups and abductions – the RFID system triggers a lock-down if an infant is removed from a secured area without authorization.

According to Commissioner Cavoukian everyone from health-care providers to patients to privacy advocates wants the best tracking technology possible in the health sector, without the needless invasion of privacy; this can easily be achieved and become a positive-sum ‘win-win’ model for everyone, not a zero-sum scenario.

The objective of the joint paper is to assist health-care providers in understanding the current and potential applications of RFID technology, the potential benefits, the information privacy implications associated with its uses, and the steps that may be taken to mitigate any potential privacy risks.

And according to Victor Garcia, Chief Technology Officer for HP Canada, the health-care sector can reap the benefits of RFID technology and make a considerable difference to patient care. RFID can save lives while the potential risks to privacy infringement can be recognized and addressed early on with governance guidelines and training, so that health-care providers will be able to take full advantage of RFID innovations. This approach will take patient care to a whole new level.

The joint paper, RFID and Privacy: Guidance for Health-Care Providers, examines a wide variety of RFID applications for the health-care sector, organizing them into three broad categories according to the increasing level of potential risk to privacy: RFID technology to track things alone; RFID technology to track things associated with people; and RFID technology to track people.

Both the Commissioner and HP believe that this paper will serve as a benchmark reference source for health-care providers to realize the benefits of RFID adoption while ensuring respect for patient privacy and a credible program of responsible information governance.

The paper is available here.

About the IPC

The Information and Privacy Commissioner is appointed by and reports to the Ontario Legislative Assembly, and is independent of the government of the day. The Commissioner's mandate includes overseeing the access and privacy provisions of the Freedom of Information and Protection of Privacy Act and the Municipal Freedom of Information and Protection of Privacy Act, as well as the Personal Health Information Protection Act, and helping to educate the public about access and privacy issues.

About HP

HP focuses on simplifying technology experiences for all of its customers – from individual consumers to the largest businesses. With a portfolio that spans printing, personal computing, software, services and IT infrastructure, HP is among the world’s largest IT companies, with revenue totaling $104.3 billion for the four fiscal quarters ended October 31, 2007. More information about HP (NYSE: HPQ) is available at

Tuesday, March 4, 2008

Cuba, to the rescue..!!!

Quality medical services, without waiting

TORONTO, March 4 /CNW Telbec/ - As waiting lists get longer, medical tourism becomes a way to get quality medical services, without waiting. Health Services International is a non profit organization which has recently begun arranging medical services in Cuba for Canadians.

Cuba has been developing medical tourism for over 20 years. Cuban doctors are now recognised as some of the world's finest. In the last 5 years, over 35 thousand patients from 32 countries have benifited from Cuban Medical expertise.

Many Cuban hospitals are certified ISO 14,001 and ISO 9001 which are international standards of cleanliness and excellance. The reputation of Cuban hospitals is well established. Many Canadians have returned from Cuba healed and reassured and are ready to tell their stories.

This was the case of Mrs. Dominique Forget who suffered severe back pain for 10 years. With less than 2 weeks in Cuba, her problem was cured and her life was transformed.

Note the case of Manon Lefrançois, a young woman forced to cancel business trips as it had become too painful to remain seated for long periods. Her doctor in Quebec told her to come back : ''when she could no longer walk''. She went to Cuba for orthopaedic surgery and today she travels the world and her business prospers.

Similarly, Mrs Anne Lortie, a young mother informed that she would go blind within two years as she had retinitis pigmentosa. The only help offered was to suggest that she register with the Braille Institute.

Specialists in Canada maintain that there is no treatment for this degenerative disease. Patients who inquire about treatments given in Cuba receive dire warnings from specialists here. But, Health Services International has helped over a dozen Canadians get treatment for this disease. After an operation and treatments, these clients of HSI will not go blind. Imagine their joy to look forward to the hope of a normal life again, after the despair of a cruel diagnosis.

The full range of medical services are available in Cuba: major surgery, diagnoses, aesthetic surgery, skin care treatments, thalassotherapy and a highly regarded drug rehabilitation program.

Health Services International has an agreement with Cubanacan Turismo Y Salud, to make access to Cuban medical services easier for Canadians. H.S.I. maintains communications between Canadian patients and Cuban medical services and arranges all the details for treatment and travel. Contact: Sandy Rhéaume, Vice President, Health Services International (HSI), (418) 479-2942, Cell: (418) 654-6762,

International symposium reports on the use of antivirals [including TAMIFLU] in patients with H5N1

MISSISSAUGA, ON, March 4 /CNW/ - Physicians from countries affected by the deadly H5N1 influenza virus (bird or avian flu) have presented case reports about antiviral use in patients infected with H5N1, including treatment with the oral antiviral TAMIFLU(R) (oseltamivir). The physicians' reports were revealed this week at the International Symposium on Respiratory Viral Infections (ISRVI) in Singapore.(1)

TAMIFLU is approved for both the treatment and post-exposure prevention (prophylaxis) of influenza in adults and in children one year and older. Studies supporting the approval of TAMIFLU are based in seasonal influenza. The magnitude of effect of TAMIFLU in treating and preventing novel strains of influenza (such as those that may be involved in a pandemic or associated with avian flu) cannot be predicted as it has not been studied or approved in a pandemic scenario. The World Health Organization (WHO) has recommended that higher doses and longer treatment durations may be required to combat novel strains of influenza.

According to the WHO, the H5N1 virus has already killed 234 people in 12 countries.(2) In the most recent clinical management guidelines issued by the WHO, TAMIFLU remains the primary antiviral agent of choice for the treatment of H5N1 virus infections.(3)

Symposium findings

In Indonesia, of the total of 119 H5N1 human cases reported, 22 survived - an 18 per cent survival rate overall. Of the 119, 33 patients received no TAMIFLU, all of whom died. TAMIFLU was administered to the other 86 patients, with a 26 per cent survival rate overall. Time from onset of illness to initiation of treatment appeared to influence survival. Of the two patients who received TAMIFLU within 24 hours of illness onset, both survived. If given the drug within four days, 55 per cent survived (6/11), and 35 per cent survived if given TAMIFLU within six days (13/37).(4) The survival rate of those receiving it later than six days after illness onset was 18 per cent(9/49).(2)

Recent information about eight Vietnamese patients infected with H5N1 was also presented. All eight patients received TAMIFLU, however, all eight patients presented to the hospital later than five days after onset of illness. Only three of the eight patients survived reinforcing that treatment benefit is reduced for patients that receive the drug later in the course of illness.(4),(5) In two patients who were unable to take the drug orally due to the severity of their illness, physicians administered the drug by nasogastric tube and found it was well absorbed and there was a reduction in H5N1 virus in these patients.

Susceptibility of circulating H5N1 strains to TAMIFLU

These clinical findings are supported by animal data, also presented at ISRVI, which shows that oseltamivir treatment was effective against H5N1 influenza viruses representing different clades/subclades. However, higher doses were required for the more pathogenic H5N1 viruses.(6)

According to study author Dr. Elena Govorkova from St. Jude Children's Research Hospital, Memphis, US., multiple factors can affect the susceptibility of antiviral therapy with highly pathogenic H5N1 influenza viruses and it is reassuring that oseltamivir, in mouse models, demonstrates activity even to the most pathogenic circulating strains. She adds that antiviral drugs are an essential component for the early control of an influenza pandemic.

Data also confirms the low level of resistance reported to-date with TAMIFLU to H5N1 avian influenza in the field; there are only five cases of published reports of H5N1 resistance or reduced susceptibility to TAMIFLU to date.(7),(8),(9) Laboratory results have shown 96 per cent of H5N1 strains (53 out of 55) tested in the laboratory were sensitive to TAMIFLU.(10)

This compares to the around 14 per cent of isolates tested this year of the seasonal influenza A H1N1 virus showing resistance to TAMIFLU, reported at the conference.(11) It is important to note that these increased levels of resistance have only been reported spontaneously in this year's H1N1 (Solomon Islands) seasonal strain, and not an avian strain such as H5N1, and not in patients who have been administered TAMIFLU.(12)

Dr. David Reddy, Global Pandemic Task Force Leader at Roche noted that currently, they are seeing that TAMIFLU has been used as part of the clinical management of patients infected with H5N1 with only isolated cases of resistance being reported. This, he adds, is reassuring for governments that have stockpiled TAMIFLU for pandemic use while it is critical that the company and the medical community remain vigilant in order to nderstand this mutating virus and be best prepared for defence against a potential pandemic strain.

Roche has undertaken several research initiatives to study the use of TAMIFLU against the evolving H5N1 avian influenza virus, including collaborations with the National Institutes of Health (NIH), the Southeast Asia Influenza Clinical Trials Research Network, and other research institutions.

Flu 101 | Back to Basics

Difference between a pandemic strain of influenza and seasonal influenza

A pandemic strain of influenza is always of the A variety and is a completely new strain to which there will be no immunity. A seasonal strain of influenza is one that has previously been circulating, which may have changed slightly (antigenic drift) and to which a level of immunity exists.

About pandemic influenza

An influenza pandemic occurs when a new strain of influenza A virus appears, against which the human population has no immunity resulting in several, simultaneous epidemics worldwide with enormous numbers of deaths and illness. The most severe influenza pandemics to date include: 'Spanish flu' A (H1N1): 1918 caused in excess of 30 million deaths worldwide; 'Asian flu' A (H2N2): 1958 caused one million deaths worldwide; 'Hong Kong flu' A (H3N2): 1968 caused 800,000 deaths worldwide in six weeks. The WHO believes that we are as close to the next pandemic as we have been at any time in the past 37 years, with two of the three widely-recognized prerequisites for a human pandemic met to date in the avian influenza outbreak in East Asia. Firstly, a new influenza virus strain has emerged (H5N1), and secondly, the virus has spread to humans. The final barrier will be the effective transmission of the virus from human to human.


TAMIFLU is designed to be active against all clinically relevant influenza viruses and works by blocking the action of the neuraminidase (NA) enzyme on the surface of the virus. When neuraminidase is inhibited, the spread of the virus to other cells in the body is inhibited. It is licensed for the treatment and prophylaxis of influenza in children aged one year and above and in adults. The most frequently reported adverse events in clinical studies were nausea, vomiting, and diarrhea. TAMIFLU is available for the treatment of influenza in more than 80 countries worldwide.

TAMIFLU was approved based on studies in seasonal influenza. The magnitude of effect of TAMIFLU in treating and preventing novel strains of influenza (such as those that may be involved in a pandemic or associated with avian flu) cannot be predicted. The WHO has recommended that higher doses and longer duration may be required.

Roche and Gilead

TAMIFLU was invented by Gilead Sciences and licensed to Roche in 1996. Roche and Gilead partnered on clinical development, with Roche leading efforts to produce, register and bring the product to the markets. Under the terms of the companies' agreement, amended in November 2005, Gilead participates with Roche in the consideration of sub-licenses for the pandemic supply of TAMIFLU in resource-limited countries. To ensure broader access to TAMIFLU for all patients in need, Gilead has agreed to waive its right to royalty payments for product sold under these sub-licenses.

About Roche

Headquartered in Basel, Switzerland, Roche is a biotech company with a reputation for in-vitro diagnostics and drugs for cancer and transplantation, and with an ongoing interest in virology and therapeutic areas such as autoimmune diseases, inflammation, metabolism and central nervous system.

Monday, March 3, 2008

Contemporary Disease Management in Quebec

Amédé Gogovor, Michelle Savoie, Yola Moride, Marilyn Krelenbaum and Terrence Montague

Healthcare Quarterly, 11(1) 2008: 30-37

Health or disease management (DM) has emerged as a promising solution to improve the quality of healthcare and patient outcomes in a cost-efficient way. This solution is particularly relevant in the care of our increasing, and aging, patient populations with multiple chronic diseases. This article reviews the recent history and current status of DM in the province of Quebec and summarizes its evolving perspectives and future prospects. Most DM projects in Quebec have developed from a public-private partnership, and they have addressed several disease states. The results of completed programs confirmed the presence of care gaps - the differences between best and usual care in several disease states. They also identified process changes leading to improved practices and enhanced professional satisfaction among stakeholders. Priorities identified for further research include increased knowledge of the underlying causes of care gaps and greater concentration on the measurement of clinical, humanistic and fiscal outcomes and their causal links to DM structures and processes. Although still embryonic in Quebec and Canada, the available evidence suggests that DM partnerships are practical and functional vehicles to expedite knowledge creation and transfer in the care of whole populations of patients. Future projects offer the promise of updated knowledge and continuously improved care and outcomes.

The companion challenges of ever-increasing costs and sub-optimal quality in modern health systems, particularly for the expanding patient populations with chronic diseases, have driven the growth of disease management (DM) programs. These programs are seen as one solution for improving the quality of patient care and outcomes in a cost-efficient way. Despite the absence of unequivocal evidence regarding cost savings, or positive return on investment (ROI), DM has essentially become an industry in the United States (Bodenheimer 2000; Norris et al. 2003) and is steadily increasing its presence in Canada (Montague 2004).

The Disease Management Association of America (DMAA) working definition of DM is increasingly considered the reference bracketing statement (DMAA 2005). Briefly, it characterizes DM as a system of coordinated interventions and communications for populations in which self-care and empowerment are prominent and where evidence-based practices, as well as economic and humanistic outcomes, are fostered, measured and fed back to participating partners. As defined by the DMAA, a DM organization is one that provides full health service components, while a service provider offers only some components of care (DMAA 2004a).

At least three organizations in the United States have defined standards for DM programs and are providing accreditation to DM providers. DM programs are initiated and implemented mainly by healthcare organizations and health plans but also by pharmaceutical companies and academic medical centres. According to a recent survey of commercial health plan members in the United States, the majority of responders expressed differential satisfaction with regard to DM outcomes: satisfaction was highest for clinical outcomes and less for improved resource utilization and cost reduction (Fitzner et al. 2005).

In Canada, there are no commercial DM organizations. However, many DM partnerships and projects have been initiated over the past decade, primarily supported by the pharmaceutical industry in conjunction with academic, government and/or community partners. A Canadian Council for Research in DM has also recently been created by a group of Canada's research-based pharmaceutical companies. Government-funded DM programs at the provincial level are beginning in some provinces, as are programs at the regional and clinic levels.

In Quebec, the importance of integrated health services and DM was outlined by the Commission of Study for Health and Social Services in 2000. The Commission recommended an increase in public/private partnerships in order to position Quebec as a leader in the field of DM, particularly in exploring the optimal use of medicines (Commission of Study for Health and Social Services 2000). In the province's updated drug policy released in early 2007, the Ministry of Health and Social Services of Quebec reiterated the importance of DM programs, as well as the necessity to develop a framework for future projects (Ministry of Health and Social Services 2007). The University of Montreal has also launched a DM research group (Groupe de recherche en gestion thérapeutique, or GRGT), which has, as part of its mission, the goal of fostering the advance of community-based and patient-centred DM programs in Quebec and elsewhere (Montague et al. 2007).

The purpose of this article is to review and summarize the recent past history and current status of DM partnerships and projects in the province of Quebec, to serve as a practical benchmark comparator for future DM projects in Quebec and Canada.

Various sources were used to collect data about DM programs in Quebec. They included repeated knowledge exchange sessions of GRGT members, literature and database searches (MEDLINE, PubMed, CINAHL, WebSPIRS, ABI/INFORM [ProQuest], ISI Web of Science) and phone and e-mail contacts with DM program investigators and coordinators.

Seven Quebec-based DM projects were identified. They are outlined below in detail, and an overview summary is presented in Table 1.

[Table 1]

CURATA (Concertation pour une Utilisation Raisonnée des Anti-inflammatoires dans le Traitement de l'Arthrose [An Integrated Approach to Improving the Appropriate Utilization of Anti-inflammatory/Analgesic Medications in the Treatment of Osteoarthritis in Quebec]) was developed in 2000 by the Association of Rheumatologists, in partnership with Merck Frosst Canada (Beaulieu et al. 2004). The aim was to improve primary care physicians' ability to identify patients with osteoarthritis (OA) and to choose appropriate pharmacological and non-pharmacological therapies using an evidence-based decision support algorithm.

The program had several interventions: assessment of the state of care of OA patients by physicians; development of the evidence-based treatment algorithm, as well as other educational tools for pharmacists and patients; small group training workshops for physicians; and outcomes evaluation tools. The governance involved professional associations of specialist and generalist physicians, pharmacists, physiotherapists and occupational therapists, as well as patient advocacy groups, the Health and Social Services Ministry of Quebec, Merck Frosst Canada and the University of Montreal.

Based on a pre-post design, evaluation revealed a significant improvement of physicians' level of knowledge and on prescription-on-evidence patterns (Beaulieu et al. 2004; Rahme et al. 2002). This was achieved via measurement and feedback of actual practice patterns - which revealed gaps between best care and usual care - supported by the education/training workshops that were centred on the optimal treatment algorithm.

Lowering blood pressure by improving compliance with hypertension therapy through the assistance of technology-enhanced tools (LOYAL) was conceived in 2002 by the Research Centre of the University of Montreal Hospitals (CHUM) with funding support from Pfizer Canada. The objective was to improve the health and well-being of hypertensive individuals and reduce therapeutic non-compliance among patients at risk for cardiovascular disease.

The LOYAL patients are randomly assigned to interventional or usual care groups. In the interventional group, patients are provided with blood pressure monitors, access to an integrated telephone support system for automated reminder and feedback and education material on hypertension and its complications. The system keeps the involved physicians and pharmacists abreast of their patients' progress in controlling their hypertension, and provides patients a direct link to their physician or pharmacist.

The governance structure is composed of CHUM clinician investigators and provider partners and collaborators from Tagge Medical Solutions, Laval's Cité de la Santé and the Centre hospitalier ambulatoire de la région de Laval, with additional partners from the Fonds de la recherche en santé du Québec, the Heart and Stroke Foundation of Quebec, the Quebec Diabetes Association, the Canadian Hypertension Society, the Laval Regional Health Board, Pfizer Canada and the Faculties of Pharmacy and Nursing of the Université de Montréal.

LOYAL was launched in 2004, and patient recruitment is ongoing. At the end of study, the clinical and economic outcomes of the two groups will be compared regarding patient, provider and system impacts (Pfizer Canada 2002).

Medical Office of the Twenty-First Century (MOXXI) is an interactive system of electronic prescribing and integrated drug and disease management. Its objective is to reduce the risk of drug-related illness and to improve the management of chronic diseases that depend heavily on regular and appropriate medication use. The project has had sequential steps, MOXXI I, MOXXI II and MOXXI III, financed by Canadian Health Infostructure Partnership Program (CHIPP). MOXXI is heavily focused on the application of information technology to drug and care management and consists of many components: electronic prescribing, improvement of medication compliance due to feedback and patient self-management and reminders for physicians, as well as an advanced decision-support system utilizing evidence-based asthma and diabetes guidelines.

This project was initiated and implemented by McGill University researchers, along with many partners and collaborators in the academic, public and private sectors (University of Montreal; CHIPP; Collège des Médecins du Québec; Ordre des pharmaciens du Québec; Association des Bannières et Chaînes de Pharmacie du Québec; Association Québécoise des Pharmaciens Propriétaires; Société Informatique des Pharmaciens Inc.; Informatique Demers, Lambert, et Desrochers Inc.; Bell Mobility; Hewlett Packard; Pharmaprix; Jean Coutu Group; TAGGE Medical Solutions; Syscor; and Astra-Zeneca).

Many evaluations have been done, including evaluations of education workshops for physicians and pharmacists. The majority of physicians reported a high satisfaction with the quality of care provided to patients (87%), their interaction with patients (73%) and their relationship with pharmacists (75%), despite low actual use of computers in their clinical practice (Health Canada, Health and the Information Highway Division 2004). To test MOXXI interventions for enhancement of medication compliance, patients have been randomly assigned to receive automated telephone support for refills and reminders of the need to take their medications. A cost-effectiveness analysis of the improvement in medication compliance vis-à-vis emergency room visits and hospitalizations will also be done. It is predicted by the investigators that the decrease in medication mistakes using electronic prescribing, as well as the anticipated improvements in prescription adherence, will likely produce cost-benefit system results (Health Canada, Health and the Information Highway Division 2004). There is also an anticipation that the impacts may be expandable to chronic diseases other than the initial disease targets, asthma and diabetes.

PRIISME (Programmes régionaux intégrés d'information, de suivi médical et d'enseignement) was launched in 1999, with a non-restricted research grant from GlaxoSmithKline (GlaxoSmithKline 2003). The program was intended to improve the management of certain chronic diseases - namely asthma, chronic obstructive pulmonary disease (COPD) and diabetes - including patients' perceptions of quality of life; to reduce the utilization of healthcare services associated with chronic diseases; and to ensure the optimal use of medication through the dissemination of clinical practice guidelines.

The different components of the PRIISME program include initial information sessions for all stakeholders of chronic DM, continuing education for all health professionals, initial personalized DM education for patients and their families and follow-up sessions. Governance is by a steering committee of regional health authority representatives, health institutions, community groups, private medical clinics and individual providers and GlaxoSmithKline.

Pre- and post-evaluations of the asthma component of the program have shown an increase in the quality of life for patients, an improved knowledge of asthma and its treatment among physicians and other health professionals and a decrease of >30% in emergency room visits and hospitalizations for asthma-related illnesses (Cimon 2003).

Started in 2003, the objective of Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) is to improve the diagnosis and treatment of osteoporosis in women aged 50 years and older with fragility fractures and a high risk of further osteoporosis-based complications. The ongoing program has several phases: identification of patients with bone fragility; assessment of the gap between current usual care and evidence-based optimal care, followed by elaboration of individual educational material and intervention evaluation; global program evaluation based on diagnosis and treatment rates; and readjustment of intervention methods. The project partners included academic and community physicians across the province, osteoporosis associations and an alliance of industry partners (Merck Frosst Canada, Sanofi-Aventis Group, Procter and Gamble Pharmaceuticals, Eli Lilly Canada and Novartis Pharma Canada).

The first phase of ROCQ, with baseline recruitment of patients and analyses of the population rates and characteristics of fractures, is ongoing. At the end of enrolment, the patients will be randomized into either the educational interventional or control group. It is anticipated that the program will improve the knowledge and care of high-risk patients with osteoporosis in Quebec (Brown et al. 2003, 2005; Montague 2004).

SIPA (System of Integrated Services for the Frail Elderly) is a model of integrated care for the frail elderly developed by the McGill University-Université de Montréal Research Group on Integrated Services for Older Persons. The demonstration project ran from 1999 to 2001 on the Island of Montreal. Its aims included responding appropriately to the needs of older persons with disabilities; optimizing their use of community, hospital and institutional resources; and evaluating organization and costs of the services and quality of care for the intervention and control groups.

The project was based on multidisciplinary care provider teams in the Centre local de services communautaires (CLSC) setting where case managers played a pivotal role in the coordination and follow-up of interdisciplinary protocol interventions, including hospital discharge planning, ongoing evaluation of patient needs and updating of the program information system. Active participation of the patients' family physicians, with financial incentives via capitation, was also part of the interventions. The coordinators and partners of the project came from McGill University, the University of Montreal, the Montreal Geriatric Institute and the Health and Social Services Board.

The results demonstrated a decrease in the hospital wait times for nursing home placement and significantly improved home health and home social care access for the interventional group compared with the control group, with no increase in global costs, as well as a better integration and continuity of care (Béland et al. 2006a, 2006b, 2006c).

The TEAM (Toward Excellence in Asthma Management) program, called VESPA (Vers l'Excellence dans les Soins aux Personnes Asthmatiques) in French, was primarily a joint venture among the Quebec Asthma and COPD Network (Réseau québécois de l'Asthme et de la MPOC [RQAM]), Merck Frosst Canada and Astra-Zeneca. The objectives of the TEAM program were to optimize asthma care, improve the quality of life of asthmatic patients and alleviate the socio-economic burden associated with the disease.

The program consisted of several phases, over several years: Phase I produced the cartography of the disease and its determinants in the province, including measures of regional variations of emergency visits for asthma care. Phase II highlighted the gap between current and evidence-based practice and its determinants in high-morbidity versus low-morbidity areas, as well as determinants of therapeutic adherence and levels of patient-physician relationships. Phases III and IV consisted of interventions, including continuing education for providers, patients and families of patients; therapeutic adherence improvement and patient environment management; emergency care; referral to asthma education centres; the use of spirometry in primary care on asthma centre attendance; and their evaluation. In addition to the providers, investigators and patients, many other partners were involved in the program, including regional health authorities, patient advocacy associations and the provincial asthma education network.

The results of the different phases have brought important contributions to the knowledge and care of the disease in Quebec. The impacts of the interventions on the rates of emergency room visits, hospital admissions and the general socio-economic burden of the disease are becoming clearer with each analysis and their publication and propagation of results. TEAM/VESPA experiences will be extended to current practice, through RQAM, the university-based networks of continuing education and the integrated clinical group practices (Boulet 2006; Boulet et al. 2002; Montague 2004).

It is worth noting that other DM projects and partnerships continued to be developed and launched as we conducted this review. For example, PERSISTANCE, a trial of patient-centred education to enhance persistence with prescribed therapy in the management of depression, and JOCOEUR, a worksite project of management of cardiovascular diseases, are both in an early stage. So, the evolution continues.

Concisely defined, DM is a partnership-driven, intervention-focused and measurement-accounted integrated application of health resources to improve the care and outcomes of whole populations of patients. Overall, in Quebec, the contemporary experiences with the partnership and measurement paradigm of DM appear to be positive.

Recent and current projects have been public-private partnerships, developed and co-funded by the pharmaceutical industry in conjunction with public and academic healthcare institutions. All the projects were designed to integrate with, and practically extrapolate results to, existing healthcare infrastructures and processes. The programs reviewed used a number of study designs, including randomized controlled trials and pre-post outcomes comparisons of interventions. Most of the methodological considerations in DM project designs appear to revolve around balancing the primacy of need for high causal attribution for project interventions versus the primacy of attaining improved outcomes with lesser need for causal attribution (DMAA 2004b; Montague 2004).

In general, interventions and outcomes measurements in DM studies have tended to be clinically focused. This was certainly true for the programs assessed in this review. Except for SIPA, which targeted frailty and its many associated health and disease conditions, these DM projects targeted one or two specific chronic diseases. Although largely funded by the pharmaceutical industry, they were based on a diversified and equitable partnership arrangement, and academic leadership was provided by well-known academic researchers. Patients and their interests, and the objective of making things better for patients in terms of care and outcomes, appeared to be the common and dominant goals of all the partnerships and projects.

None of the reviewed projects evaluated global economic impact, including consideration of opportunity costs and net ROI for project expenditures in their various communities of practice. This is however an increasing area of interest for payers in the health system. For example, in the United States, the Medicare health plan is conducting such programs to demonstrate, or not, the economic benefits of DM programs (Centers of Medicare and Medicaid Services 2006). Similarly, in the United Kingdom, where commercial DM is developing, Greenhalgh and colleagues have drafted quality standards and recommendations for use by public sector organizations when considering packages for DM from companies with a commercial interest (Greenhalgh et al. 2000). Recently, the economic impact of the Improving Cardiovascular Outcomes in Nova Scotia DM project was assessed, and the results demonstrated a significant multiplier effect of the initial investment (Crémieux et al. 2007).

Where Does DM Need to Go?
Thus far, DM projects and research studies have tended to focus on measures of process and efficiency, with less attention to structure or measurement of interrelationships of structure, process and outcomes (Steuten et al. 2006). Although some causal links between the partnership structure, its knowledge translation processes and improved clinical, fiscal and humanistic outcomes have been suggested, much remains in the realm of hypothesis and requires further investigation (Montague 2004, 2006; Steuten et al. 2006). Even very basic structural concepts, such as the idea that networks, or provider teams, are more valuable than individuals in improving care, are more premise than evidence-based fact (Montague 2006).

In DM projects that have focused on measuring and improving patient outcomes, the contributory, or root, causes of traditional gaps in prescription, adherence, access and diagnosis have often been ignored and, thus, remain largely speculative. The underlying causes of the age-based differences in care remain a particularly counter-evidence conundrum, despite their wide prevalence and increasingly greater relevance for our aging population with chronic disease (McAlister et al. 1999; Montague 2004).

Thus, we need to reduce the knowledge deficits around root causes of care gaps, including the age gap, and determine the best interventions to cure them. We also need to determine the most efficacious processes for cross-disciplinary team building and functioning in DM. And, we need to determine how structure, process and outcomes are linked.

Ideally, we need to do these things to find solutions for multi-disease management. Because, if DM is to become more relevant for our changing demography, its programs must be able to deal successfully with an aging population with multiple, coexisting chronic diseases for whom knowledge-driven, patient-centred outcomes like improved quality of life and decreased need for re-hospitalization are seen as very valuable end points (Montague 2006).

There is also a need to promote the value of DM to all stakeholders in the chronic care model of DM. Patient safety initiatives come to mind as a particular field of opportunity. The strategic goals of patient safety are the reduction and mitigation of unsafe acts and the optimal use of best practices leading to optimal patient outcomes. The dominant culture that has evolved, however, is nearly exclusively focused on reducing sentinel adverse events. In other words, the contemporary patient safety culture is narrower than its strategy. The unintended, but adverse, outcome of this situation is that optimizing care and closing care gaps, the larger world of optimizing DM, are being largely ignored.

As we move beyond the acute care and individually centred models of health management to embrace the management of chronic care in whole population segments, there is a practical opportunity to combine research and community health goals (Montague et al. 2007). Succeeding in improving health and quality of life by providing patients with integrated care - without submitting them to multiple and competing programs - and simultaneously constraining or decreasing costs are definite challenges. It remains an open question as to whether the evolution of DM will contribute to the attainment of these goals in Quebec and in Canada. However, the future is promising; things can be better.

About the Author

Amédé Gogovor, DVM, MSc, is Research coordinator and secretary of the scientific committee, Health Management Research Group, Université de Montréal, Montreal, Quebec. You can contact Amédé Gogovor by phone at 514-343-6111, ext. 1853, by fax at 514-343-2448 or by e-mail at

Michelle Savoie, MBA, MPH, PhD, is Visiting Professor, Faculty of Pharmacy, Université de Montréal.

Yola Moride, PhD, FISPE, is Associate Professor, Faculty of Pharmacy, Université de Montréal.

Marilyn Krelenbaum, MSc, is consultant in design strategy and management of healthcare research projects and senior medical communications specialist, Health Management Research Group, Université de Montréal.

Terrence Montague, CD, MD, FRCPC, is Professor of Medicine and director, Health Management Research Group, Université de Montréal.

The authors wish to acknowledge the review and suggestions of the following persons toward the development of this manuscript: François Béland of the Department of Health Administration, University of Montreal; Louis-Philippe Boulet of Institut de cardiologie et de pneumologie de l'Université Laval; and Michèle Beaulieu of Patient Health Management Group, Merck Frosst Canada Ltd.

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