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.

Methods
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.

Results
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
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.

LOYAL
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).

MOXXI
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
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).

ROCQ
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
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).

TEAM (VESPA)
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.

Discussion
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 amede.gogovor@umontreal.ca.

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.

Acknowledgements
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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20 Surprising Ways Wal-Mart Clinics Will Affect Healthcare

By Jessica Hupp

Originally published on Wednesday February 27th , 2008 on RNCentral.com

And originally titled:
20 Surprising Ways Wal-Mart Clinics Will Affect US Healthcare

Re-posted here with permission


Big-box behemoth Wal-Mart has ventured into the healthcare realm, offering low-cost, walk-in clinics in more and more of its stores every day. Although Wal-Mart medicine may not sound like a great idea at first, these clinics can bring good changes to the health care industry, like insurance-free care, eased emergency rooms, and more widespread treatments. Of course, the plan is not without its drawbacks, creating a "Wal-Mart effect" on small practitioners, as well as a race to the bottom. Here, we'll take a good look at some of the implications you might not have thought about.

1. More immunizations: With immunizations available at Wal-Mart, they're much more convenient for those that may not have time to go to the doctor. As a result, more people will be immunized, and the risk of contagious disease will be lowered.

2. Flat fee visits: Most Wal-Marts charge a flat $45 for a "Get Well" visit, which is painstakingly simple when compared with health care's typical insurance, co-pay, and deductible scheme. As Wal-Mart clinics become more popular, other health practitioners may be forced to adopt a similar pay structure in order to compete.

3. Faster care: Wal-Mart offers walk-in visits, offering a refreshing alternative to appointment-based health care. As Wal-Mart's clinics and others like them become more popular, we'll see patients getting care right when they need it.

4. Automated health: At Wal-Mart clinics, practitioners check out patients with the aid of a proprietary computer program that diagnoses illnesses. This sort of automation can help make diagnosis more accurate and efficient, while still allowing for human expert guidance when needed.

5. No insurance necessary: Perhaps the biggest thing to come out of Wal-Mart clinics is that they don't require insurance. Paired with flat-fee service, this simple pricing structure is likely to bring in patients that otherwise would just go without medical care.

6. Race to the bottom: Wal-Mart tends to have this effect on local businesses, creating a situation where quality must be sacrificed for price. In the healthcare world, cheaper isn't always better, and competing with Wal-Mart clinics could result in decreased quality of care.

7. One-stop shopping: Retail clinics like Wal-Mart's open up an opportunity for a place to take care of basic medical needs, combining the clinic with optometry, pharmacy, and over the counter supplies.

8. Primary care providers can narrow their focus: As Wal-Mart takes on all of the sniffles and scratches, doctors can spend more time working with patients who need more professional help. They'll be able to use their time more effectively and appropriately.

9. Automated health care could be problematic: Although automation increases efficiency and reduces human error, that doesn't mean that a computer program is the best way to diagnose a patient. Critics are worried that this type of diagnosis will cause important intricacies to be missed.

10. Eased emergency room crunches: As health care becomes more accessible, the patients that generally clog up emergency rooms unnecessarily will be able to take care of problems before they become worse. Additionally, clinics like Wal-Mart's can take care of ailments that for some without insurance would require a trip to the hospital.

11. More retail pricing information: To compete with Wal-Mart, physicians will start sharing information about how much specific visits and procedures will cost. This can make health care more competitive and consumer-friendly.

12. Better rural medical access: In many rural areas, the nearest health care practitioner isn't so near. However, you can often find a Wal-Mart even in remote parts of the country. This would make it much more convenient for rural citizens to get hassle-free care.

13. Increased medical awareness: With health care right where people shop, it's a lot harder to ignore aches and pains. Plus, as stores run campaigns for prevention services and screening, they'll be able to catch and stop ailments earlier than before.

14. Increased office hours: Wal-Mart's clinics offer evening and weekend hours, while many primary care physicians do not. To compete, these doctors will need to offer extended hours to patients.

15. Mall health clinics: Wal-Mart isn't the only one in the neighborhood clinic game. As their clinics become more successful, we can expect to see this sort of health care facility popping up in more places, like malls and strip centers.

16. Traditional medical offices will feel the crunch: As Wal-Mart's clinics tackle the easy patients, regular health practitioners will be left with more complicated patients that take more time and money. These patients are generally less profitable, and could cause monetary problems for these offices.

17. More referrals: Primary care physicans and specialists will see more referrals as Wal-Mart and others like it determine that some cases are too difficult to be handled by the clinic. This would include finding doctors and sharing medical records.

18. Increased utilization of nurse practitioners: For the most part, Wal-Mart clinics are and will be staffed by nurse practitioners. This is part of a growing trend to use highly skilled and trained nurses instead of doctors.

19. Less red tape for known illnesses: For patients who have recurring or easily-diagnosed illnesses, Wal-Mart clinics will make getting treatment easier. This will help patients avoid the high cost of taking the time to visit a primary care physician.

20. Decreased continuity of care: With traditional doctors, patients have charts and medical records, but at in-store clinics, diagnosis is a one-off deal. Problems that could be caught over multiple visits and diagnosis could go unearthed unless the patient works to inform practitioners.

VON Canada selected as Regional Management Centre for the SMILE program (Seniors Managing Independent Living Easily)

February 26, 2008 (Ottawa, ON) – VON Canada - Ontario (Victorian Order of Nurses), through its local sites in Kingston and Trenton, has been selected, by the South East Local Health Integration Network (LHIN), as the Regional Management Centre for the SMILE program (Seniors Managing Independent Living Easily). The SMILE program will empower seniors and their caregivers in the South East to access home support services that are individualized to their specific needs.

According to VON President, Dr. Judith Shamian, this program is a collaborative initiative that focuses on empowering seniors by giving them new options to remain in their homes for as long as possible.

VON is responsible for ensuring equitable access to seniors across the region for selected traditional and non-traditional support services and resources (i.e. those that may come from a neighbour or friend, as well as established agencies), for developing and supporting the access portals, for providing service coordination, and for accountability for the performance of the SMILE program to the South East LHIN.

VON will administer the $9.7M program (over three years) in the region. The South East LHIN Board of Directors also approved the Victorian Order of Nurses as the program administrator. “We are very fortunate in the South East to have a network of terrific home-support care agencies and services.

VON will work with the community at large, its partner provider agencies, such as the South East Community Care Access Centre, and other agencies serving seniors to:
· Implement the SMILE functional program plan;
· Administer a system that allows an individualized service and delivery plan
for each senior on the SMILE program, and for accommodating the senior’s
choice in the level of assistance with service navigation;
· Establish service contracts with providers that include performance targets,
and for funding allocations; and,
· Manage or assist users in handling the transactions needed to pay for aging
at home services.

As the regional focal point for the program, the Regional Management Centre will play an integral role in facilitating the provision of comprehensive and standardized information related to the SMILE program and will work collaboratively with existing health service providers, associations and community groups to share information about health services already available in each community.

Coaching and Interprofessional Collaboration Project: Update from St. Joseph’s Health Centre in Toronto

St. Joseph’s Health Centre is continuing to develop knowledge and practice base around interprofessional collaboration. A new project, Enhancing Interprofessional Collaboration through Coaching in Healthcare Settings aims to further develop and evaluate coaching interventions within health care teams. Expanding on work the Health Centre has already successfully studied in a Ministry funded pilot in 2006, this new project will look at coaching interventions of health care teams within the hospital and community health care settings.

The project will increase the number of “Coach Champions” within the organization, disseminate coaching interventions to all point of care teams at the Health Centre and enhance the Interprofessional Collaboration (IPC) curriculum content in a previously created coaching manual. “The coaches are interdisciplinary,” said Keith Adamson, Manager, Interprofessional Practice. “There are coaches from pharmacy, diagnostic imaging, social work, and we are hoping to include physicians.”

The focus is mainly on group work although a tool is used called an ‘electronic maze’. “It’s a tool that really helps participants understand their communication and teamwork styles,” explained Chris Daly, Project Consultant. “It is a fun exercise and people love to take part. It really does allow people to see how they function.”

The project will also facilitate collaboration with Parkdale Community Health Centre in implementing their IPC initiative across five teams and support them in the development of a coaching manual tailored to the Community Health Centre context.

The project will be evaluated using three methods: survey, observation and a semi-structured questionnaire. The survey will be given to participants before the coaching intervention and then one month after. It was constructed based on the literature about core collaborator competencies (Oandasan & Reeves, 2005) and the essential elements for collaboration (Way & Jones, 2000). “The survey focuses on six dimensions critical to interprofessional collaboration’” explained Adamson. “Those dimensions are trust and respect, communication, shared decision making, knowledge of roles, willingness to collaborate, and conflict resolution.”

An observation tool will also be used pre and post intervention, looking for evidence of the same seven dimensions in the survey. A semi-structured questionnaire will be administered post intervention for the collection of further qualitative data.

“Currently there are eight coaches and we are looking to train another 20 at various levels within the organization,” said Adamson. “By the end of this phase in March 2009, 350 people at St. Joseph’s will have been involved, and a total of 400 including our community partners. The whole idea of building champions internally is so that there will be sustainability once the project comes to its conclusion,” he said.

The Health Centre believes in building a firm foundation for Interprofessional practice and we look forward to reporting back on the successes of this exciting new project.

Simple urine test leads to more accurate diagnoses, fewer false-positive results

PHILADELPHIA – An experimental biomarker test developed by researchers at the University of Michigan more accurately detects prostate cancer than any other screening method currently in use, according to a study published in the February 1 issue of Cancer Research, a journal of the American Association for Cancer Research.

The researchers say a simple urine test that screens for the presence of four different RNA molecules accurately identified 80 percent of patients in a study who were later found to have prostate cancer, and was 61 percent effective in ruling out disease in other study participants.

This is far more accurate than the PSA blood test currently in use worldwide, which can accurately detect prostate cancer in men with the disease but which also identifies many men with enlarged prostate glands who do not develop cancer, researchers say. Even the newer PCA3 test, which screens for a molecule specific to prostate cancer and which is now in use both in the U.S. and Europe is less precise, they say.

“Relative to what is out there, this is the best test so far,” said the study’s lead author, Arul Chinnaiyan, M.D., Ph.D., director of the Michigan Center for Translational Pathology at the University of Michigan.

He also says that this “first generation multiplex” biomarker test will likely be improved upon as researchers continue to uncover the molecular underpinnings of prostate cancer.

“We want to develop a test to allow physicians to predict whether their patients have prostate cancer that is so accurate a biopsy won’t be needed to rule cancer out,” Chinnaiyan said. “No test can do that now.”

Chinnaiyan and the Michigan researchers developed the test based on their recent finding that gene fusions – pieces of chromosomes that trade places with each other, causing two genes to stick together - are common in prostate cancer, and that by overriding molecular switches that turn off excess growth, they may be the causative factor in some forms of the disease. In 2005 they identified a prostate-specific gene called TMPRSS2 which fuses with either ERG or ETV1, two genes known to be involved in several types of cancer. In 2007, they identified another five genes that fuse on to ERG or ETV1 to cause prostate cancer.

In the current study, researchers built upon the PCA3 test by screening for six additional biomarkers, including TMPRSS2:ERG as well as some molecules generally over-expressed in prostate cancer, and some which are over-expressed in specific cancer subtypes.

Researchers collected urine samples from 234 men with rising PSA levels before they underwent prostate biopsy at a University of Michigan urology clinic. Among this group, biopsy results confirmed a diagnosis of prostate cancer in 138 patients; 96 patients were cancer-free.

Correlating the urine biomarker test results with the biopsy data, researchers found that, in combination, four of the seven biomarkers were significant predictors of prostate cancer: GOLPH2, which is generally over-expressed in prostate cancer; SPINK1, over-expressed in a subset of these cancers; the PCA3 transcript expression; and TMPRSS2:ERG fusion status. Of the seven markers, only PCA3 had been previously reported as a diagnostic biomarker.

When tested as individual biomarkers, GOLPH2, PCA3, and SPINK1 each outperformed PSA, which had identified all of the men in the study as potentially positive for prostate cancer. “PSA was not predictive at all,” Chinnaiyan said. “You might as well have flipped a coin.”

The combination of the four biomarkers achieved a specificity and positive predictive value of greater than 75 percent, which they found to be five percent better than use of a PCA3 test alone, he says. Specificity is the probability that a test indicates a negative result if a person does not have a disease, and the positive predictive value is the proportion of patients with positive test results who are correctly diagnosed.

Chinnaiyan believes that any tests that are developed and widely tested would first be used to supplement a PSA blood screen.

The study was funded by the Early Detection Research Network, Department of Defense, the National Institutes of Health, the Prostate Cancer Foundation, and Gen-Probe Incorporated of San Diego. The gene fusion technology has been patented by the University of Michigan and licensed to Gen-Probe Inc, which is also developing the PCA3 screening test. Chinnaiyan is a paid consultant to Gen-Probe.

# # #

The mission of the American Association for Cancer Research is to prevent and cure cancer. Founded in 1907, AACR is the world's oldest and largest professional organization dedicated to advancing cancer research. The membership includes nearly 27,000 basic, translational, and clinical researchers; health care professionals; and cancer survivors and advocates in the United States and more than 70 other countries. AACR marshals the full spectrum of expertise from the cancer community to accelerate progress in the prevention, diagnosis and treatment of cancer through high-quality scientific and educational programs. It funds innovative, meritorious research grants. The AACR Annual Meeting attracts more than 17,000 participants who share the latest discoveries and developments in the field. Special Conferences throughout the year present novel data across a wide variety of topics in cancer research, treatment, and patient care. AACR publishes five major peer-reviewed journals: Cancer Research; Clinical Cancer Research; Molecular Cancer Therapeutics; Molecular Cancer Research; and Cancer Epidemiology, Biomarkers & Prevention. Its most recent publication and its sixth major journal, Cancer Prevention Research, is the only journal worldwide dedicated exclusively to cancer prevention, from preclinical research to clinical trials. The AACR also publishes CR, a magazine for cancer survivors, patient advocates, their families, physicians, and scientists. CR provides a forum for sharing essential, evidence-based information and perspectives on progress in cancer research, survivorship, and advocacy.

New Chair in Diabetes Management at The University of Western Ontario

Dr. Stewart Harris to lead diabetes research Chair

     LONDON, ON, Jan. 31 /CNW/ - Dr. Stewart Harris, the lead investigator of
a study which revealed that half of Canadians with diabetes are not properly
controlling their disease, has been selected as the first holder of the
Canadian Diabetes Association Chair in Diabetes Management at The University
of Western Ontario.
     The Canadian Diabetes Association and Western each committed $1 million
to the Chair, the cornerstone of a $5 million National Diabetes Management
Strategy. The Chair was established to develop and evaluate evidence-based
models of optimal diabetes management, and to advance the prevention and
treatment of diabetes, with the ultimate goal of improving the lives of the
approximately two million Canadians diagnosed with the disease, and the
millions of others at risk.
     "I am honoured to accept this position, as it offers exciting
opportunities to harness the existing expertise and programs of related
research here at Western. My vision is to establish a diabetes research
population cohort that will allow us to identify and respond to major gaps in
care, and to provide interdisciplinary research and training opportunities,"
said Dr. Harris. "As Ontario embarks on a major reform of primary care
delivery, the time is ripe to promote optimal diabetes care as a model of
effective chronic disease management."
     Dr. Harris is a professor in Family Medicine, Epidemiology and
Biostatistics, and Endocrinology at Western's Schulich School of Medicine &
Dentistry. He also holds the Ian McWhinney Chair in Family Medicine Studies.
Dr. Harris was the chair of the 2003 Clinical Practice Guideline Committee and
past-chair of the Clinical and Scientific Section of the Canadian Diabetes
Association. His major research interests focus on type 2 diabetes in
high-risk populations including Aboriginal Canadians and new immigrants, as
well as translational research on improving the management of diabetes in
primary care settings.
     "We're especially pleased about the appointment of Dr. Stewart Harris as
the inaugural Canadian Diabetes Association Chair in Diabetes Management at
The University of Western Ontario," said Michael Howlett, President & CEO,
Canadian Diabetes Association. "Stewart's commitment to diabetes is clear and
his position as a leader in the diabetes research community is well
established."
     Western and the Canadian Diabetes Association are working together to
raise an additional $3 million for the National Diabetes Management Strategy.

     The Canadian Diabetes Association works to prevent diabetes and improve
the quality of life for those affected by diabetes, through research,
education, service and advocacy. With a presence in more than 150 communities,
the Canadian Diabetes Association's strong network of assistance includes
volunteers, employees, healthcare professionals and partners. To learn more,
visit www.diabetes.ca or call 1-800-BANTING (226-8464).

     The Schulich School of Medicine & Dentistry at The University of Western
Ontario provides an outstanding education within a research intensive
environment where tomorrow's physicians, dentists and health researchers learn
to be socially responsible leaders in the advancement of human health.

McGuinty government halts bidding process for home care contracts across the province

Minister acts out of concern for loss of continuity of patient care

   TORONTO, Jan. 28 /CNW/ - The McGuinty government is halting the
competitive bidding process for home care contracts across the province in
order to ensure that Ontarians receiving home services continue to receive the
highest quality of care.
   "I work for patients and I am not going to put their relationships with
health care workers at risk," said George Smitherman, Ontario's Minister of
Health and Long Term Care.
   A January 28 memo from the ministry to board chairs and executive
directors of Ontario's Community Care Access Centres asks all centres to
cancel bidding processes now underway for nursing, personal support,
homemaking and therapy services and to not restart such processes.
   "To ensure there is no uncertainty, existing contracts will be extended,"
said Smitherman. "All processes for other contracts are being halted. In the
meantime, we have a fair bit of policy work to do. And my focus is on
maintaining the quality of services currently being provided."
   Last week, Smitherman stopped the awarding of the home care services
contract in Hamilton and surrounding areas, which was the only community where
the awarding of a contract was imminent.
   The January 28 memo further tells CCACs that the government is reviewing
the bidding process and related policies and procedures to "ensure they
support the principles of putting the client first, continuity of care and
stability for health care workers to ensure Ontarians receive the highest
quality home care services possible." It also states that further details will
be provided in the near future.

The Michener Institute looking to expand archives during its 50th Anniversary

January 28^th, 2008 TORONTO – The Michener Institute for Applied Health Sciences is beginning its 50^th Anniversary celebrations with The Golden Archives Launch on Tuesday, January 29^th, 2008 at 10 a.m.

As the first 50^th Anniversary event, The Golden Archives Launch marks the beginning of a year long campaign to gather items from alumni, students and past and present faculty and staff to expand the school’s archives. Michener is looking for donations of brochures, event programs, photos and other items people may have from their time at Michener. There will also be a video camera set up at the Launch for guests to record their favourite Michener memories. Some messages will be transcribed into the 50^th Anniversary commemorative book at the end of the year.

“This event will give us the opportunity to add to our archives and give people a chance to tell us stories about what Michener means to them,” says Dr. Paul Gamble, President and CEO, The Michener Institute. “In celebration of our 50^th year we invite anyone with memories and artifacts from Michener to come and share those with us and donate items to our archives.”

n addition to The Golden Archives Launch there are other events throughout 2008 to celebrate the major milestone of reaching 50.

• An appreciation event for Michener educators, past and present, held in May.
• In September Michener will host a street party for the Michener community, the University Avenue hospitals, Baldwin Village and the Queen Street West community.
• At the end of November, the very first Homecoming weekend will be held in conjunction with Michener’s Open House.
• On Homecoming weekend Michener will also host it’s first Alumni and Friends Gala Dinner.

What began as a Medical Laboratory pilot program at Toronto General Hospital is now an educational facility boasting over 18 full-time, part-time and continuing education programs, many unique to Ontario and Canada.

In the last 50 years many new programs and initiatives have helped Michener gain the reputation it has today. Programs like Respiratory Therapy, introduced in 1969, and Anesthesia Assistant, introduced in 2005, show that Michener is always evolving to fill the needs set forth by the Canadian health care system. Partnerships with Canadian universities such as U of T and Dalhousie, and international connections in Trinidad & Tobago and Jamaica make Michener well respected in the academic communities of many countries.

For Michener, the 50^th Anniversary is a celebration of accomplishments from the past, enjoyment of the present and a look forward towards the future at what is to come.

Event: The Golden Archives Launch

Date: Tuesday, January 29^th, 2008 at 10 a.m.

Where: The Michener Institute for Applied Health Sciences, 222 St. Patrick Street, Toronto, Ontario (One block west of University Avenue and north of Dundas Street)

For more information about Michener, interview requests or media tours:
Iliana Arapis 416-596-3120 / IArapis@michener.ca

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Government of Canada is investing $3.7 million to ensure that public health services can be more efficient and effectively delivered in First Nations

January 10, 2008

KENORA - The Honourable Tony Clement, Minister of Health and Minister for the Federal Economic Development Initiative for Northern Ontario, today announced that the Government of Canada is investing $3.7 million to ensure that public health services can be more efficient and effectively delivered in First Nations communities across Ontario.

This new project – the Ontario First Nations Public Health Initiative – is a three-year agreement supported by the Government of Canada, the Province of Ontario, and the Chiefs of Ontario, and will ensure that:

• The public and on-reserve health systems will be better integrated with better coordination of health information systems;
• A new information system will be established which will be used in First Nations communities for sharing on-reserve patient information with provincial public health units;
• Health professionals will be able to share information about communicable diseases with First Nations communities.

This agreement will also include extensive consultations with the more than 130 First Nations communities in Ontario.

"I am pleased to announce that the Government of Canada is providing $3.7 million to support this initiative," said Minister Clement. "This project is the first of its kind to improve the delivery of public health services to Ontario First Nations communities. It will ensure that First Nations people in Ontario have an effective role in the design and delivery of public health services."

"This is a very exciting day for all First Nations in Ontario as we welcome the announcement of the first “Made-in-Ontario” First Nation Public Health Project," said Angus Toulouse, Regional Chief, Chiefs of Ontario. "It should be recognized that almost one-third of all First Nations people in Canada originate from territories in Ontario. The project is aimed at improving public health services on reserve and has been driven by First Nations communities desiring, and entitled, to improved public health services," he added.

Today's announcement builds upon an agreement made in May 2006 at the Ontario First Nations Public Health Dialogue Forum to investigate opportunities for collaboration on First Nations public health information management.

At the event, Minister Clement also noted other initiatives currently underway to help improve the quality of life for First Nations in the Kenora area:

• The Government of Canada has provided $200,000 to the Kenora Chiefs for the development of a local public health pilot project, in cooperation with the Assembly of First Nations.
• The Government of Canada has provided the Kenora Access Centre with $122,156.00 and the Northwestern Health Unit with $152,580 this year for the Children's Oral Health Initiative, which helps to prevent and control tooth decay and other oral diseases in young First Nations and Inuit children. To date, some 1,450 children have benefited from this project in the Kenora area.
• In October 2007, the Government of Canada provided over $1M to the Kenora region to support: broadband infrastructure in four remote First Nations, the local Community Futures Development Corporations, an online bookkeeping system for Shibogama First Nations Council, and to support a feasibility study for the Northern Forest Innovation Centre.