bluuebunny/crossref_metadata_2025_split huggingface dataset:
“I think this is maybe our Achilles heel…” exploring GPs’ responses to young people presenting with emotional distress in general practice: a qualitative study
Authors: Roberts Jane H , Crosland Ann , Fulton John 
Published: September 2013

ObjectiveAn exploratory study to investigate general practitioners’ (GPs’) views and experiences of consulting with young people (aged 12–19 years) presenting with emotional distress in general practice.DesignA qualitative study using grounded theory and situational analysis. Empirical data were generated through in-depth interviews based on a topic guide developed from the literature, and augmented with a series of situational maps. Continuous field notes and theoretical memos were recorded during data collection and analysis.The data were analysed using the constant comparative method of grounded theory. There were three levels of analysis. The first level developed the open codes and is presented here.Setting18 general practices located in the north east of England. The practices recruited included rural, urban and mixed populations of patients who were predominantly living in socioeconomically disadvantaged communities.Participants19 GPs (10 women) aged between 29 and 59 years participated. The modal age range was 40–49 years. Theoretical sampling was used to guide recruitment and continued until theoretical saturation was reached.ResultsThe overarching finding was that anxiety about practice dominated clinical consultations involving young people presenting with emotional distress. GPs responded differently to anxiety and to related uncertainties about professional practice, independent of GP age or gender. Anxiety occurred in the consultation, at an external level, across disciplinary boundaries, in relation to communication with young people and secondary to the complexity of presentations.ConclusionsAdolescent emotional distress presents professional challenges to GPs who feel ill-equipped and inadequately prepared to address early need. Medical education needs to prepare doctors better. More research is needed to look at what factors facilitate or prohibit greater GP engagement with emotionally distressed young people.
The work of commissioning: a multisite case study of healthcare commissioning in England's NHS
Authors: Shaw Sara E , Smith Judith A , Porter Alison , Rosen Rebecca , Mays Nicholas 
Published: September 2013

ObjectiveTo examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.DesignMultisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.ParticipantsPrimary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.SettingThree ‘commissioning communities’ (areas covered by a primary care trust) in England, 2010–2012.ResultsCommissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official ‘commissioning cycle’ promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.ConclusionsCommissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.
THE EPIDEMIOLOGY AND HEALTH SYSTEM IMPACT OF MEDIUM-CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY AMONG AFFECTED CHILDREN AND THOSE WITH FALSE POSITIVE NEWBORN SCREENING RESULTS IN ONTARIO, CANADA
Authors: Karaceper Maria D , Chakraborty Pranesh , Coyle Doug , Wilson Kumanan , Potter Beth K 
Published: September 2013

IntroductionLimited research has focused on the health system impact of rare genetic disorders, including inborn errors of metabolism (IEM). Investigating patterns of health services use and their association with social and geographic characteristics is important for understanding the burden of disease, including the impact of screening and clinical management; and for identifying potential inequities in access to care.ObjectivesWe conducted an observational study to provide a comprehensive description of the epidemiology and health system impact of IEM in Ontario, beginning with medium-chain acyl-CoA dehydrogenase deficiency (MCADD).MethodsThe study cohorts consist of Ontario infants diagnosed with MCADD following a positive newborn screening result from April 2006 through March 2010 (n=45); and those who received a false positive screening result for MCADD during the same time period (n=51). The primary control population includes a random sample of infants with negative screening results. Two distinct secondary control groups were created by matching to the truly affected cohort and the false-positive cohort, respectively. Screening and confirmatory testing results are securely linked at the individual level with population-based administrative databases encompassing health services use (physician visits, hospitalizations, and emergency department care) for all insured Ontarians from April 2006 through March 2012. Based on the results of a literature review we conducted to identify existing approaches to addressing statistical reliability with small sample sizes, analyses are largely descriptive.ResultsWe will describe: (i) the patterns of health care services use overall and by sociodemographic and geographic characteristics, (ii) the associations between types of service use and proxy health outcomes, and (iii) the costs of care.
SCOPE AND NATURE OF YOUNG SUDDEN CARDIAC DEATH IN NEWFOUNDLAND & LABRADOR
Authors: Hamilton Gina , Avis Simon , Curtis Fiona , Young Terry-Lynn , Connors Sean , Hodgkinson Kathleen 
Published: September 2013

IntroductionSudden cardiac death (SCD) in young people is a tragedy for families and communities alike. It is often due to an underlying genetic arrhythmic condition. In 2008, we identified a significant genetic defect (TMEM43; P358L) in patients and extended relatives from 22 unrelated families with Newfoundland ancestry. We showed that the clinical consequence of harboring the TMEM43 mutation is early SCD (50% of untreated males deceased by 40 years, 80% by 50 years). One study from Ontario using a 2008 cohort assessed the incidence of potential SCD in persons aged 2–40y to be 14.8 per 100,000. We hypothesize that NL may have a higher incidence of early SCD in this age category due to TMEM43 and possibly other underlying genetic causes, given the historical genetic isolation of the population.MethodsFollowing local REB approval (#12.199) we ascertained cases of sudden death from the comprehensive Medical Examiners provincial database. Cases that satisfied the following three inclusion criteria were reviewed: 1) date of death in 2008, 2) age at death aged 2-40y inclusive, and 3) manner of death listed as “natural-cardiac”, “natural-other”, “accidental”, or “undetermined”. Each case was then individually analyzed by the research team to determine likelihood of SCD.ResultsAll the 2008 NL cases were ascertained, and all (anonymous) data maintained on an SPSS dataset. There were 12 “natural-cardiac” cases, 8 “natural-other”, 48 “accidental”, and 2 “undetermined”, giving a total of 70 'potential' SCD cases in those aged 2–40y. The Ontario study yielded 976 'potential' cases. The 'potential' incidence of sudden death for Ontario of 14.8 per 100,000 compares with 30.1/100,000 in NL (with denominators of 6,602, 680 and 232,210 derived from statistics Canada for the provincial populations between 2–40y respectively). This represents a significant increase of potential SCD in NL (p=0.02).ConclusionThese figures include cases which are likely not SCD's. However, the methodology used to compare the populations was exactly the same. It appears therefore that NL had more deaths in 2008 in this age cohort than Ontario. The reasons for this difference are yet to be determined.
SOCIO-DEMOGRAPHIC DETERMINANTS OF FAMILIAL AND PARTNER PRESSURES TO CONCEIVE IN HIV-POSITIVE WOMEN IN ONTARIO, CANADA
Authors: Mehta Sachin , Newmeyer Trent , Loutfy Mona , Faught Brent 
Published: September 2013

IntroductionAccess to antiretroviral therapy has improved quality of life, minimized vertical transmission, and reduced mortality and morbidity in HIV-infected women. With these advances, many HIV-infected women and their partners are deciding to have children or carry unplanned pregnancies to term.ObjectiveTo examine the relationship between socio-demographic factors and family and partner pressures to conceive in HIV-positive women in Ontario, Canada.MethodsCross-sectional design examined data from the HIV Pregnancy Planning Questionnaire conducted in Ontario, Canada between 2007 and 2009. HIV-positive women aged 18-52 years were included in the analysis. A total of 486 women and 336 women provided information on family and partner pressures to conceive, respectively. Step-wise logistic regression was used to examine the relationship between socio-demographic variables and family and partner pressures to conceive. Socio-demographic variables included age, ethnicity, religion, country of birth, marital status, annual household income, education, years lived in Canada, number of lifetime births, HIV medication, hepatitis C co-infection, CD4 cell count, and viral load.ResultsThere is 0.95 (95% CI: 0.91-0.99; p-value: 0.0253) and 0.95 (95% CI: 0.93-0.98; p-value: <.0001) lower odds of family pressures to conceive with increased age and years lived in Canada, respectively. Women married or in common-law relationship have 3.08 (95% CI: 1.39–6.80; p-value: 0.0055) and women having 2 lifetime births have 1.98 (95% CI: 1.02–3.84; p-value: 0.0428) higher odds of family pressures to conceive. There is 0.96 (95% CI: 0.93-0.98; p-value: 0.0013) lower odds of partner pressure with increased years lived in Canada. Women married or in common-law relationship have 4.20 (95% CI: 1.58–11.17; p-value: 0.0040) and those living with partner (but are not married or in common-law relationship) have 4.47 (95% CI: 1.27–15.67; p-value: 0.0195) higher odds of partner pressures to conceive.ConclusionResults suggest that age, number of years lived in Canada, marital status, and number of lifetime births are associated with family and partner pressures to conceive. Identification of these factors will allow health care providers to assist HIV-positive women and their partners make informed reproductive decisions.
DEVELOPING AND TESTING A TOOL FOR ASSESSING PHARMACOECONOMIC EVALUATIONS
Authors: Sabarre Kelley-Anne , Coyle Doug , Lee Karen 
Published: September 2013

IntroductionManufacturers seeking reimbursement from publicly funded drug plans submit a drug submission to the Common Drug Review (CDR). This includes clinical data and a pharmacoeconomic evaluation (PE) which is assessed by clinical and economic teams. Clinical and pharmacoeconomic reports are used by the Canadian Drug Expert Committee (CDEC) in their deliberations, which could result in a “do not list”, “list with criteria” or “list” formulary listing recommendation (FLR). Given growing financial constraints, the need to economic information to inform FLR decision makers is critical. Therefore, understanding the quality and limitations with regards to economic submissions can assist FLR decision makers. This report focuses on the development and piloting of a PE appraisal instrument.ObjectivesTo develop an instrument for assessing the quality of PEs in terms of adherence to guidelines, methodological quality and transparency of reporting, and use of indirect treatment comparisons.MethodsAn existing PE appraisal instrument was updated using a quality assessment framework (QAF). A literature review was conducted to identify additional key factors affecting methodological quality. Modifications to the tool were made upon consensus. The instrument was piloted by three investigators using 29 selected PEs and accompanying pharmacoeconomic reports. A pooled kappa statistic was calculated. The instrument was evaluated by identifying items met from QAF and comparing it to four highly-recognised appraisal tools.ResultsThis tool includes 69 multiple-choice and short answer questions and covers: economic evaluation details, quality of pharmacoeconomic submissions, and use of pharmacoeconomic information by CDEC. The kappa statistic indicates substantial agreement [0.72(0.67–0.77)]. The tool fulfils all dimensions of QAF and is at least as comprehensive as other published appraisal instruments.ConclusionsThe steps in developing this PE quality appraisal instrument involved: quality assessment framework, literature review, draft tool, pretesting, re-drafted instrument, inter-rater reliability testing, and final instrument. Although this tool was created to examine PEs submitted to CDR, components of this instrument can be used beyond the realm of CDR PE assessments. Its practicality, reliability and parity to other appraisal tools demonstrate its potential application in the development and appraisal of PEs.
DISEASE, PATIENT AND HEALTHCARE SYSTEM LEVEL PREDICTORS OF ACCUMULATED INPATIENT DAYS AND HOME CARE USE FOR METASTATIC GASTRIC CANCER PATIENTS
Authors: Mahar Alyson L. , Viola Raymond , Johnson Ana P. , Coburn Natalie G. 
Published: September 2013

IntroductionHome care has been proposed as a means of reducing costs in palliative care by decreasing inpatient stay without impacting quality of clinical care. Predictors of major cost drivers for end-of-life care are unknown for the management of metastatic gastric cancer.ObjectivesThis study examined disease, patient and healthcare system predictors of inpatient hospital days and receipt of home care.MethodsThis is a population-based, retrospective cohort study of data on patients diagnosed in Ontario between 2005 and 2008. Chart review and administrative data were linked, using a twenty-six month time horizon and the healthcare system perspective. The cumulative inpatient hospital stay was defined using admission and discharge dates from hospitalizations in the Canadian Institute for Health Information database. Home care use was defined as yes/no, using data from the Ontario Home Care Database. Negative binomial regression was used to model the number of inpatient hospital days and modified poisson regression to model the receipt of home care.ResultsPatients with primary tumours in the gastroesophageal junction compared to the distal stomach, and younger age incurred significantly fewer inpatient days. Patients who underwent a gastrectomy were significantly less likely to accumulate inpatient hospital days (RR 0.65; 95% CI 0.55-0.76), as were patients who interacted with a high volume specialist (RR=0.54; 95% CI=0.46-0.63). Proximal compared to distal tumour location was associated with an increased likelihood of receiving homecare (RR=1.12; 95% CI: 1.04-1.20). Increasing age was significantly associated with not receiving a home care visit (p=0.0010). Patients in the high resource use category were 78% more likely to receive home care than healthy users (RR=1.78; 95% CI=1.02-3.08). Patients interacting with a high volume specialist were 15% more likely to receive home care than those who did not (RR=1.15; 95% CI=1.09-1.21).ConclusionA number of predictors of healthcare resource utilization were identified; however, not all were modifiable. Further research needs to examine how differences in home care use and inpatient hospital stay impact clinical outcomes such as symptom relief and quality of life, and how policies may be targeted to reduce costs to the healthcare system while maintaining optimal clinical care.
A NON-PARAMETRIC APPROACH TO SELECTION BIAS: EXAMINING THE ORGANIZATIONAL EFFECT OF FAMILY MEDICINE GROUPS ON ACCESS TO PRIMARY CARE AMONG DIABETICS IN QUEBEC
Authors: Carter Renee , Quesnel-Vallée Amélie , Lévesque Jean-Frédéric , Harper Sam , Strumpf Erin 
Published: September 2013

IntroductionWithin Canada, Quebecers experience the greatest barriers in accessing primary care with over 25% of the population without a regular family physician and the highest rate of emergency department (ED) use. Family Medicine Groups (FMGs) were introduced in 2002 to provide greater access to care, namely for individuals with chronic conditions such as diabetes. Some key characteristics of the FMG organizational reform are: (1) it is based on voluntary physician take-up; (2) its regional variation in implementation; (3) its gradual deployment across the province. These factors may produce selection bias between early and late physician implementers.ObjectivesTo determine whether the regional rate of avoidable ED visits among diabetics co-varies with FMG wave of implementation distinguishing between early and late physician adopters of the model.MethodsAn ecological analysis will be conducted to meet this objective. The outcome is access to primary care measured by the regional rate of avoidable ED visits among diabetics between 2003 and 2012. Regions are defined on an urban to rural continuum according to each administrative region's distance from the province's main city centers, Montreal and Quebec City. The study will be conducted using linked administrative health databases for which access has already been granted. Non-parametric spline regression will be used to distinguish between waves of FMG implementation. The spline knots, denoting a significant change in the rate of avoidable ED visits, will be estimated from the data. To improve internal validity, the analysis will incorporate a control series examining trauma visits to the ED that should not be affected by the FMG reform.ResultsThe analyses are in progress and results are expected by the end of May.ConclusionThis study will be the first to empirically define waves of FMG implementation and their effects on access to primary care among diabetics. These findings will inform future studies examining access to primary care at an individual patient level where failure to control for FMG waves may produce biased estimates of the reform's organizational effect.
CLINICAL USE OF HEALTH-RELATED QUALITY OF LIFE OUTCOMES FROM CANCER CLINICAL TRIALS: PRELIMINARY RESULTS FROM A SURVEY OF ONCOLOGISTS
Authors: Rouette Julie , Blazeby Jane , Calvert Melanie , King Madeleine , Meyer Ralph , Peng Paul , Ringash Jolie , Walker Melanie , Brundage Michael D. 
Published: September 2013

IntroductionThere have been increasing efforts aimed at enhancing patient-centered care and incorporating patients' voice into clinical practice. As such, a growing body of literature has recognized the importance of Health-Related Quality of Life (HRQOL) outcomes from clinical trials. HRQOL outcomes are often collected in Phase III randomized controlled trials (RCTs), along with survival data, morbidity, and toxicity data. HRQOL outcomes are measures reported directly by the patient through a questionnaire and represent the patient's own evaluation of symptoms, physical functioning status, psychological well-being, and global health-related quality of life. In clinical practice, HRQOL outcomes from Phase III cancer clinical trials are key elements in treatment decision making, clinical outcomes interpretation, and determination of prognosis. However, several challenges to the use of HRQOL outcomes have led to difficulties for oncologists in interpreting HRQOL results and have contributed to their unfamiliarity with these outcomes, resulting in a difficulty understanding what a clinically meaningful finding is.ObjectivesTo describe oncologists' knowledge, attitudes, experience, facilitators and perceived barriers in HRQOL outcomes and to determine the association between these attributes and their demographic variables.MethodsA cross-sectional web-based survey was sent to all practicing oncologists from the NCIC Clinical Trials Group in Canada, the NCRI Clinical Trials Units in the United Kingdom and the Multi-site Collaborative National Cancer Clinical Trials Groups in Australia to collect information on the oncologists' attributes described above.ResultsPrevious findings from a qualitative preliminary study showed that there was strong support for reporting HRQOL outcomes in cancer clinical trials, but that barriers to the uptake of HRQOL data in clinical practice included the accessibility, generalizability, and quality of the data; reporting methods; and oncologists' perceived lack of knowledge required to interpret the data.ConclusionThe importance of HRQOL outcomes from RCTs to inform clinical practice is well described. However, there remain significant barriers to their uptake and use in clinical practice. Findings from this project will help develop future knowledge translation strategies in oncology and provide a basis for the design of effective ways to optimize the clinical applicability of these outcomes in the oncology practice.
A new proof of the Lie–Trotter–Kato formula in Hadamard spaces
Authors: Bačák Miroslav 
Published: September 2013

The Lie–Trotter–Kato product formula has been recently extended into Hadamard spaces by Stojkovic [Approximation for convex functionals on non-positively curved spaces and the Trotter–Kato product formula, Adv. Calc. Var. 5 (2012) 77–216]. The aim of our short note is to give a simpler proof relying upon weak convergence instead of an ultrapower technique.