Objectives: To monitor changes in human resource indicators during six years of restructuring in Newfoundland and Labrador, and to measure providers' perceptions of reform impact and attitudinal and ...behavioural reactions comparing changes in the St John's region, where hospital aggregation occurred, to other regions. Methods: Data on human resource indicators from 1995/96 to 2001/02 were obtained and analysed. The Employee Attitude Survey was sent to acute care staff (n = 5353) to assess perceptions of reform impact on workplace conditions, work-related attitudes, turnover intentions and personal characteristics. The response rate for 2000 and 2002 was approximately 42% (n = 1222 and 1034, respectively). Only respondents to both surveys (n = 589) were used in the analysis. Results: Increases in average employee and full-time equivalent numbers occurred in the St John's region, despite hospital closure and aggregation. Increases in staff dislocation and turnover were observed, but paid sick hours decreased. Sick leave and overtime costs increased. Although perceived workplace conditions, and attitudes and behaviours were generally negative, there was evidence of improvement over time, especially in St John's. Few significant regional or provider group differences were observed on most study variables. Conclusions: Aggregation of hospitals in St John's did not lead to a decrease in employee counts, or deterioration in human resource indicators or attitudes. However, province-wide initiatives are needed to promote more positive work environments and increase organizational effectiveness.
La population canadienne est vieillissante. À Terre-Neuve-et-Labrador, les maisons de soins infirmiers et les centres de santé supervisés offrent des soins de longue durée (SLD). Il peut y avoir une ...disparité entre l'offre de lits pour soins de longue durée et les besoins des clients. Afin de comparer le genre et le taux annuel de clients à la recherche d'un placement en SLD, les cohortes annuelles (N = 1 496) de cinq régions des services de santé provinciaux de Terre-Neuve-et-Labrador ont été comparées en utilisant des mesures objectives d'invalidité. Les besoins des clients ont été évalués à l'aide d'un arbre de décision et la répartition optimale des lits de SLD a été déterminée.
Dans les quatre régions, une petite différence a été observée en ce qui concerne le niveau d'invalidité. Toutefois, les clients du Labrador différaient de ceux des régions insulaires en âge, en intensité et en genre d'invalidité. Un arbre de décision a suggéré que le placement optimal était de 7 % pour l'hébergement, de 34 % pour les soins supervisés, de 17 % pour les soins supervisés pour les déficiences cognitives et de 42 % pour les soins infirmiers à domicile.
À Terre-Neuve-et-Labrador, les SLD en centre hospitalier reposent sur les maisons de soins infirmiers, alors que le principal besoin se situe sur le plan des soins supervisés destinés aux personnes souffrant d'une légère invalidité, avec ou sans déficience cognitive. Afin de restructurer les soins de longue durée, diverses approches sont nécessaires en raison de l'incidence de SLD et des disparités en ce qui a trait à la disponibilité des maisons de soins infirmiers et de lits de soins supervisés appropriés.
Cardiomyopathy and IHD are important morbid complications among renal transplant recipients. Age, diabetes, and sex remain important markers of risk. Smoking, hyperlipidemia, and hypertension appear ...to be the major reversible risk factors for IHD. Anemia and hypertension predict CHF. Definitive evidence on optimal intervention is lacking. Similarities in the renal transplant recipients to CRI patients with respect to cardiomyopathy and to the general population with respect to IHD suggest that extrapolation from those groups is reasonable in the interim.
The Canadian population is aging. In Newfoundland and Labrador, nursing homes and supervised care facilities provide Long-Term Care (LTC). There may be a mismatch between the provision of LTC beds ...and clients' needs. To compare the type and annual rate of clients seeking placement, to LTC, incident annual cohorts (N = 1,496) in five provincial health regions within Newfoundland and Labrador were compared using objective measures of disability. Client need was assessed using a decision tree and the optimal distribution of LTC beds was determined.
Within the four island regions, little difference was observed in degree of disability, but Labrador clients differed from the island regions in age, degree and type of disability. A decision tree suggested that optimal placement was 7% to housing, 34% to supervised care, 17% to supervised care for cognitive impairment and 42% to nursing home care.
In Newfoundland and Labrador, institutional LTC is dependent on nursing homes, whereas the major need is for appropriate supervised care for those with modest disability, with or without cognitive impairment. Different approaches to restructuring of long-term care in each region are necessary because of the differences in rates of presentation for LTC and differences in availability of nursing home and appropriate supervised care beds.
Autosomal dominant polycystic kidney disease (ADPKD) is a common Mendelian disorder that affects approximately 1 in 1000 live births. Linkage studies have shown that the majority (approximately 85%) ...of cases are due to mutations in PKD1 on chromosome 16p, while mutations in PKD2 on chromosome 4q account for most of the remaining cases. Locus heterogeneity in ADPKD is known to contribute to differences in disease severity, with PKD1-linked families having earlier onset of end-stage renal disease (ESRD) than PKD2-linked families (mean age at ESRD: 56 versus 70, respectively). In this study, 11 Canadian families with ADPKD were screened for PKD2 mutations. In four families, linkage to PKD2 was previously documented. In the remaining seven smaller families, one or more affected members had late-onset ESRD at age 70 or older. Using single-stranded conformational polymorphism analysis, one affected member from each family was screened for mutations in all 15 exons of PKD2, which were PCR-amplified from genomic templates. A spectrum of mutations was found in approximately 73% (8 of 11) of the families screened, with no difference in the detection rate between the PKD2-linked families and the families with late-onset ESRD. In three unrelated families, insertion or deletion of an adenosine in a polyadenosine tract (i.e., (A)8 at nt 2152-2159) was found on exon 11, suggesting that this mononucleotide repeat tract is prone to mutations from "slipped strand mispairing." All mutations, scattered between exons 1 and 11, are predicted to result in a truncated polycystin 2 that lacks both the calcium-binding EF-hand domain and the two cytoplasmic domains required for the interaction of polycystin 2 with polycystin 1 and with itself. Furthermore, no correlation was found between the location of the mutations in the PKD2 coding sequence and disease severity. Thus, these findings are consistent with other recently published reports and suggest that most PKD2 mutations are inactivating.
Objectives: To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of ...hospitals in the St John's region. Methods: Retrospective chart audits for the years 1995/96,1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery and women's health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the St John's region, and separately for hospitals in the rest of the province. Results: There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St John's. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronary artery bypass grafting (CABG) morbid event rate improved, although access to CABG was not optimal. Conclusions: Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.
Objectives: To monitor changes in registered nurses' perceptions of the impact of seven years of health care restructuring in Newfoundland and Labrador (NL) and to measure the attitudinal and ...behavioural reactions over four years comparing the St John's region, where hospital aggregation occurred, to other regions of the province. Methods: Data were collected on acute care nurses' personal characteristics and perceptions of the importance of reform and its impact on workplace conditions and health care quality in 1995,1999, 2000 and 2002. Nurses' attitudes and intentions were monitored across three time periods (i.e. 1999, 2000 and 2002). Results: Perceived workplace conditions and health care quality, as well as attitudes and behaviours were generally negative. However, there was some improvement over time. The temporal sequence of scores suggests that restructuring had an adverse impact on nurses' attitudes. Few significant regional differences were observed. Conclusions: Although health services restructuring had an adverse impact on nurses' attitudes, aggregation of hospitals in St John's region was achieved without further deterioration. Provincial wide initiatives are needed to promote more positive work environments and increase the organizational effectiveness.
Objectives: To determine whether increased expenditures to provide unrestricted access to expensive atypical antipsychotic drugs would be associated with a reduction in hospital utilization and cost ...by patients with schizophrenia. Secondary objectives were to determine the factors associated with length of stay (LOS) and readmission for schizophrenia sufferers.
Methods: Retrospective chart review identified all acute hospitalizations for schizophrenia in the province of Newfoundland and Labrador. LOS and readmission rates, as well as risk factors influencing them, were measured during three time periods: (1) 1995/96, beginning of restricted access; (2) 1998, last year of restricted access; and (3) 2000, second year of open access. Average per diem costs were multiplied by LOS to determine hospital expenditures, and the provincial drug plan database provided the amount of money reimbursed for antipsychotic drugs.
Results: Days of hospitalization for schizophrenia totalled 15,089 in 1995/96, 16,318 in 1998 and 15,691 in 2000, resulting in per annum costs of $6,474,095, $7,080,065 and $6,615,795, respectively. There were 57 (18.2%) fewer patients hospitalized and 98 (16.7%) fewer admissions during open access (2000) when compared to a period of restricted access (1995/96). However, median LOS in 2000 was significantly longer than in 1995/96 (22.0 vs. 15.0 days, P<0.001), and was independent of other factors significantly associated with LOS (e.g., suicidal ideation on admission). No change in the number of readmissions was observed. Government expenditures for atypical agents were $217,273 in 1995/96 and $3.8 million in 2000, a 17.5-fold increase.
Conclusions: The unrestricted reimbursement policy for atypical antipsychotics was associated with a large increase in drug plan expenditure, which was not offset by a decrease in hospital utilization by schizophrenia sufferers. Although a decrease in hospital admissions occurred, any associated savings were negated by an increase in LOS.
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