Research

Baker and Norton Release Results of First National Study of Adverse Events

"The Canadian Adverse Events Study: the incidence of adverse events in hospital patients in Canada", authored by HPME's Ross Baker , University of Calgary's Peter Norton, and others, was published in the May 25 edition of the Canadian Medical Association Journal. The study is the first to map the extent and nature of adverse events which occur in Canadian hospitals. An adverse event is defined as any unintended injury or complication resulting in death, disability or prolonged hospital stay caused by health care management rather than the patient's underlying condition.

The methods used in the study are based on a protocol from the Harvard Medical Practice Study of adverse events in New York State Hospitals (1984). This protocol was modified and used in subsequent studies in Australia, the UK, New Zealand, Utah and Colarado (US) and Denmark . Twenty hospitals were randomly selected in five provinces (BC, Alberta, Ontario, Quebec and Nova Scotia), including a teaching hospital, a large community hospital and two small hospitals from each province. Data was collected from adult patient charts, not including pediatric, obstetric or psychiatric charts. A total of 3,745 charts were reviewed according to 18 criteria known to be associated with adverse events.

Study results found that the Canadian adverse events rate was 7.5 per hundred patient admissions. Nearly 37 per cent of errors were found to be preventable. Based on hospital admission of 2.5 million adults for medical or surgical care in Canada in 2000, this rate suggests that approximately 185,000 experienced an adverse event. Few adverse events resulted in permanent disability (5%) or death (1.6%). These findings were similar to studies conducted in UK, New Zealand and Australia. However, most adverse events resulted in longer hospital stays. Patients who experienced an adverse event spent an estimated six days in hospital as a result of the event. Adverse events occurred more frequently in teaching hospitals, most likely due to the greater complexity of patient conditions and the interaction of a greater number of care providers. Key areas that were identified for improvement included medication safety and surgery, and the authors emphasized the need for system change to reduce the likelihood of adverse events occurring.

For responses to this study, click on the links listed below:

Association of Canadian Academic Healthcare Organizations (ACAHO)

Academy of the Canadian Executive Nurses (ACEN)

Canadian College of Health Services Executives (CCHSE)

Canadian Council on Health Services Accreditation (CCHSA)

Canadian Medical Association (CMA)

Canadian Pharmacists Association (CPA)

Canadian Society for Hospital Pharmacists (CSHP)

Ontario Hospital Association (OHA)

Ontario Medical Association (OMA)

Ontario Ministry of Health and Long-Term Care (MOHLTC)

Registered Nurses of Ontario (RNAO)

The Canadian Adverse Events Study was co-funded by the Canadian Institute for Health Information (CIHI) and the Canadian Institute for Health Research (CIHR). The national research team includes Dr. Ross Baker (HPME), Dr. Peter Norton (University of Calgary), Virginia Flintoff (HPME), Dr. Adalsteinn Brown (HPME), Dr. Ed Etchells and Dr. Philip Hebert (U of T), Drs. William Ghali and Dr. Maeve O'Beirne (University of Calgary), Dr. Sumit Majumdar (University of Alberta), Dr. Sam Sheps and Dr. Robert Reid (UBC), Dr. Regis Blais (Universite de Montreal), Dr. Jafna Cox (Dalhousie University) and Dr. Robyn Tamblyn (McGill University).

Bonney and Baker Review Federal and Provincial Patient Safety Initiatives

Just preceding the release of the Canadian Adverse Events Study, Elizabeth Bonney (MHSc student in HPME) and Ross Baker (Professor in HPME) published an overview of federal and provincial patient safety initiatives in Canada in Healthcare Quarterly (Vol.7 No.2). In "Current Strategies to Improve Patient Safety in Canada: An Overview of Federal and Provincial Initiatives" (abstract only), Bonney and Baker describe a variety of approaches which governments have taken, including the development of patient safety frameworks, patient safety working groups, surveys, legislation, the inclusion of patient safety in quality improvement initiatives, patient safety symposiums and lectures, and improved reporting. The authors emphasize the need for policy and organizational responses from governments and the creation of open reporting environments as keys to creating a culture of patient safety.

Raisa Deber on Taking Our Medicine: Who Should Pay for What?

In the most recent edition of Healthcare Papers (Vol.4 No.2), Professor Raisa Deber provides a Commentary on the proposal by Morgan and Willison funding pharmacare: "Taking Our Medicine: Who Should Pay for What?" (full-text). Morgan and Willison's "Post-Romanow Pharmacare: Last-Dollar First…First-Dollar Lost?" argues for the development of a pharmacare system that combines first-dollar coverage for required care with additional support for catastrophic costs. Deber supports Morgan and Willison's blended policy approach. However, Deber suggests that Morgan and Willison underestimate the difficulty of this task. First-dollar coverage requires defining which drugs are medically necessary and unlikely to cause more harm than good. First-dollar coverage may also drive up the demand for pharmaceuticals which produce marginal health benefits. How can policymakers decide when payment will improve health sufficiently to justify costs? Deber suggests that catastrophic drug coverage be implemented immediately while a program with the right blend of first and last-dollar coverage is developed. Raisa Deber is a full Professor in the Department of HPME and is the Director of the Medicare to Home and Community Research Unit (M-THAC).

Kevin Leonard Identifies Critical Success Factors for New Technology Adoption

Dr. Kevin J. Leonard, Associate Professor in the Department of HPME, published the article, “Critical Success Factors Relating to Healthcare's Adoption of New Technology: A Guide to Increasing the Likelihood of Successful Implementation” in Electronic Healthcare, Vol.2, No.4, 2004. In this article, he uses storytelling to illustrate the struggles in implementing information technology in healthcare, such as remote access to patient records, film-less radiology, telemedicine, electronic discharge summaries, and so on. Five vignettes capture the problem, the decision-making processes, the solution selected and the outcomes when organizations in healthcare or other industries attempt to adopt a technological innovation. Leonard identifies five Critical Success Factors for the adoption and implementation of new technologies, emphasizing the need to evaluate the outcomes of the adoption of the technology and whether it meets the objectives of different stakeholders. Finally, Leonard proposes a framework for the evaluation of healthcare technology innovations, based on its ability to meet user needs, a comparison of the current and new technologies, and the functionality of the new technology. This promises to be an important contribution to improving the ability of the healthcare sector to take advantage of new and emerging technologies and innovations.

Williams Warns of Problems Facing Community Support Agencies in Downtown Toronto

If community support agencies (CSAs) are unable to address current challenges, many seniors in Toronto, including those at the greatest risk of illness and dependency due to poverty and isolation, will have nowhere left to turn for the services they require, warn co-investigators Paul Williams (Professor, Department of HPME), Janet Lum (Associate Professor, Department of Politics and Public Administration, Ryerson University) and Fern Teplitsky (Senior Health Planner, Toronto District Health Council) in their recently published report: “A Final Frontier: Impacts of Health Reforms and Population Change on the Community Support Sector in Toronto” (full-text).

Community support agencies play a vital role in the continuum of care in Toronto. They provide a wide range of health and social services including meals-on-wheels, supportive housing, friendly visiting, Alzheimer's day programs, adult day programs, crisis intervention and assistance, and transportation. “If hospitals reduce services, Community Care Access Centres and community agencies are often able to fill in the service gaps that result, but if the community support sector reduces service or is unable to meet client need, there is no further health ‘safety net'”, say the investigators. Care of elderly, disabled or ailing individuals will necessarily default to family members, although for many isolated seniors, even this is not an option.

Based on an analysis of the annual service plans that CSAs are required to submit to the provincial government, the report provides a snapshot of the demographic, economic and policy pressures at work within the sector. Despite fixed resources, CSAs are being asked to treat more clients with chronic illness and complex care needs than in previous years in part due to demographic changes, but also because of “upstream” policy shifts such as earlier hospital discharges, and caps on Community Care Access Centre budgets. Existing strategies aimed at holding down costs, increasing revenues and redesigning business practices to accommodate these changes are not enough to overcome the sector's declining ability to meet client needs, conclude the investigators.

The report lays the groundwork for additional solutions and strategies to be developed by the Toronto District Health Council in conjunction with sector providers; demonstrates the need for further investment into the sector from the Ministry of Health and Long-Term Care and other sources; and helps inform the city's ongoing health system planning process.

Bronskill, Anderson and Team Find High Use of Antipsychotics in Nursing Homes

A recent study of the use of neuroleptic drug therapy in nursing homes found that neuroleptic drugs (antipsychotics) were dispensed to 17% of older adults who had no previous history and to 24% of patients within one year of admission to a nursing home; in addition, 10% of patients received doses that exceeded thresholds. The study examined the medical records of 20,000 people aged 66 and over who entered a nursing home in Ontario between 1998 and 2000. Susan Bronskill (ICES, HPME) and Geoff Anderson (ICES, HPME) were lead authors of the article “Neuroleptic Drug Therapy in Older Adults Newly Admitted to Nursing Homes: Incidence, Dose and Specialist Contact” , published in the May 4, 2004 Journal of the American Geriatrics Society. Other members of the research team included Kathy Sykora (ICES), Walter P. Wodchis (Toronto Rehabilitation Institute and HPME), Sudeep Gill (ICES, Baycrest Centre for Geriatric Care), Kenneth I. Shulman (Sunnybrook and Women's College Health Science Centre) and Paula A. Rochon (ICES, Baycrest Centre for Geriatric Care, HPME).

Antipychotics, typically given for major psychiatric illnesses, are being prescribed for older adults with dementia. In an interview with CBC News on May 5, 2004 , Dr. Paula Rochon noted that, "These therapies have been associated with problems like instability and falls and some problems like Parkinson-type symptoms". The use of antipsychotics has been steadily increasing since the 1990's without conclusive evidence of their effectiveness and with the potential to cause harm, such as increased risk of stroke. Unlike the US, Canada does not have legislation restricting the use and dosage of these types of drugs for older adults.

Research and Teaching Profiles

Faculty associated with the Department of Health Policy, Management and Evaluation (HPME) are involved in a broad range of research activities with a variety of organizations. Success of the HPME Knowledge Transfer initiative is dependent on presenting our stakeholders with a unified, clear image of the depth and breadth of Departmental expertise. To promote greater internal awareness of the knowledge developed through HMPE, faculty research profiles are a regular feature of the newsletter.

This issue of the HPME newsletter features a research profile for Professor Audrey Laporte.

+ + PROFILE OF THE MONTH + +

Audrey Laporte , PhD

Audrey Laporte is an Assistant Professor in the Department of HPME, and is cross-appointed to both the Faculties of Law and Dentistry at the University of Toronto. Dr. Laporte is an economist with expertise in microeconomic analysis of resource allocation issues in healthcare. Her research interests include access to health care services; nurse retention and turnover across sectors; the operational efficiency of long-term care facilities, CCACs and hospitals; and the impact of socio-economic status on health.

Education and Work Background

Dr. Laporte completed her BA in Economics and Political Science at the University of Toronto in 1993 and her MA and PhD in Economics at the University of Guelph, graduating in 2001. Between 2000 and 2002, Laporte held a status-only appointment as an assistant professor with HPME. She was awarded a Lupina Foundation, Munk Centre for International Studies, Post-Doctoral Fellowship (2001-2002) and a Canadian Health Services Research Foundation (CHSRF) Post-Doctoral Training Award (2001-2003). As a post-doctoral fellow, Dr. Laporte benefited from the mentorship of the Health Care, Technology and Place (HCTP) program under the supervision of Professor Peter Coyte of the Department of HPME. Audrey joined HPME as a full-time tenure-track faculty in January 2003.

In addition to her research and teaching responsibilities, Dr. Laporte is currently also serving as:

• Co-chair of the 2005 Canadian Health Economics Study Group (CHESG) Conference in Toronto
• Organizer of the 2004 American Public Health Association (APHA) Annual Meeting pre-conference session, “Advances in economic evaluation methods”, to be held in Washington DC , November 2004
• Organizer of abstract review and planning of contributed sessions for the Economics Committee of the 2004 AUPHA Annual Meeting
• Manuscript Reviewer for a number of journals ( Health Economics, Social Science and Medicine, Canadian Journal on Aging, and Applied Health Economics and Health Policy )
• Grant/Proposal Reviewer for Alberta Heritage Foundation for Medical Research (AHFMR), Health Services Research Advisory Committee, Social Sciences and Humanities Research Council (SSHRC) and the Canadian Institute for Health Research (CIHR)
• Director of the Ontario Problem Gambling Research Centre

Research Activities

Dr. Laporte is currently a co-investigator and mentor in the Health Care Technology and Place (HCTP) program, a participant in the CHSRF/CIHR Chair in Health Care Settings and Canadians research program, a member of the From Medicare to Home and Community (M-THAC) research unit, and a research associate with the Institute for Policy Analysis (IPA). She is the principal or co-investigator of research grants totaling over $2.5 million. As principal investigator, Laporte is leading a number of studies which include: research on the operational efficiency of long-term care facilities in Canada (co-PI W. Berta), an inquiry into the impact of work setting and work choice on nurse retention and turnover across care settings (co-PI R. Deber), and an analysis of the relationship between health status, health behaviour and income inequality. She is also equally involved in studies that assess mechanisms for introducing cost effective interventions to improve the dental health of Aboriginal children (PI: H. Lawrence) and an economic analysis of the costs and quality of life in prostate cancer survivors (PI: M. Krahn).

A sample of recent publications (2002-4) include:

• Laporte, A. "Do economic cycles have a permanent impact on population health? Revisiting the Brenner hypothesis," forthcoming, Health Economics.
• Laporte, A . and Ferguson , B.S. (2003) “Income inequality and mortality: Time series evidence from Canada” , Health Policy, 66, 107-117.
• Ferguson , B.S., & Laporte, A . (2003). Investment in Health When Health is Stochastic (full-text). A working paper of the IPA.
• Coyte, P., Baranek, P., Laporte, A. , & Croson. (2002). Forecasting Facility & In-home Long-Term Care for the Elderly in Ontario: The Impact of Improving Health and Changing Preferences. (full-text). A working paper of M-THAC.
• Laporte, A. (2002) "A note on the use of a single inequality index in testing the effect of income distribution on mortality", Social Science and Medicine , 55(9), 1561-1570

Teaching and Supervisory Responsibilities

Dr. Laporte teaches Health Economics I (HAD5730) and Health Economics II (HAD5760), supervises Master's level students and is a thesis committee member for six doctoral students. She provides encouragement to students to prepare and submit conference abstracts and journal manuscripts. Under Dr. Laporte's mentorship, HPME students presented 4 papers at the CAHSPR conference in Montreal and five manuscripts based on their work are in preparation for journal submission.

Future Research and Training

Building on current research, Dr. Laporte is presently developing funding proposals to explore the operational efficiency and quality of care in Ontario's acute care hospitals, performance evaluation in home and community care and a comparative analysis of access to primary care services in the Canadian and US health care systems. More information on research programs Dr. Laporte is affiliated with can be found on the following websites:

• Health Care Settings and Canadians: www.hcerc.utoronto.ca
• Health Care, Technology and Place (HCTP): www.hctp.utoronto.ca
• From Medicare to Home and Community (M-THAC): http://www.m-thac.org
• Institute for Policy Analysis (IPA): http://www.chass.utoronto.ca/ipa/

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