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Objective: To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals.Design: Single-arm study with historical controls.Setting: Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario.Participants: Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity.Interventions: Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone.Main Outcome Measures: Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and costs incurred by community home-care services for patients following discharge from hospital.Results: The outcomes of 43 hospital admissions were matched with those of 363 controls. Patients enrolled in the program stayed longer in hospital (coefficient 3.3 days, P < .001), used more community care services following discharge (coefficient $729, P = .007), and were more likely to be readmitted to hospital within 3 months of discharge (coefficient 17%, P = .012) than patients treated in hospital. Total substituted costs of home-based care were not significantly different from the costs of hospitalization (coefficient -$501, P = .11).Conclusion: While estimated cost savings were not statistically significant, the limitations of our study suggest that we underestimated these savings. In particular, the economic inefficiencies of a small immature program and the inability to control for certain factors when selecting historical controls affected our results. Further research is needed to determine the economic effect of mature home-based programs. [ABSTRACT FROM AUTHOR]

Objective: To examine the feasibility and efficacy of integrating home health monitoring into a primary care setting.Design: A mixed method was used for this pilot study. It included in-depth interviews, focus groups, and surveys.Setting: A semirural family health network in eastern Ontario comprising 8 physicians and 5 nurses caring for approximately 10 000 patients.Participants: Purposeful sample of 22 patients chosen from the experimental group of 120 patients 50 years old or older in a larger randomized controlled trial (N = 240). These patients had chronic illnesses and were identified as being at risk based on objective criteria and physician assessment.Interventions: Between November 2004 and March 2006, 3 nurse practitioners and a pharmacist installed telehomecare units with 1 or more peripheral devices (eg, blood-pressure monitor, weight scale, glucometer) in patients' homes. The nurse practitioners incorporated individualized instructions for using the unit into each patient's care plan. Patients used the units every morning for collecting data, entering values into the system either manually or directly through supplied peripherals. The information was transferred to a secure server and was then uploaded to a secure Web-based application that allowed care providers to access and review it from any location with Internet access. The devices were monitored in the office on weekdays by the nurse practitioners.Main Outcome Measures: Acceptance and use of the units, patients' and care providers' satisfaction with the system, and patients' demographic and health characteristics.Results: All 22 patients, 12 men and 10 women with an average age of 73 years (range 60 to 88 years), agreed to participate. Most were retired, and a few were receiving community services. Common diagnoses included hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease. All patients had blood pressure monitors installed, 11 had wired weight scales,5 had glucometers, and 5 had pulse oximeters. The units were in place for 9 to 339 days. Three patients asked to have the systems removed early because they did not use them or found them inconvenient. The other patients and their informal caregivers found the technology user-friendly and useful. Health care providers were satisfied with the technology and found the equipment useful. They thought it might reduce the number of office visits patients made and help track long-term trends.Conclusion: These pilot results demonstrate that telehomecare monitoring in a collaborative care community family practice is feasible and well used, and might improve access to and quality of care. [ABSTRACT FROM AUTHOR]

A randomized controlled study called Anticipatory and Preventative Team Care (APTCare) explored a new role for nurse practitioners (NPs) within a multidisciplinary team. The aim of the study was to evaluate whether integrating NPs and a pharmacist was an effective approach for the management of patients living with multiple chronic illnesses. Over an 18-month period, three part-time NPs and a pharmacist became part of a rural Family Health Network (FHN). They established relationships with study patients and collaborated to provide optimum care. Each NP had 40 patients, all of whom received care in the home. Study results showed that an initial home visit was invaluable for establishing a care plan, developing a relationship with the patient and assessing the home environment. Ongoing monitoring at home, however, was found to be an inefficient use of the NP role. By the end of the study, all clinicians agreed that the NP role had been successfully integrated into the multidisciplinary team. [ABSTRACT FROM AUTHOR]

BACKGROUND: We hypothesized excess resistance factor ('active resistance') gives a dose--response curve (DRC) shoulder, deficiency of a factor required for drug sensitivity ('saturable passive resistance') gives a DRC terminal plateau, and alteration of a factor gives decreased DRC slope. METHOD: We used response rates from published non-small cell lung cancer (NSCLC) clinical studies to estimate mean percent tumor cell kill in each study (assuming cell kill is proportional to tumor volume change) and performed regression and meta-regression analyses of percent cell survival and patient survival vs planned dose-intensity. RESULTS: As single agents, cell kill approached that of combinations only at highest doses. While DRC shape varied between single agents, DRCs for all combinations tested flattened at higher doses. Patient median survival times also failed to vary significantly with dose for any combination. CONCLUSIONS: DRC flattening at higher doses suggests therapy efficacy is limited by deficiency/saturation of factors required for cell killing. Based on this and other clinical observations, we hypothesize: (1) active resistance may modulate cell killing at lower doses, but ability to overcome this by increasing doses is limited by saturable passive resistance (e.g. by non-cycling cells). (2) Cells surviving initial chemotherapy may upregulate active resistance mechanisms (permitting growth despite therapy). (3) If active resistance mechanisms are insufficient for growth/survival, cells may survive until therapy cessation by downregulating metabolism/cycling, becoming temporarily quiescent. This could help explain broad cross-resistance between agents and would imply that improved targeting of non-cycling cells will be required for major improvement in therapy efficacy. [ABSTRACT FROM AUTHOR]

Objectives: Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death., Methods: We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit., Results: Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both., Conclusions: Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients' preferences-emphasising the importance of NPs and physicians' role in supporting people near the end of life., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: The COVID-19 pandemic highlighted and exacerbated health inequities worldwide. While several studies have examined the impact of individual social factors on COVID infection, our objective was to examine how interactions of social factors were associated with the risk of testing positive for SARS-CoV-2 during the first two years of the pandemic., Study Design and Setting: We conducted an observational cohort study using linked health administrative data for Ontarians tested for SARS-CoV-2 between January 1st, 2020, and December 31st, 2021. We constructed multivariable models to examine the association between SARS-CoV-2 positivity and key variables including immigration status (immigrants vs. other Ontarians), and neighbourhood variables for household size, income, essential worker status, and visible minority status. We report main and interaction effects using odds ratios and predicted probabilities, with age and sex controlled in all models., Results: Of 6,575,523 Ontarians in the cohort, 88.5 % tested negative, and 11.5 % tested positive for SARS-CoV-2. In all models, immigrants and those living in neighbourhoods with large average household sizes had greater odds of testing positive for SARS-CoV-2. The strength of these associations increased with increasing levels of neighbourhood marginalization for income, essential worker proportion and visible minority proportion. We observed little change in the probability of testing positive across neighbourhood income quintiles among other Ontarians who live in neighbourhoods with smaller households, but a large change in probability among other Ontarians who live in neighbourhoods with larger households., Conclusion: Our study found that SARS-CoV-2 positivity was greater among people with certain combinations of social factors, but in all cases the probability of testing positive was consistently greater for immigrants than for other Ontarians. Examining interactions of social factors can provide a more nuanced and more comprehensive understanding of health inequity than examining factors separately., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Claire E. Kendall reports financial support was provided by Canadian Institutes of Health Research. Dr. Bayoumi was supported by the 10.13039/100004702Baxter and Alma Ricard Chair in Inner City Health at Unity Health Toronto and the 10.13039/501100003579University of Toronto. Dr. Claire Kendall was supported by a Clinical Research Chair in Strengthening Primary Care for Integrated Health Equity and the 10.13039/100008572University of Ottawa. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Inc. CC BY-NC-ND 4.0.)

Social prescribing (SP) embodies a comprehensive approach to addressing the social determinants of health. Access to Resources in the Community (ARC) is an innovative SP program offering bilingual services that involves a single point of entry for health and social needs and introduces practice changes to assist primary care providers in engaging patients, along with a nonclinical lay navigator who supports patients in accessing relevant community resources. The ARC team has created a SP toolkit offering practical guidance for setting up, implementing, monitoring the progress of and evaluating SP programs. The four ARC guides can be easily customized for application in diverse practice and research settings., Competing Interests: The authors declare no conflicts of interest.

Background: For more than a decade, the Patient-Centered Medical Home model has been a guiding vision for the modernization of primary care systems. In Canada, Ontario's Family Health Teams (FHTs) were designed in the mid-2000s with the medical home model in mind. These primary care clinics aim to provide accessible, comprehensive, and person-centered primary care services to communities across Ontario. Their services typically include mental health care for people experiencing common mental disorders, such as depression and anxiety disorders. It remains unclear, however, whether the mental health care delivered within FHTs is consistent with person-centered care approaches. In the current study, we aimed to explore the perspectives of FHT providers on the care delivered to people with common mental disorders to determine whether, and to what extent, they believed this care was person-centered., Methods: We conducted a qualitative grounded theory study involving interviews with 65 health professionals and administrators from 18 FHTs across Ontario. Transcripts were coded using a three-step process of initial, focused, and axial coding that mixed inductive and deductive approaches informed by sensitizing concepts on person-centeredness., Results: Practices and challenges associated with the delivery of mental health care in a person-centered way were captured by several themes regrouped into five domains: (1) patient as unique person, (2) patient-provider relationship, (3) sharing power and responsibility, (4) connecting to family and community, and (5) creating person-centered care environments. FHT providers perceived that they delivered person-centered care by delivering mental health care that was responsive, flexible, and consistent with biopsychosocial approaches. They emphasized the importance of creating long-lasting relationships with patients grounded in empathy and trust. Their challenges included being able to ensure continuity of care, adequately prioritizing patients' mental health issues, and meaningfully engaging patients and families as partners in care., Conclusions: Our findings suggest that FHT providers have adopted a range of person-centered practices for people with common mental disorders. However, greater attention to practices such as shared decision making, supporting self-management, and involving families in care would strengthen person-centeredness and bring teams closer to the Patient-Centered Medical Home vision., (© 2024. The Author(s).)