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Summary measures of population health, such as health-adjusted life expectancy, are increasingly being used to monitor the health status of regions and to evaluate public health interventions. Such measures are based on aggregated indicators of individual health and summarize health in a population. They describe population health status but have limitations in analytic studies of population health. We propose a broader framework for population health measurement. This classifies indicators according to their application (descriptive, prognostic, or explanatory), according to the conception of population (as an aggregate or a dynamic entity), and according to the underlying model of health. This approach extends the measurement repertoire to include indicators of the health of a population. [ABSTRACT FROM AUTHOR]

Stroke is amenable to the entire spectrum of health services, ranging from prevention of its risk factors, to the treatment of acute stroke and rehabilitation and palliation of stroke. The aim of this study was to determine the number of persons with the capacity to benefit from evidence-based effective stroke services. Population-based survey and registry data along with published, evidence-based recommendations for services were used to determine the number of persons in Eastern Ontario with stroke (including risk factors, acute stroke and chronic stroke) and their related need for services (including prevention programs, diagnostic services, treatment of acute stroke and rehabilitation). These estimates were then compared to the actual provision of these services. Estimates of the need for effective services exceeded the provision of all services with the exception of pharmacologic treatment for diabetes mellitus and carotid endarterectomy for acute stroke. The approach was able to identify both the under-provision and over-provision of evidence-based effective services for stroke. This study has shown that an epidemiologically-based needs assessment could be a useful basis for the planning of health services.

We used synthetic estimation and linear regression to estimate the prevalence of selected risk factors and health status indicators in small populations. The derivation was based on the sociodemographic characteristics of the populations and the relationships between these variables and the health variables, as measured by the Ontario Health Survey (OHS). The estimates were validated by a comparison with the direct results of the OHS (gold standards). Synthetic estimates were much less dispersed than the regression estimates or the direct OHS estimates. Regression estimates performed better than synthetic estimates on most validation indicators, and combined approaches performed marginally better yet, although there were few clear patterns. Although correlation coefficients with gold standards in excess of 0.8 were obtained for some variables, the estimates rarely met pre-determined criteria for accuracy. At present these techniques have limited value for public health workers, but further work is justified, especially on approaches combining synthetic and regression estimation.

Public administration of the Canadian health care program has been very successful in preserving a single-tiered system, ensuring accessibility and accountability, reducing administrative costs and the need for regulation, and fairly successful in achieving orderly planning and cost control. Although the provincial programs are administered by health departments, failure to link personal to public health services has robbed them of a population perspective, resulting in insufficient emphasis on prevention and on the effectiveness of interventions, and has hampered the development of comprehensive primary care. The program supports insufficient research and innovation, and has failed to link payments to performance. Four lessons for a national health care program are drawn from the Canadian experience: (1) keep it public; (2) use a single payer; (3) link personal health services to public health; and (4) provide health departments with policy expertise. Despite its overall success, the Canadian program can no longer be afforded. Many of the proposals for its reform challenge the values upon which the program is built.

Public Health agencies need up-to-date population data, and Statistics Canada's Taxation Family File (T1FF) database, developed annually from T1 personal income tax forms, may meet this need. We compared 1989 T1FF data for Ottawa-Carleton with census data. The overall population estimate for the region was 98% of the census figure. Equivalent figures were 94% for central cities, 98% for suburbs and 122% for rural areas. The T1FF underestimated the population of children (89%) and seniors (93%). Population estimates for smaller neighbourhoods were poorer, some being wrong by a factor of more than two. The errors are probably due to postal code conversion. The T1FF provides fairly accurate estimates of the population of larger areas, and can be much more current than census data. It is less accurate for smaller areas, offers a limited range of variables, does not specify gender for children, and is fairly expensive. Health units with a major commitment to needs-based planning should consider using the T1FF for denominator data, despite its limitations.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province's evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project's five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.

Background: Thrombotic thrombocytopenic purpura is an uncommon disease with a high mortality rate even with current treatment. The cause of the syndrome and its optimal treatment are unknown. Although both plasma exchange and plasma infusion have been useful treatments, it is not clear which is superior. In this report we describe a prospective randomized trial comparing plasma exchange with plasma infusion for the treatment of thrombotic thrombocytopenic purpura., Methods: One hundred two patients with thrombotic thrombocytopenic purpura were randomly assigned to receive either plasma exchange or plasma infusion with fresh-frozen plasma on seven of the first nine days after entry into the trial. The total volume of plasma received by patients undergoing plasma exchange was three times that received by patients undergoing plasma infusion. All the patients also received aspirin and dipyridamole. The outcomes in the two groups were compared at the end of the first treatment cycle (day 9) and after six months., Results: At the end of the first treatment cycle patients receiving plasma exchange had a higher rate of response as defined by an increase in the platelet count (24 of 51 patients) than those who received plasma infusion (13 of 51, P = 0.025). Of the 51 patients treated with plasma exchange, 2 died, whereas 8 of the 51 patients who received plasma infusion died (P = 0.035). After six months the outcome in the plasma-exchange group was still superior, with a response observed in 40 of 51 patients, whereas 25 of 51 patients in the plasma-infusion group responded (P = 0.002). Eleven patients in the plasma-exchange group died, as did 19 patients in the plasma-infusion group (P = 0.036). The overall mortality was 29 percent., Conclusions: Plasma exchange is more effective than plasma infusion in the treatment of thrombotic thrombocytopenic purpura.

The Motor Control Assessment has been developed as a research tool for the assessment of motor skills in physically disabled children. In tests of concurrent validity it was found to be highly correlated with the results of the Physical Abilities Chart (Pearson coefficient = .96), and satisfactorily correlated with ranking of motor ability assigned using the clinical judgment of physiotherapists (Spearman rank coefficients = .63 to .97 in diagnostic subgroups). Estimates of both interrater and intrarater reliability were also high, with intraclass coefficients above .95.

The Canadian national health insurance plan has not extended to disease prevention in any comprehensive way, and to this extent is incomplete. The Task Force on the Periodic Health Examination has done outstanding work, but no provincial insurance plan has systematically adjusted the benefit schedule to reflect its recommendations. Thus, the place of disease prevention under the Canadian system of universal health insurance is remarkably similar to that in the United States. Health promotion has a somewhat different meaning in Canada from that in the United States, emphasizing intervention at the population level more than health education of individuals. The health promotion movement now enjoys considerable support in Canada, especially in the public health sector, in voluntary agencies, and in the policies of the federal and several provincial departments of health. The movement is almost completely separate from mainstream health services, and is unrelated to the insurance program. To date, there has been mostly talk, but several structures are in place which should lead to action.

As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.

Indicator conditions were used to evaluate the quality of 686 episodes of care provided in two emergency departments and in five family physicians' offices. Overall, the care was considered adequate in 53% of the emergency department cases and in 40% of the cases dealt with in family physicians' offices, the difference being significant (P less than 0.01). Referrals were very common in both settings, and when quality was assessed solely on the basis of the care actually given by the primary-care providers the difference between the two settings disappeared. Half the observed deficiencies in care related to failure to document the findings from history-taking and physical examination. From these and earlier findings we conclude that the emergency department can be an appropriate setting for the care of nontraumatic illness.

As part of a study of long-term institutional care of the elderly, this report presents salient data concerning 193 elderly applicants. Physicians play an important role in decisions to apply for such care. More than half of the applicants and about 80% of their family members approved of the proposed move. The number applying to homes for the aged vs. other institutions seemed much greater than appropriate; many of these applicants appeared more elibible for placement in foster homes and specialized facilities for the demented, or for remaining in their own homes. About a fifth of the applicants could have continued living independently if they had received a reasonable amount of community assistance. Action implications include: 1) expansion and more informed use of community services, 2) more programs of supervised foster homes for the elderly, 3) construction of specialized institutions for the demented, and 4) a greater effort by institutions to satisfy the desire of many new residents to be involved there in useful tasks.

Health risk appraisal is an attractive health education technique but suffers from methodologic weaknesses. Many of the problems center on the formula that is usually used to estimate the combined effects of different disease precursors. The formula does not reflect current models of disease causation, underestimates the effects of protective factors, and confounds the effects of different precursors. We suggest a modification that resolves these problems by estimating the prevalence and associated composite relative risk for each combination of precursors before calculating the numerical estimate of combined risk. This method can be applied to the many diseases for which the data needed to support a multivariate approach are not available. We recommend its incorporation into existing appraisal instruments.

An attempt has been made to determine the true cost of providing primary health care for nontraumatic conditions in the emergency departments of two hospitals in Ontario and in the offices of family physicians. A total of 1117 patients presenting with 1 of 10 common symptom/sign complexes at the emergency departments or the offices of 15 participating family physicians were studies with regard to number of visits made, type of assessment by the physician, investigations undertaken, management, therapy and outcome of the illness. Costs were calculated from the charges that would be made against the provincial health services insurance plan and from the system of hospital financing in effect in the province. The average true cost per illness episode of this type of care was $14.63 in hospital A, $14.20 in hospital B and $15.90 in the family physician's office.

A random sample of 120 physicians in Ontario was studied to assess quality of care in primary care and test an hypothesis that quality of care was related to continuing medical education (CME) activities. The quality-of-care scores were obtained by an in-office audit of a random selection of charts. The scores were global scores for charting, prevention, the use of 13 classes of drugs, and care of a two-year period for 182 different diagnoses. There were no relationships between global quality-of-care scores based on these randomly chosen charts and either the type or quantity of the physicians' CME activities. These activities were reading journals, attending rounds, attending scientific conferences, having informal consultations, using audio and video cassettes, and engaging in self-assessment. The implications of these findings are significant for future research in CME and for planners of present CME programs.

As part of a study of long-term institutional care of the elderly, this report presents a comparison of the characteristics, health problems, and state of mind of 193 elderly applicants for such care (Group A) with those of 141 elderly persons living independently in the community (Group I). Group A members were older, living with a spouse less often, and had low incomes. They showed much more cerebrovascular disease, incontinence, recent loss of independence in the activities of daily living, dementia, recent hospitalization, loneliness, and depression. They had had much less recent involvement in social and recreational activities, although most had not been socially isolated. They had received more extensive help from relatives and friends, and it seemed unlikely that additional help from these sources would keep many more of these elderly persons out of institutions. Community agencies and services had been used by a relatively low proportion of Group A, and hardly at all by Group I.

A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days' care and were less likely to receive more than 31 days' care; those without a family physician more often received additional care (were referred, admitted or asked to return).

Obtaining the voluntary participation of family physicians in quality of care research is a major problem in family practice research. An innovative approach was therefore required to recruit 120 randomly selected family physicians in southern Ontario in a quality of care study by the College of Family Physicians of Canada. A network of physician recruiters oriented to the study was organized for each district. This recruitment method resulted in an 84.5% participation rate. The relationship of these physician recruiters to the candidate and the method of approach were important factors in the enrolment process: the highest participation rate (95%) was obtained when the recruiters were friends of the candidate and when a personal meeting was arranged (91%). Recruiters were given an information package to help them in the recruitment process and rated the most useful items as follows: a policy statement about confidentiality, a description of the study and reprints of a published feasibility study. These results illustrate that cooperation in research in family physicians' offices can become a reality.

The physician-social worker team in family practice offers potential benefits to both physician and patient. A demonstration of such attachments in Kingston, Ontario involved the equivalent of 3.5 fulltime social workers and 41 physicians. Social work services were provided to each participating physician for approximately half a day per week. Physicians used the service extensively, referring 630 patients over 24 months for a wide range of problems. Physicians evaluated the services favorably and the study shows social worker attachments to be feasible in the primary care setting.

The Sharbot Lake Family Medical Centre has a number of features which are unusual for medical practices in this rural area, including a nurse practitioner, a secretary-receptionist, and the use of an appointment system. Surveys were conducted to determine the acceptability of this style of practice to the population of the area. The results suggest that the health centre is just as acceptable as is conventional solo practice, and that a high proportion of residents in the area have quickly come to regard the physician in the centre as their family doctor.

For several years, the government of Ontario has undertaken to foster and develop experimental systems for the delivery of primary health care in the province. At the same time, the government wished to devise a strategy whereby the new health care programs could be rigorously evaluated. A Task Force on Evaluation of Primary Health Care Services produced a plan which yields quantitative information about the function of primary health care units. Three essential indexes of performances, comprising categories of Utilization and Financial Performance (UF-Index), Availability, Accessibility and Scope of Services (A-Index) and Quality of Care (Q-Index), were designed. Two additional quantitative indexes, Consumer Satisfaction and Health Professional Satisfaction, were proposed. The derivation and determination of the three essential indexes are provided in the paper in detail, along with acceptable criteria for performance and methods for comparing the performances of different types of practices in different kinds of population.

A prospective double-blind study of high cervical spinal cord stimulation conducted in eight moderately disabled, spastic, cerebral palsied children failed to demonstrate any significant improvement over base line function during chronic spinal cord stimulation at either optimal stimulation parameters or random placebo parameters. Chronic stimulation included 4 consecutive months of stimulation for 24 hours each day. Stimulators were randomly programmed at optimal parameters for 2 of the 4 months and at placebo parameters for the remaining 2 months. At the end of each month of chronic stimulation, subjects were assessed with a multidisciplinary test battery that included a self-assessment, specific clinical examinations, tests of gross and fine motor control, neuropsychological and neurophysiological tests, a detailed gait analysis, and video recordings. By 6 months after the completion of the study, only 1 of the 8 subjects continued to use his stimulator on a regular basis, with minimal benefit.

A satellite clinic provided treatment for children living in a community 50 miles from an established Crippled Children's Treatment Centre. An evaluation of the service indicated that children attending the Satellite received more frequent treatment, at reduced costs to parents and social agencies. These children showed greater improvement in motor function than a control group, although no corresponding improvement in self-help skills was detected. Parents expressed a high level of satisfaction with the new service. The Satellite Clinic is recommended as a model for children unable to obtain regular treatment at an established centre.

This feasibility study by the Practice Assessment Committee of the College of Family Physicians of Canada was conducted to define and produce instruments that could be used to assess quality of care rendered in family physicians' offices. The favorable response to these evaluations and the acceptance of the results indicates that this method can be useful to family physicians. The instruments identify family physicians' strengths and deficiencies so that with appropriate changes in the quality and efficiency of care, they are able to achieve higher levels of professional satisfaction. These methods may ultimately be used to establish acceptable standards for care given by family physicians in their offices.

We carried out a cohort study of mortality among 954 Canadian military personnel exposed to low-dose ionizing radiation during nuclear reactor clean-up operations at Chalk River Nuclear Laboratories, Chalk River, Ont., and during observation of atomic test blasts in the United States and Australia in the 1950s. Two controls matched for age, service, rank and trade were selected for each exposed subject. Mortality among the exposed and control groups was ascertained by means of record linkage with the Canadian Mortality Data Base. Survival analysis with life-table techniques did not reveal any difference in overall mortality between the exposed and control groups. Analysis of cause-specific mortality showed similar mortality patterns in the two groups; there was no elevation in the exposed group in the frequency of death from leukemia or thyroid cancer, the causes of death most often associated with radiation exposure. Analysis of survival by recorded gamma radiation dose also did not show any effect of radiation dose on mortality. The findings are in agreement with the current scientific literature on the risk of death from exposure to low-dose radiation.

Little information is available on the health status of persons 85 years or over. Recent United States data indicate that 20% of individuals 85 years of age or over reside in nursing and personal care homes and that among these institutional residents 31% are bedfast, 11% are chairfast and 71% manifest evidence of senility. An investigation into the health of persons 85 years of age or over in two Ontario counties revealed that 39% resided in long-stay institutions, and that one of the main differences between old people living independently in the community and those in institutions was the higher proportion of the latter needing help with the activities of daily living and showing mental disorientation. Of those individuals 85 years of age or over in institutions for 1 year, 26% acknowledged often feeling depressed and 18% acknowledged often wishing they were dead, but these tendencies were not more frequent in those 85 years of age or over than in those 65 to 84 years of age. These findings have implications for service and research needs and attitudes towards death.