This thesis is composed of three studies pertaining to the quality of care for radical cystectomy in Ontario between 1992 and 2004. In the first paper, the associations between provider volume and both operative and overall mortality were assessed. In the second paper, potential factors that could explain the association between volume and outcome were explored. In the final paper, the impact of waiting for cystectomy on survival outcomes was evaluated. Methods: A total of 3296 patients undergoing cystectomy for bladder cancer in Ontario between 1992 and 2004 were identified using the Canadian Institute for Health Information Discharge Abstract Database and the Ontario Cancer Registry. The effects of hospital and surgeon volume on operative mortality and overall survival were assessed using random effects logistic regression and marginal Cox Proportional Hazards modeling, respectively. To elucidate the factors underlying the volume-outcome association, the ability of a number of structure and process of care variables to attenuate the impact of volume was assessed. The effect of waiting for care, from transurethral resection to cystectomy, on overall survival was also assessed using marginal Cox models. Results: Neither hospital nor surgeon volume was significantly associated with operative mortality; however, both were associated with overall mortality. Of the measured structure/process measures, hospital factors caused the greatest attenuation of the volume hazard ratios, albeit to a limited degree. The wait time between the decision for surgery and cystectomy was also significantly associated with overall survival. The impact of delayed care was greatest for patients with lower stage disease. The data suggested a maximum wait time of 40 days for cystectomy. Conclusions: In this thesis, gaps in the quality of care for radical cystectomy in Ontario were identified. Patients treated by low volume hospitals and surgeons or those with long wait times all experienced worse outcomes. Since the underlying measures responsible for provider volume remain elusive, additional work is required to understand what these factors are. Initiatives to decrease wait times, however, are under way in Ontario. Whether these interventions decrease wait times and benefit patients remains to be seen.

Objectives: (1) To calculate rates for maxillofacial (MF) injury-related visits in emergency departments (EDs) and hospitals in Ontario; (2) To investigate socio-demographic distribution of MF injuries; (3) To identify common causes for MF injuries. Methods: An 8-year retrospective study design was implemented. Two datasets were used: Discharge Abstract Database and National Ambulatory Care Reporting System. Color-coded maps were created using ArcGIS. Results: From 2004 to 2012 in Ontario, 1,457,990 ED visits and 41,057 hospitalizations due to MF injuries were registered. MF injuries are most frequent in males and occur mainly in evenings (7:00 to 9:00 pm) and weekends. Higher rates of MF injury are seen in rural areas and low-income neighborhoods. The leading cause of MF injuries is falls. Conclusion: 3 out of 100 ED visits and 1 out of 200 hospitalizations were caused by MF injury. Male youth and female older people suffered high rates of MF injury.

Objectives: (1) To calculate rates for maxillofacial (MF) injury-related visits in emergency departments (EDs) and hospitals in Ontario; (2) To investigate socio-demographic distribution of MF injuries; (3) To identify common causes for MF injuries. Methods: An 8-year retrospective study design was implemented. Two datasets were used: Discharge Abstract Database and National Ambulatory Care Reporting System. Color-coded maps were created using ArcGIS. Results: From 2004 to 2012 in Ontario, 1,457,990 ED visits and 41,057 hospitalizations due to MF injuries were registered. MF injuries are most frequent in males and occur mainly in evenings (7:00 to 9:00 pm) and weekends. Higher rates of MF injury are seen in rural areas and low-income neighborhoods. The leading cause of MF injuries is falls. Conclusion: 3 out of 100 ED visits and 1 out of 200 hospitalizations were caused by MF injury. Male youth and female older people suffered high rates of MF injury.

This randomized-controlled pilot study explored the impact of a pretreatment, telephone engagement intervention on adolescents’ (ages 13-19) initial mental health service attendance (i.e., the first 3 counseling sessions) and four secondary outcome variables (i.e., autonomous/ controlled treatment motivation, self-efficacy, and working alliance). Twenty-seven adolescents received the engagement intervention and completed assessments and 24 adolescents completed assessments only. Both groups completed follow-up assessments 6 weeks after study enrollment. Associations between the outcome variables and initial treatment attendance were explored. The extent to which demographic variables (i.e., age, gender, race, immigration status, and residence in low income neighbourhoods), psychological distress, and self-reported barriers (i.e., mismatched treatment expectations and external demands) were associated with treatment attendance was also explored. The primary findings from this pilot study indicated that adolescents who received the engagement intervention had greater initial treatment attendance (M=2.11, SD=1.01) than the assessment only group (M=1.54, SD=1.22), but the difference only approached significance. Moreover, no significant between-group differences in the secondary outcome variables were found. Paired samples t-tests were used to examine changes in autonomous/controlled treatment motivation and self-efficacy within groups between baseline and follow-up. The results of the paired samples t-tests indicated that that the experimental and control groups both demonstrated a significant decrease in controlled motivation at follow-up. In addition, the control group demonstrated a significant decrease in autonomous treatment motivation at follow-up. Post hoc analyses, using correlation and linear regression analyses, explored the associations between initial attendance and the secondary outcome variables, psychological distress, self-reported barriers, and demographic variables. A negative association between age, self-reported barriers and initial attendance was found. A positive association was found between working alliance and initial attendance. While the majority of adolescents who participated in this research lived in low income neighbourhoods and nearly half were second generation immigrants, these demographic variables were not associated with initial treatment attendance. Although the engagement intervention had a medium effect on initial treatment attendance, this difference was not statistically significant. Future research with a larger sample size and longer follow-up is needed to determine the effectiveness of the engagement intervention.

Aims: To describe use of post-operative radiation for endometrial cancer in Ontario. To identify system-related and patient-related factors affecting access to this treatment. Materials and Methods: We performed a retrospective population-based cohort study of patients with surgically resected endometrial cancer in the Canadian province of Ontario between 1992-2003. Patients with evidence of incurable cancer at diagnosis or previous cancer diagnosis were excluded. We used multiple logistic regression to assess patient and system factors affecting radiation use. We controlled for disease-related and treatment-related factors: histology, surgical staging, type of hysterectomy and peritoneal biopsy. We applied a mixed model to account for clustering of data by operating hospital. Results: 9,411 women comprised the study cohort. The median age was 63 years. 26.2% received adjuvant radiation. The proportion of patients receiving radiation varied between cancer centre catchment areas from 18.0% to 34.3% (median 26.3%). In multivariate analysis, older patients were more likely to receive radiation up to the age of 80 (p<.0001). Patients who lived further from regional cancer centres were less likely to receive radiation (p=.0210). Patients who had their surgery during longer prevailing wait times at regional cancer centres were less likely to receive radiation (p=.0441). There was a 2.7-fold variation in the odds of radiation use between cancer centre catchments (p<.0001). Management at a comprehensive gynecologic oncology centre was associated with use of radiation for patients who had surgical staging of lymph nodes. Year of diagnosis and neighborhood income quintile did not significantly affect the use of radiation. Conclusions: There is wide variation in use of radiation for endometrial cancer in Ontario. There is evidence that system factors unrelated to patient’s needs affect use of adjuvant radiation for endometrial cancer in Ontario. Age is a key patient-related factor affecting radiation use. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2009-08-07 22:02:37.308

Background: A significant number of laryngeal cancer patients are diagnosed with advanced-stage disease. Since stage at diagnosis is an important prognostic factor, it is necessary to understand the characteristics of individuals at risk of being diagnosed at an advanced stage. Objectives: (1) Compare usual health care utilization between laryngeal cancer patients and the general population. (2) Evaluate the association between usual health care utilization and stage at diagnosis in laryngeal cancer. Methods: The study population included 1,702 laryngeal cancer patients diagnosed from 2005–2008, and 8,510 matched-controls from the general population. Demographic, clinical, and health administrative data from Ontario were used to measure usual health care utilization in a two-year period (i.e. frequency of encounters, continuity of care, primary care model enrolment, and preventive services use), stage at diagnosis, and covariates. Results: Laryngeal cancer patients had fewer health care encounters and a greater propensity for using preventive services than the general population. Comparisons of usual health care utilization among laryngeal cancer patients showed significant trends across Stage I–IV for the frequency of encounters (p=0.002), continuity of care (p=0.02), and preventive services use (p<0.0001). Stage I patients were less likely than Stage II–IV patients to have a low frequency of encounters (10%), low continuity of care (28%), and no preventive services use (28%). In adjusted multivariable analyses, low continuity of care was marginally associated with an increased risk of advanced-stage laryngeal cancer (RR [95% CI]: 1.17 [1.01, 1.34]). Stratification by subsite showed a marginally significant association between continuity of care and stage in glottic cancer (RR [95% CI]: 1.25 [0.98, 1.58]), but no association in supraglottic cancer (RR [95% CI]: 1.01 [0.89, 1.15]). Conclusions: Laryngeal cancer patients’ patterns of usual health care utilization differ from the general population. There was little evidence of an effect of usual health care use on the risk of advanced-stage laryngeal cancer in multivariable analyses adjusting for confounders. Multinomial regression may be needed to fully elucidate the effects of health care utilization across Stage I–IV. Understanding health care utilization among laryngeal cancer patients is important for improving early detection and warrants further research. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-04-26 10:50:05.976

In 2011 the University of Kentucky opened the first two inpatient floors of its new hospital. With an estimated cost of over $872 million, the new facility represents a major investment in the future of healthcare in Kentucky. This facility is outfitted with many features that were not present in the old hospital, with the expectation that they would improve the quality and efficiency of patient care. After one year of occupancy, hospital administration questioned the effectiveness of some features. Through focus groups of key stakeholders, surveys of frontline staff, and direct observational data, this dissertation evaluates the effectiveness of two such features, namely the ceiling-based patient lifts and the placement of large team meeting spaces on every unit, while also describing methods that can improve the overall state of quality improvement research in healthcare.

Background and Objectives: Antipsychotic medications (APMs) are used for the treatment of behavioural symptoms of dementia. The use of APMs among residents of long-term care facilities (LTCFs), who have a high probability of dementia, is correspondingly high, and has been linked to adverse patient outcomes. The study objectives were to: (a) describe facility variation in APM discontinuation rates, (b) test the association between time to APM discontinuation and patient and facility explanatory variables, and (c) conduct a sensitivity analysis about the effect of changes in the measurement of APM discontinuation on variable associations. Methods: The study used a population-based retrospective cohort design. Saskatchewan’s (SK) administrative health databases for the period from April 1, 2004 to March 31, 2011 were the data sources. The study cohort included all seniors (≥65 years of age) with a first admission to a SK LTCF and an APM dispensation on or after the admission date. Discontinuation was defined as a 70-day gap after the last APM dispensation. Patient-level explanatory variables included socio-demographics, comorbidity, prior medication exposure, behavioural and cognitive status, and health services utilization. Facility-level explanatory variables included size, location, licensing status, and type. Percentage discontinuation across facilities was descriptively analyzed. Cox proportional hazards regression models with adjustment for clustering of patients within LCTFs were used to test associations with time to discontinuation. A sensitivity analysis of APM discontinuation was conducted by shortening (35 days) and lengthening (105 days) the time from last dispensation. Results: Among all residents eligible to be cohort members 35.7% were dispensed an APM. A total of 19.5% of the 8358 cohort members discontinued APMs in the observation period. The Kaplan-Meier estimate of the median time to discontinuation was 6.5 years. Demographic, comorbidity, behavioural, and drug exposure variables were most strongly associated with APM discontinuation. Discontinuation was not associated with facility characteristics. Variable associations were insensitive to the definition of APM discontinuation, but changed over time. Conclusion: Discontinuation of APMs is low, despite high rates of utilization over long periods of time. Patient characteristics are associated with APM discontinuation, but not facility characteristics, suggesting that LCTFs are applying consistent approaches to patient management. However, low levels of discontinuation suggest that there may be a need for health care providers to regularly review the prescribing, dispensing, and administration of APMs to LTCF residents in order to ensure appropriate use of these pharmaceuticals.

This randomized-controlled pilot study explored the impact of a pretreatment, telephone engagement intervention on adolescents’ (ages 13-19) initial mental health service attendance (i.e., the first 3 counseling sessions) and four secondary outcome variables (i.e., autonomous/ controlled treatment motivation, self-efficacy, and working alliance). Twenty-seven adolescents received the engagement intervention and completed assessments and 24 adolescents completed assessments only. Both groups completed follow-up assessments 6 weeks after study enrollment. Associations between the outcome variables and initial treatment attendance were explored. The extent to which demographic variables (i.e., age, gender, race, immigration status, and residence in low income neighbourhoods), psychological distress, and self-reported barriers (i.e., mismatched treatment expectations and external demands) were associated with treatment attendance was also explored. The primary findings from this pilot study indicated that adolescents who received the engagement intervention had greater initial treatment attendance (M=2.11, SD=1.01) than the assessment only group (M=1.54, SD=1.22), but the difference only approached significance. Moreover, no significant between-group differences in the secondary outcome variables were found. Paired samples t-tests were used to examine changes in autonomous/controlled treatment motivation and self-efficacy within groups between baseline and follow-up. The results of the paired samples t-tests indicated that that the experimental and control groups both demonstrated a significant decrease in controlled motivation at follow-up. In addition, the control group demonstrated a significant decrease in autonomous treatment motivation at follow-up. Post hoc analyses, using correlation and linear regression analyses, explored the associations between initial attendance and the secondary outcome variables, psychological distress, self-reported barriers, and demographic variables. A negative association between age, self-reported barriers and initial attendance was found. A positive association was found between working alliance and initial attendance. While the majority of adolescents who participated in this research lived in low income neighbourhoods and nearly half were second generation immigrants, these demographic variables were not associated with initial treatment attendance. Although the engagement intervention had a medium effect on initial treatment attendance, this difference was not statistically significant. Future research with a larger sample size and longer follow-up is needed to determine the effectiveness of the engagement intervention.

Health system restructuring combined with the preferences of palliative care recipients to be cared for at home has lead to a shift in the delivery of care from the hospital to the home setting. An analysis was conducted on five main home-based palliative care health service components: home-based nurse visits, home personal support worker visits, home-based physician visits, ambulatory physician visits, and other ambulatory and home-based visits. First, we assessed the proportion of total cost associated with the main services at different time points over the palliative care trajectory. Second we examined the socio-demographic and clinical factors that predict the propensity and intensity of service use, using a two-part model. The results suggest that the greatest contributor to the total cost of home-based palliative care was personal support worker visits, followed by nurse visits. The regression analysis revealed that patient age as well as functional status most often predicted health service use.