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Long term benzodiazepine use for insomnia in patients over the age of 60: discordance of patient and physician perceptions
Leevin Mah, Ross EG Upshur
BMC Family Practice , 2002, DOI: 10.1186/1471-2296-3-9
Abstract: A cross-sectional study (written survey) was conducted in an academic primary care group practice in Toronto, Canada. The participants were 93 patients over 60 years of age using a benzodiazepine for insomnia and 25 physicians comprising sleep specialists, family physicians, and family medicine residents. The main outcome measure was perception of benefit and risk scores calculated from the mean of responses (on a Likert scale of 1 to 5) to various items on the survey.The mean perception of benefit score was significantly higher in patients than physicians (3.85 vs. 2.84, p < 0.001, 95% CI 0.69, 1.32). The mean perception of risk score was significantly lower in patients than physicians (2.21 vs. 3.63, p < 0.001, 95% CI 1.07, 1.77).There is a significant discordance between older patients and their physicians regarding the perceptions of benefits and risks of using benzodiazepines for insomnia on a long term basis. The challenge is to openly discuss these perceptions in the context of the available evidence to make collaborative and informed decisions.Many older people suffer from insomnia and are commonly prescribed benzodiazepines for symptomatic management. Among adults aged 65 and older who live in the community, up to 42% reported difficulty falling asleep or staying asleep [1]. The prevalence of benzodiazepine prescriptions in older people is also high: 22.5% of people aged 65 and older in Ontario, Canada reported use of benzodiazepines [2]. Furthermore, older people are more likely to continue using these medications for extended periods once they are prescribed them [3].The research available on the benefits and risks of benzodiazepine use for insomnia in older people is surprisingly deficient for the magnitude of this issue. Notably, there are no prospective studies that have looked at the efficacy of benzodiazepine use for insomnia for a duration of greater than one month [4]. Over the short term, meta-analyses show a mild to moderate treatment effect in q
The health care information directive
Ross EG Upshur, Vivek Goel
BMC Medical Informatics and Decision Making , 2001, DOI: 10.1186/1472-6947-1-1
Abstract: A health care information directive is described which creates a decision matrix that combines the ethical appropriateness of the use of personal health information with the sensitivity of the data. It creates a range of possibilities with in which individuals can choose to contribute health information with or without consent, or not to contribute information at all.The health care information directive may increase individuals understanding of the uses of health information and increase their willingness to contribute certain kinds of health information. Further refinement and evaluation of the directive is required.As health care enters the 21st Century, information technology (IT) is assuming greater importance for clinical care and health delivery systems. IT promises rapid access to the health information required for clinical decisions and management of the health care system, leading to improved health outcomes and more efficient use of resources. Efforts to integrate information technology into health care continue to rise at a rapid rate. In many settings and for many types of services, such information systems are indispensable for health care.The widespread dissemination of information technology raises several problems. While one of the most heralded areas of health information technology is the electronic patient record, they also draw the most concern [1]. Since medical records are highly personal, many fear loss of confidentiality and privacy [2]. Fair information principles, ethical codes and studies of patient's preferences all support the importance of preserving confidentiality and privacy [3-5].The uses of health information extend beyond the clinical domain [6]. Health services research, disease registries, and population epidemiology rely on data collected and archived in administrative databases. Such data reservoirs can be linked and are a rich source of knowledge on patterns of health care. The advent of electronic health records could grea
DNA databanks and consent: A suggested policy option involving an authorization model
Timothy Caulfield, Ross EG Upshur, Abdallah Daar
BMC Medical Ethics , 2003, DOI: 10.1186/1472-6939-4-1
Abstract: In this paper, we discuss the difficulties of an informed consent model for future ineffable uses of genetic data. We argue that variations on consent, such as presumed consent, blanket consent or constructed consent fail to meet the standards required by current informed consent doctrine and are distortions of the original concept. In this paper, we propose the concept of an authorization model whereby participants in genetic data banks are able to exercise a certain amount of control over future uses of genetic data. We argue this preserves the autonomy of individuals at the same time as allowing them to give permission and discretion to researchers for certain types of research.The authorization model represents a step forward in the debate about informed consent in genetic databases. The move towards an authorization model would require changes in the regulatory and legislative environments. Additionally, empirical support of the utility and acceptability of authorization is required.Recent developments in genetics, particularly the sequencing of the human genome, have energized large-scale genetics and genomics research. One of the outcomes has been the establishment of large-scale genetic data banks aiming to identify genetic predispositions to major public health conditions that appear to have complex associations rather than being caused by single genetic mutations. Although many small collections have existed for a long time, none have been on a massive national scale until recently, when a private Icelandic company working closely with the government of Iceland established the Icelandic genetics database [1]. Specific legislation had to be passed to enable the creation of that database. Since then various countries, including Estonia, have attempted to establish their own national data banks. The United Kingdom is now in the process of creating the world's largest such bank. It will be known as Biobank and will collect DNA samples from approximately half a
Public perceptions of quarantine: community-based telephone survey following an infectious disease outbreak
C Shawn Tracy, Elizabeth Rea, Ross EG Upshur
BMC Public Health , 2009, DOI: 10.1186/1471-2458-9-470
Abstract: We conducted a telephone survey of the general population in the Greater Toronto Area in Ontario, Canada. Computer-assisted telephone interviewing (CATI) technology was used. A final sample of 500 individuals was achieved through standard random-digit dialing.Our data indicate strong public support for the use of quarantine when required and for serious legal sanctions against those who fail to comply. This support is contingent both on the implementation of legal safeguards to protect against inappropriate use and on the provision of psychosocial supports for those affected.To engender strong public support for quarantine and other restrictive measures, government officials and public health policy-makers would do well to implement a comprehensive system of supports and safeguards, to educate and inform frontline public health workers, and to engage the public at large in an open dialogue on the ethical use of restrictive measures during infectious disease outbreaks.Long considered an anachronism from a bygone era, quarantine has re-emerged in the 21st century as an important (albeit controversial) tool in the battle against infectious disease. Prior to the 2003 outbreak of severe acute respiratory syndrome (SARS), it had been more than 50 years since mass quarantine measures had been invoked in North America [1]. The SARS containment measures imposed in Canada and Asia, and on a lesser scale in the U.S., provoked a heated debate within the public health community regarding the ethics and legality of quarantine [2-7].Likewise, the SARS experience has sparked a renewed research interest in the ethics and effectiveness of quarantine. The findings of two recent retrospective studies of the 1918 Spanish flu pandemic strongly suggest that it was non-pharmaceutical inventions such as quarantine and other social distancing measures that were most effective in slowing the rate of spread and minimizing the rate of death [8,9]. And data from SARS-affected regions have pointe
Evidence-based medicine in primary care: qualitative study of family physicians
C Shawn Tracy, Guilherme Dantas, Ross EG Upshur
BMC Family Practice , 2003, DOI: 10.1186/1471-2296-4-6
Abstract: Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians.Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician.Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour.Evidence-based medicine (EBM) has emerged as an influential model for the teaching and practice of clinical medicine. Although the concept has been successfully disseminated in the health care field, there have been numerous criticisms advanced. Arguments have been put forth that EBM represents reductionism by its narrow definition of evidence; ignores the legitimacy of clinical judgement, experience, and the time constraints of non-academic practice; fails to include and respond to patient values; fosters an inappropria
Lack of chart reminder effectiveness on family medicine resident JNC-VI and NCEP III guideline knowledge and attitudes
Paul S Echlin, Ross EG Upshur, Tsveti P Markova
BMC Family Practice , 2004, DOI: 10.1186/1471-2296-5-14
Abstract: A pilot study was performed to determine if change in a previously identified CPG compliance factor (accessibility) would produce a significant increase in family medicine resident knowledge and attitude toward the guidelines. The primary study intervention involved placing a summary of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP III) CPGs in all patient (>18 yr.) charts for a period of three months. The JNC VI and NCEP III CPGs were also distributed to each Wayne State family medicine resident, and a copy of each CPG was placed in the preceptor's area of the involved clinics. Identical pre- and post- intervention questionnaires were administered to all residents concerning CPG knowledge and attitude.Post-intervention analysis failed to demonstrate a significant difference in CPG knowledge. A stastically significant post-intervention difference was found in only on attitude question. The barriers to CPG compliance were identified as 1) lack of CPG instruction; 2) lack of critical appraisal ability; 3) insufficient time; 4) lack of CPG accessibility; and 5) lack of faculty modeling.This study demonstrated no significant post intervention changes in CPG knowledge, and only one question that reflected attitude change. Wider resident access to dedicated clinic time, increased faculty modeling, and the implementation of an electronic record/reminder system that uses a team-based approach are compliance factors that should be considered for further investigation. The interpretation of CPG non-compliance will benefit from a causal matrix focused on physician knowledge, attitudes, and behavior. Recent findings in resident knowledge-behavior discordance may direct the future investigation of physician CPG non-compliance away from generalized barrie
Chaperone use during intimate examinations in primary care: postal survey of family physicians
David H Price, C Shawn Tracy, Ross EG Upshur
BMC Family Practice , 2005, DOI: 10.1186/1471-2296-6-52
Abstract: Questionnaires were mailed to a randomly selected sample of 500 Ontario members of the College of Family Physicians of Canada. Participants were asked about their use of chaperones when performing a variety of intimate examinations, namely female pelvic, breast, and rectal exams and male genital and rectal exams.276 of 500 were returned (56%), of which 257 were useable. Chaperones were more commonly used with female patients than with males (t = 9.09 [df = 249], p < 0.001), with the female pelvic exam being the most likely of the five exams to be attended by a chaperone (53%). As well, male physicians were more likely to use chaperones for examination of female patients than were female physicians for the examination of male patients. Logistic regression analyses identified two independent factors – sex of physician and availability of a nurse – that were significantly associated with chaperone use. For female pelvic exam, male physicians were significantly more likely to report using a chaperone (adjusted Odds Ratio [OR] 40.62, 95% confidence interval [CI] 16.91–97.52). Likewise, having a nurse available also significantly increased the likelihood of a chaperone being used (adjusted OR 6.92, 95% CI 2.74–17.46). This pattern of results was consistent across the other four exams. Approximately two-thirds of respondents reported using nurses as chaperones, 15% cited the use of other office staff, and 10% relied on the presence of a family member.Clinical practice concerning the use of chaperones during intimate exams continues to be discordant with the recommendations of medical associations and medico-legal societies. Chaperones are used by only a minority of Ontario family physicians. Chaperone use is higher for examinations of female patients than of male patients and is highest for female pelvic exams. The availability of a nurse in the clinic to act as a chaperone is associated with more frequent use of chaperones.Professional guidelines and clinical practice reg
Is there a clinically significant gender bias in post-myocardial infarction pharmacological management in the older (>60) population of a primary care practice?
Romolo Di Cecco, Umesh Patel, Ross EG Upshur
BMC Family Practice , 2002, DOI: 10.1186/1471-2296-3-8
Abstract: A comprehensive chart audit was conducted of 142 men and 81 women in an academic primary care practice. Variables were extracted on demographic variables, cardiovascular risk factors, medical and non-medical management of myocardial infarction.Women were older than men. The groups were comparable in terms of cardiac risk factors. A statistically significant difference (14.6%: 95% CI 0.048–28.7 p = 0.047) was found between men and women for the prescription of lipid lowering medications. 25.3% (p = 0.0005, CI 11.45, 39.65) more men than women had undergone angiography, and 14.4 % (p = 0.029, CI 2.2, 26.6) more men than women had undergone coronary artery bypass graft surgery.Women are less likely than men to receive lipid-lowering medication which may indicate less aggressive secondary prevention in the primary care setting.In the last decade, cardiovascular disease has become the leading cause of death in women. [1] Concerns have been raised about gender differences in both outcomes and in access to medical care for cardiovascular disease.[2] Gender differences have been documented in care sought for myocardial infarction. Women are more likely to receive in-hospital care from primary care physicians rather than cardiologists. Patients admitted by cardiologists have a significantly better survival rate than those admitted by primary care physicians.[3,4]Studies looking at the use of thrombolytic agents show that they are consistently underused in eligible women compared to men.[5] Beta-blockers and Aspirin are under-prescribed in females who are post-MI.[6,7]Most investigations into gender differences in post-MI pharmacological management originate from specialist care. Until recently there was little published data regarding post-MI pharmacological management in primary care. A study in a primary care setting revealed that women were twice as likely to have a diagnosis of hyperlipidemia, yet a higher percentage of men were on lipid-lowering agents.[8]This study als
Seasonality of service provision in hip and knee surgery: A possible contributor to waiting times? A time series analysis
Ross EG Upshur, Rahim Moineddin, Eric J Crighton, Muhammad Mamdani
BMC Health Services Research , 2006, DOI: 10.1186/1472-6963-6-22
Abstract: We performed a retrospective, cross-sectional time series analysis examining all hip and knee replacement surgeries in people over the age of 65 in the province of Ontario, Canada between 1992 and 2002. The main outcome measure was monthly hospitalization rates per 100 000 population for all hip and knee replacements.There was a marked increase in the rate of hip and knee replacement surgery over the 10-year period as well as an increasing seasonal variation in surgeries. Highly significant (Fisher Kappa = 16.05, p < 0.01; Bartlett-Kolmogorov-Smirnov Test = 0.31, p < 0.01) and strong (R2Autoreg = 0.85) seasonality was identified in the data.Holidays and utilization caps appear to exert a significant influence on the rate of service provision. It is expected that waiting times for hip and knee replacement could be reduced by reducing seasonal fluctuations in service provision and benchmarking services to peak delivery. The results highlight the importance of system behaviour in seasonal fluctuation of service delivery.Waiting times for important health interventions such as hip and knee replacements, cataracts, cancer surgery, and coronary artery bypass surgery have assumed increasing prominence in publicly funded health care systems globally. In Canada, waiting times have been identified as one of the crucial challenges facing the health care system, have featured in debates during federal and provincial elections and have served as the basis for a challenge to the Canada Health Act at the level of the Supreme Court.Prolonged wait times for crucial health interventions raise concerns about the quality of service that can be delivered by such systems. These issues figure prominently in policy debates internationally. A recent OECD report identified waiting times as a significant policy issue in 50% of all OECD countries, including among them Canada, the United Kingdom, Australia, Finland, Sweden, Denmark and the Netherlands, all of which have publicly funded health c
Is there a clinically significant seasonal component to hospital admissions for atrial fibrillation?
Ross EG Upshur, Rahim Moineddin, Eric J Crighton, Muhammad Mamdani
BMC Health Services Research , 2004, DOI: 10.1186/1472-6963-4-5
Abstract: We conducted a retrospective population cohort study using time series analysis to evaluate seasonal patterns of atrial fibrillation hospitalizations for the province of Ontario for the years 1988 to 2001. Five different series methods were used to analyze the data, including spectral analysis, X11, R-Squared, autocorrelation function and monthly aggregation.This study found evidence of weak seasonality, most apparent at aggregate levels including both ages and sexes. There was dramatic increase in hospitalizations for atrial fibrillation over the years studied and an age dependent increase in rates per 100,000. Overall, the magnitude of seasonal difference between peak and trough months is in the order of 1.4 admissions per 100,000 population. The peaks for hospitalizations were predominantly in April, and the troughs in August.Our study confirms statistical evidence of seasonality for atrial fibrillation hospitalizations. This effect is small in absolute terms and likely not significant for policy or etiological research purposes.Atrial fibrillation is the most common cardiac arrhythmia in the elderly population requiring medical treatment. The prevalence of this disease is clearly related to age and can be as high as 15 to 18% after the age of 80 [1,2]. The seasonality of hospitalizations for atrial fibrillation has been the focus of epidemiological study as seasonality is a potential clue to etiology. Recent studies examining the seasonality of atrial fibrillation using monthly aggregations of emergency reports over a 10-year period in one study, and emergency room visits over a 1-year period in another, both found statistically significant seasonal differences in monthly values, with peaks typically occurring in the winter and troughs in the summer [3,4]. Frost et al in a study of hospitalizations for atrial fibrillation in Denmark found a winter peak and summer trough, with a small but statistically significant relative risk of 1.20 (95% confidence interval: 1
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