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Kreindler S.A.,Winnipeg Regional Health Authority | Kreindler S.A.,University of Manitoba | Larson B.K.,Dartmouth Institute for Health Policy and Clinical Practice | Wu F.M.,University of California at Berkeley | And 7 more authors.
Milbank Quarterly | Year: 2012

Context: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? Methods: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. Findings: In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not "integration"; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change. Conclusions: The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. "Soft integration" may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations. © 2012 Milbank Memorial Fund. Source


Bowen S.,University of Alberta | Johnson K.,Winnipeg Regional Health Authority | Reed M.H.,University of Manitoba | Zhang L.,Winnipeg Regional Health Authority | Curry L.,CurryCorp.
Journal of the American College of Radiology | Year: 2011

Purpose: The objectives of this collaborative evaluation of the Manitoba Demonstration Project in Demand-Side Control for Diagnostic Imaging were to determine the impacts of both the computerized order entry and decision support components of the intervention, identify barriers to implementation, and provide insight into quantitative findings. Methods: Mixed methodology was used. A stakeholder committee guided project implementation and evaluation and assisted in interpreting findings. Orders placed through the software (July 2006 to August 2007) were analyzed in conjunction with qualitative data from semistructured interviews, focus groups, consultations, and observational methods. Data were collected before implementation, after the introduction of the computerized ordering system, after the introduction of decision support prompts, and at project completion. Analysis was conducted simultaneously with data collection. Results: Although the process change of computerized provider order entry was well accepted, there was low acceptance of the practice change of decision support. Of 8,757 orders placed after guidelines were activated, 1,678 (19.2%) had relevant guidelines and 957 (10.9%) were inappropriate according to the guidelines. In only 19 (2%) of these cases did the physician follow the advice given. Contributing factors included setting, implementation of only a subsection of the Canadian Association of Radiologists guidelines, implementation issues, physician perspectives on usefulness of decision support, the timing of advice, a lack of integration with existing patient information systems, and software limitations. Setting predicted satisfaction with ordering time. The potential for computerized provider order entry to decrease useful information accompanying orders was identified. Conclusions: The results of this study highlight the importance of ensuring both appropriate timing of decision support and integration with patient information systems. Implementation evaluation, as well as impact evaluation, is needed to assess new system adoption; early engagement of users can support this process. Further research is needed to determine the actual extent of inappropriate ordering. © 2011 American College of Radiology. Source


Chochinov H.M.,University of Manitoba | Chochinov H.M.,Manitoba Palliative Care Research Unit | Kristjanson L.J.,Swinburne University of Technology | Kristjanson L.J.,Curtin University Australia | And 7 more authors.
The Lancet Oncology | Year: 2011

Background: Dignity therapy is a unique, individualised, short-term psychotherapy that was developed for patients (and their families) living with life-threatening or life-limiting illness. We investigated whether dignity therapy could mitigate distress or bolster the experience in patients nearing the end of their lives. Methods: Patients (aged ≥18 years) with a terminal prognosis (life expectancy ≤6 months) who were receiving palliative care in a hospital or community setting (hospice or home) in Canada, USA, and Australia were randomly assigned to dignity therapy, client-centred care, or standard palliative care in a 1:1:1 ratio. Randomisation was by use of a computer-generated table of random numbers in blocks of 30. Allocation concealment was by use of opaque sealed envelopes. The primary outcomes-reductions in various dimensions of distress before and after completion of the study-were measured with the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale, Patient Dignity Inventory, Hospital Anxiety and Depression Scale, items from the Structured Interview for Symptoms and Concerns, Quality of Life Scale, and modified Edmonton Symptom Assessment Scale. Secondary outcomes of self-reported end-of-life experiences were assessed in a survey that was undertaken after the completion of the study. Outcomes were assessed by research staff with whom the participant had no previous contact to avoid any possible response bias or contamination. Analyses were done on all patients with available data at baseline and at the end of the study intervention. This study is registered with ClinicalTrials.gov, number NCT00133965. Findings: 165 of 441 patients were assigned to dignity therapy, 140 standard palliative care, and 136 client-centred care. 108, 111, and 107 patients, respectively, were analysed. No significant differences were noted in the distress levels before and after completion of the study in the three groups. For the secondary outcomes, patients reported that dignity therapy was significantly more likely than the other two interventions to have been helpful (χ2=35·50, df=2; p<0·0001), improve quality of life (χ2=14·52; p=0·001), increase sense of dignity (χ2=12·66; p=0·002), change how their family saw and appreciated them (χ2=33·81; p<0·0001), and be helpful to their family (χ2=33·86; p<0·0001). Dignity therapy was significantly better than client-centred care in improving spiritual wellbeing (χ2=10·35; p=0·006), and was significantly better than standard palliative care in terms of lessening sadness or depression (χ2=9·38; p=0·009); significantly more patients who had received dignity therapy reported that the study group had been satisfactory, compared with those who received standard palliative care (χ2=29·58; p<0·0001). Interpretation: Although the ability of dignity therapy to mitigate outright distress, such as depression, desire for death or suicidality, has yet to be proven, its benefits in terms of self-reported end-of-life experiences support its clinical application for patients nearing death. Funding: National Cancer Institute, National Institutes of Health. © 2011 Elsevier Ltd. Source


Wazny L.D.,Winnipeg Regional Health Authority
CANNT journal = Journal ACITN | Year: 2011

Interest in optimizing iron management in the treatment of anemia of CKD is growing due to concerns that high doses of ESAs may have deleterious effects and the high cost of ESAs in comparison to iron therapy. International guidelines have defined iron targets for this patient population, but there are some unanswered questions with respect to long-term use of iron, such as the maximum TSAT or ferritin concentration and concerns with oxidative stress. Large head-to-head safety studies of the different i.v. iron preparations have not been performed to date and current safety data rely on small studies and spontaneous adverse event reporting. Interprofessional management of anemia, including iron therapy, has shown beneficial effects and should be encouraged. Source


Tagin M.,Winnipeg Regional Health Authority | Shah P.S.,University of Toronto | Lee K.-S.,University of Toronto
Journal of Perinatology | Year: 2013

OBJECTIVE:Magnesium may have a role in neuroprotection in neonatal hypoxic-ischemic encephalopathy (HIE). The objective of this study was to systematically review the efficacy and safety of postnatal magnesium therapy in newborns with HIE.STUDY DESIGN:MEDLINE, EMBASE, CINAHL and CCRCT were searched for studies of magnesium for HIE. Randomized controlled trials that compared magnesium to control in newborns with HIE were selected. The primary outcome was a composite outcome of death or moderate-to-severe neurodevelopmental disability at 18 months. When appropriate, meta-analyses were conducted using random effects model and risk ratios (RRs) and 95% confidence intervals (CIs) were calculated.RESULT:Five studies with sufficient quality were included. There was no difference in the primary outcome between the magnesium and the control groups (RR 0.81, 95% CI 0.36 to 1.84). There was significant reduction in the unfavorable short-term composite outcome (RR 0.48, 95% CI 0.30 to 0.77) but no difference in mortality (RR 1.39, 95% CI 0.85 to 2.27), seizures (RR 0.84, 95% CI 0.59 to 1.19) or hypotension (RR 1.28, 95% CI 0.69 to 2.38) between the magnesium and the control groups.CONCLUSION:The improvement in short-term outcomes without significant increase in side effects indicate the need for further trials to determine if there are long-term benefits of magnesium and to confirm its safety. Mortality was statistically insignificant between the magnesium and the control groups. However, the trend toward increase in mortality in the magnesium group is a major clinical concern and should be monitored closely in future trials. © 2013 Nature America, Inc. Source

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