Canada’s First Nations communities are experiencing their worst nursing shortage in 30 years. First Nations health care professionals are the most effective nursing personnel in their own communities, yet efforts to recruit and retain them in nursing schools have been largely unsuccessful. The little research done on this issue indicates there are barriers to be bridged, including a feeling among First Nations nurses that they must compromise their traditional beliefs and culture to succeed in nursing education. In her doctoral research, Donna Martin is developing a clearer picture of these barriers. Her research involves interviews with students, faculty, health care professionals, First Nations elders and others, along with classroom observation and analysis of course materials, textbooks and university policies. Martin hopes the research will ultimately help nursing schools develop more effective recruitment and retention strategies for First Nations nurses.
Research Pillar: Health Services
The clinical and economic outcomes of patients with lumbar disc herniation and sciatica
Lower back and leg pain from a herniated disk and sciatica (pain on the sciatic nerves) is one of the most common causes of chronic disability and workplace absenteeism. Treatment approaches are inconsistent as there is still much to learn about this condition. Dr. Jeffrey Quon hopes to address this knowledge gap by comparing the long-term outcomes for patients treated through surgery and non-surgical therapies at Vancouver Hospital and Health Sciences Centre. Quon’s research aims to identify the physical, psychosocial and clinical factors that contribute to early or delayed recovery. Another goal is to identify patients at risk for chronic disability and help physicians make informed decisions about which cases will respond best to surgical or non-surgical treatments. Quon, whose diverse background includes chiropractic training and research in complementary medicine, hopes this work will culminate in cost-effective therapies that prevent long-term disability.
The evaluation of human telemanipulation under spatial misalignment conditions in minimally invasive surgery
Bin Zheng isn’t daunted by challenge. At 16, he entered medical school. By age 27, he was a specialist in pediatric orthopedic surgery at a hospital affiliated with China Medical University. Now he is in Canada focusing his efforts on research to refine and improve the technology used in minimally invasive surgery. Because of more rapid healing and other benefits, this surgical practice is increasingly common. Zheng is working on an issue, which he has experienced first-hand, that occurs when images projected by the tiny cameras inserted into the body to guide the surgeon’s action do not align exactly with the area of the body on which the surgeon is working. His immediate goals are to assess the effects of this misalignment on surgical performance and patient outcome and also look for ways of improving the technology. In the long term, Zheng hopes to use these findings in the development of a systematic approach (scientific methodology) that can be applied to the evaluation of any new health technology.
Developing an effective and efficient health care delivery system for Canadians at the end-of-life
In the mid-eighties, while working as a palliative care nurse, Dr. Kelli Stajduhar cared for a young man dying from AIDS. A few years later, her mother was diagnosed with lung cancer and died. Both received less than optimal care at the end of their lives. Stajduhar was profoundly affected by those experiences, which gave her a strong desire to examine ways to improve care and support for people at the end-of-life. Stajduhar’s PhD research focused on the provision of home-based care for people who are dying, and its impact on family caregivers. Her postdoctoral work aims to identify the elements needed for an effective, efficient, comprehensive and coordinated system of health care for Canadians who have come to that point in their lives. Ultimately, Stajduhar would like to advance health policy on end-of-life care.
Hepatitis A virus infections among children in British Columbia: Is routine vaccination needed?
Hepatitis A is a viral disease that causes inflammation of the liver. Once contracted, there is no treatment. Adults and older children with the disease usually suffer for four to ten weeks, and the symptoms include jaundice, fatigue, abdominal pain and fever. Young children usually have mild, symptom-free cases that go unrecognized, but can transmit the virus to people of all ages. The BC infection rates for hepatitis A virus have exceeded the national average for more than a decade. Yet a safe, effective vaccine has been available since 1994. The vaccine is currently only given to high-risk groups, and most cases reported by physicians come from these groups. I am investigating the risk of hepatitis A for children in two areas of BC that consistently report high infection rates. The study will determine whether universal childhood immunization is warranted. We can gauge risk for hepatitis A by testing saliva for antibodies to the virus, which would indicate a past infection. Our research team has tested about 800 randomly selected grade nine students. Students also filled out a questionnaire on potential risk factors. We are analyzing this data to identify why the hepatitis A rates may be higher in these areas and whether the scope of the disease is broader than reported cases indicate. If we find high rates of past infection, routine vaccination may be warranted. If low rates are found, the results will provide reassurance that existing sanitary measures are adequate to protect local children.
Determinants of excessive waiting for cardiac catheterization and revascularization in British Columbia
Cardiovascular disease is the most common cause of morbidity and mortality in British Columbia and Canada, accounting for one-third of all deaths and over one-half of deaths among persons aged 50 years and over. The economic burden of cardiovascular disease is enormous. In BC in 1998, the most recent year for which there are reliable figures, the annual direct costs were approximately $1.1 billion and the indirect costs were estimated at $3 billion, making this the most costly of any category of diseases in the province. I have developed a research program for the systematic investigation of the delivery and outcomes of cardiovascular diagnostic procedures, and medical and surgical care in BC and the rest of Canada. The projects in the research program largely involve using linked administrative and clinical databases. One project of particular interest in BC is the issue of wait times for cardiac bypass surgery. In Canada in the late 1980s, a dramatic increase in referrals for coronary artery bypass surgery outstripped capacity for this procedure. The Ontario government expanded capacity and developed criteria for placing patients on cardiac surgery waitlists. Capacity was increased in BC, but patients were put on the waitlist in an ad hoc manner, which continues today. I am conducting a large study to examine waitlists for cardiac operations in BC. The official wait time is the interval between being booked for an open heart operation and actually having the procedure. There is evidence this wait has decreased in the past two years. I am investigating whether there is a true decrease or if patients are waiting earlier in their process of care, before the operation is booked. This study will compare wait times in BC to benchmarks established in Ontario, identify the proportion of patients who wait longer than recommended by medical guidelines, examine the characteristics that predict longer wait times, and propose ways to shorten the waitlist for people waiting the longest. The results of this research will help determine whether we need a more formal system for managing cardiac resources in BC.
Heroin and Methadone Maintenance Treatment: Accessibility, Barriers and Quality of Life issues for Women in the Downtown Eastside, Vancouver, British Columbia
Magdalena Recsky developed her passion for epidemiology while working summers as a research assistant at the BC Centre for Excellence in HIV/AIDS. She put that passion into practice through her Masters research, which explored issues surrounding methadone dosing, satisfaction with methadone doses and associated HIV-risk behaviours. Using existing data, she investigated the barriers women face in accessing methadone maintenance programs, which led to a broader study into methadone dosing. Results from the studies and a literature review demonstrate that high patient satisfaction with methadone treatment can potentially decrease certain HIV-risk behaviours. The results also highlight the importance of physician-patient relationships in the treatment of heroin addiction and the importance of individualizing methadone treatment. Although certain methadone doses are pharmacologically required to curb heroin withdrawal, the research shows that once that dose is reached, patient satisfaction with treatment may be more important in positively influencing methadone treatment outcomes. Ultimately, she hopes this research will contribute to improvements in methadone treatment programs that more effectively address the needs of specific population groups, such as those involved in high HIV-risk behaviours.
Quality improvement of stroke surveillance, prevention and care in a sentinel health region
Stroke is the third leading cause of death in BC and the leading cause of brain disability. Stroke is also estimated to be the most expensive disease in Canada that, until recently, was considered untreatable. My research team is evaluating a three-step stroke program in the Vancouver Island Health Region to improve prevention and treatment options. The first step will be developing a surveillance system to collect information on all strokes in the region and to find people who are at high risk. Next, the project team will work on providing new tools to help patients and their doctors plan ahead and implement life style changes that will reduce stroke risk. The third component will use Stroke Victoria’s computer system as a tool for quality improvement initiatives in stroke care. The team will evaluate every stage of the project to assess the effectiveness of this approach for saving lives, improving care and reducing the costs of health care delivery. Stroke is so debilitating, complex and costly that it is worth investing in innovative approaches to prevention. We believe relevant, rapid and rigorous epidemiology is key.
Patient-focused care over time: issues related to measurement, prevalence, and strategies for improvement among patient populations in B.C.
Patients often see multiple health professionals in a variety of places for the care of their health problems. Linking care from different providers over time is challenging, with the risk that some care may be missed, duplicated or ill-timed. Concern about this fragmentation of care is growing in Canada and worldwide. Continuity of care, which is accomplished when the connections between care are seamless, is thought to improve patient outcomes, patient satisfaction with their care and physician and health providers’ satisfaction as well. I am studying the impact of continuity of care on costs and quality of care. A common way to connect care over time is to have one central person, usually a primary care physician, responsible for providing the majority of services and linking a patient to specialists. I am examining a variety of data to measure the concentration of care in this type of sustained relationship. A growing trend is team care provided at a clinic, where patients see any one of the physicians working there. My study will compare outcomes for patients who use health care teams to those who primarily see one physician, and I will look at the way walk-in clinic care affects continuity and patient outcomes. I will also examine how continuity of care affects patient health over time for people with severe and persistent mental illness, individuals with workplace injuries, and patients with HIV/AIDS.