Maternal serum screening in Ontario
Regional discontent
The high response rate (86%) to a survey by Joanne Permaul-Woods and colleagues of the Ontario Maternal Serum Screening (MSS) Program attests to the strength of attitudes held by family physicians, obstetricians and midwives. There were marked regional differences in MSS practices: 90% of respondents in the Central East region, which includes Toronto, said that they routinely offer MSS to all pregnant women in accordance with the Ontario Ministry of Health's recommendations, as compared with only 71% of those in the Northwest region. In a logistic regression analysis these differences were explained less by practice location than by the respondents' perceptions that patient characteristics, such as low education and cultural differences, are barriers to counselling (OR 0.42) and by beliefs that follow-up services are not readily available (OR 0.33). There were complaints that the false-positive rate was too high, the protocol too complex and counselling too time consuming. What lessons can be learned for future genetic screening programs?
Guidelines for referral to nephrology
Late referral a problem in Canada
Did you know that a serum creatinine level of 120 micro mol/L represents a loss of filtration function of more than 50%? In one study 84% of physicians surveyed said they would not refer a patient with such a level to a nephrologist. Evidence indicates that late referral is a problem in Canada. A subcommittee of the Canadian Society of Nephrology conducted a systematic review of the literature relating to referral. Clinical practice guidelines, endorsed by the College of Family Physicians of Canada and the Canadian Society of Nephrology, outline referral criteria for 4 classes of patients: those who have an elevated creatinine level, those who have newly discovered renal insufficiency, those with chronic creatinine increases and those who need dialysis.
Newspaper medical advice columns
Should they be peer reviewed?
Frank Molnar and colleagues raise this question in their study of 50 medical advice articles randomly selected from Canadian newspapers. Five geriatricians reviewed the content and concluded that in 50% of the articles the advice was inappropriate and in 28% it may have been dangerous and potentially life threatening. In her editorial Vikki Entwistle cautions against assuming that readers will blindly follow any advice given. She suggests that advice columns prompt patients to consult with their physicians and calls for widespread strategies to improve patients' appraisal skills. Figure 1
Home visits
Who does what and why?
Renal Bergeron and colleagues surveyed 487 GPs in the Quebec City area; 283 (58%) made home visits, of whom 88 (31%) dedicated 3 hours or less a week to these. There were telling differences between GPs in private practice and their counterparts in local community service centres (CLSCs) or family medicine units. Private practitioners reported more home visits (11.5 v. 5.8 per week), were more likely to visit patients with acute conditions (21% v. 16%) and to see patients at their request (28% v. 14%), and were less likely to see patients at the request of a colleague (4% v. 18%) or to do regular follow-up (37% v. 51%). Do these data tell of economic decisions or practice preferences? Figure 2
Debunking cost-effectiveness of home care
According to Peter Coyte and Wendy Young the Ontario rate of home care use per 100 hospital discharges was 12.5 for inpatients and 3.6 for same-day surgery patients. There was a 3.5-fold regional variation (range 8.6 to 29.9) in the rates of home care use following inpatient care and a 7-fold regional variation (range 1.7 to 11.9) following same-day surgery. The authors estimate that an additional $48.9 million would be needed to equalize services in the province and suggest that a research program to evaluate alternative methods of delivering home care is warranted.