Dalla Lana School of Public Health

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The Dalla Lana School of Public Health (DLSPH), a Faculty of the University of Toronto, is a regional and global leader in public health education, research and service, with the largest concentrations of academic population and public health researchers in Canada and over $30 million in research funding per year.

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Variation in sexual orientations among men who have sex with men, and their current sexual practices
(1995) Myers, Ted; Allman, Dan; Jackson, Edward A.; Orr, Kevin
Purpose: To explore group variations in sexual risk-taking among different sexual orientations of men who have sex with men (MSM). Method: A convenience sample of men was recruited in gay-identified venues. An analysis was conducted to determine the independence of sexual orientation (gay, gay-previously heterosexual, currently bisexual), age and risk-taking. Results: Bisexual men were younger, lived outside metropolitan areas and socialized more in bathhouses. In general, bisexuals reported the safest sexual practices and previously heterosexual men the most unprotected. Conclusions: Among MSM, variation in sexual orientations was associated with differences in unprotected sex for older age groups. For the youngest age group, a similar level of risk-taking of the different orientation groups suggests uniform sociocultural influences.
Bisexuality and HIV/AIDS in Canada
(Taylor & Francis, 1996) Myers, Ted; Allman, Dan
This chapter explores what is known about bisexuality and HIV/AIDS in Canada. It focuses primarily on research definitions, behavioural manifestations, and the political movement and organization of bisexuals in relation to HIV/AIDS. Published research, largely epidemiological, relating to the sexual behaviour of various populations since the beginning of the AIDS epidemic are the predominant source of information. This documentation is critical because it is the only Canadian information currently available on bisexuality. While these data shed some light on the national picture as well as on regional variation, they ultimately raise more questions than answers. Scholarly reflection on sexuality in Canada and the placement of bisexuality along the continuum of human sexual relations is a discourse in its infancy. Our consideration of bisexuality in the arena of HIV/AIDS has had to take this into account.
Bisexuality and HIV Risk: Experiences in Canada and the United States
(Taylor and Francis Group, 1997) Doll, Lynda; Myers, Ted; Kennedy, Meaghan; Allman, Dan
The human immunodeficiency virus (HIV) epidemic has presented unparalleled challenges to sex researchers. Investigators have sought to understand a range of sexual behaviors and have scrutinized their roles in disease transmission. Opportunities have also emerged for developing and evaluating large-scale behavioral interventions to facilitate sexual risk reduction. In this article, we examine a topic of interest to sex researchers and HIV prevention programs, namely the relationship between bisexual behavior and HIV risk. We have gathered the theoretical and empirical literatures from two countries, Canada and the United States, permitting us to describe diverse experiences in countries in which variations in demographics and social norms as well as prevention programs may have consequences for the prevalence and contexts of bisexual behavior and for HIV risk. We begin our article with a review of the theories of bisexual behavior and a critique of methods used to study these populations. These sections provide a foundation for interpreting the empirical literature and for understanding the limitations of research related to HIV risk. We then provide for each country and for each gender a brief overview of data on the prevalence of bisexual behavior, HIV prevalence and AIDS cases, and the prevalence and determinants of HIV risk behaviors. We also review the emerging findings on prevention approaches for each population. Our review ends with a synthesis of the data across countries and genders and a proposed research agenda to increase our understanding of bisexual behavior and HIV risk among men and women who engage in sexual behavior with both genders.
Applying activity based costing in long term care
(Canadian College of Health Service Executives, 1998-11) Wodchis, Walter P
As greater numbers of elderly use health services and health care costs climb, effective financial tracking is an essential activity. Cost management in health care can benefit if costs are linked to the care activities where they are incurred. Activity based costing (ABC) provides a useful approach. The framework aligns costs (inputs) through activities (process) to outputs and outcomes. It allocates costs based on client care needs rather than management structure. The ABC framework was tested in a residential care facility and in supportive housing apartments. The results demonstrate the feasibility and advantages of ABC for long term care agencies, including community based care.
Male Sex Work and HIV/AIDS in Canada
(Routledge, 1999) Allman, Dan; Myers, Ted
Unlike some deviant sub-populations which only began to be seriously scrutinized by researchers upon the advent of HIV, the study of sex work in Canada was well developed by the time HIV was identified. Though sex work as a social issue has been much discussed in academic, political and legal discourses in Canada, there have been few attempts to understand the experiences of male sex workers. In this chapter we describe findings from a recent review of male sex work and HIV and AIDS in Canada. This review examined past and present understanding of male sex work in Canada, with an emphasis on issues relating to HIV and AIDS.
Gay and bisexual men's sexual partnerships and variations in risk behaviour
(1999) Myers, Ted; Allman, Dan; Calzavara, Liviana; Morrison, Ken; Marchand, Rick; Major, Carol
In epidemiological studies that focus on gay men's sexual risk behaviour the context in which it occurs is often ignored. Increasingly, knowledge of the type and nature of the partnerships is seen to be important when assessing sexual risk behaviour. For this study, gay and bisexual men were recruited through community groups, gay bars and bathhouses to complete a questionnaire on sexual practices with primary and casual same-sex partners. Partnerships were grouped as primary (162%, n = 110), casual (40.0%, n = 187) and both primary and casual (162% n = 76). In these configurations 40.0%, 13.3% and 31.4% respectively reported at least one episode of unprotected sex in the previous three months. In the subgroup of men with both primary and casual partners a number varied their behaviour significantly with partner type. Most important, the pattern was for men to refrain from risky activities with their casual partners. However, for some men a reverse pattern of risk was reported. These findings emphasize that, for HIV education and prevention, there is a need to address the diversity of mens' relationships, to recognize the diversity of behaviour within relationships and to open discussion about the factors that influence condom use.
Variations in geographical distribution of foreign and domestically trained physicians in the United States: ‘safety nets’ or ‘surplus exacerbation’?
(Elsevier, 1999-10) Mick, S S ; Lee, S-Y D ; Wodchis, Walter P
In the United States. a debate has existed for decades about whether foreign-trained physicians (known in the US as ‘international medical graduates’ or ‘IMGs’) and US medical graduates (USMGs) have been differentially distributed such that IMGs were more likely to be found in locales characterized as high in need or medical underservice. This ‘safety net’ hypothesis has been countered by the IMG ‘surplus exacerbation’ argument that IMGs have simply swelled an already abundant supply of physicians without any disproportionate service to areas in need. Through an analysis of the American Medical Association Physician Masterfile and the Area Resource File, we classified post-resident IMGs and USMGs into low and high need counties in each of the US states, compared the percentage distributions, and determined whether IMGs were found disproportionately in high need or underserved counties. Using four measures (infant mortality rate, socio-economic status, proportion non-white population, and rural county designation), we show that there were consistently more states having IMG disproportions than USMG disproportions. The magnitude of the differences was greater for IMGs than for USMGs, and there was a correlation between IMG disproportions and low doctor/100,000 population ratios. These findings are shown to exist simultaneously with two empirical facts: first, not all IMGs were located in high new or underserved counties; second, IMGs were more likely than USMGs to be located in states with a large number of physicians. The juxtaposition of an IMG presence in ‘safety net’ locales and of IMGs' contribution to a physician abundance is discussed within the context of the current debate about a US physician ‘surplus’ and initiatives to reduce the number of IMGs in residency training.
Planning for Community-based Evaluation
(2000) Cockerill, Rhonda; Myers, Ted; Allman, Dan
We present a planning guide that can be used to improve community-based evaluation. The planning guide consists of a set of questions that need to be discussed with all stakeholders. It covers issues relating to the nature and purpose of a community-based evaluation project, research methods and approaches, participation and decision-making, conflict and conflict resolution, and dissemination and use of results. The planning guide was developed through our experiences in an HIV/AIDS research and evaluation unit and a review of the literature. If community-based evaluators keep in mind the questions in this planning guide and discuss them early on with stakeholders, the evaluation process should benefit.
Voice-related quality of life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis
(Elsevier, 2000-09) Hogikyan, N ; Wodchis, Walter P ; Terrell, J E ; Bradford, C R ; Esclamado, R M
Unilateral vocal fold paralysis is a common clinical problem which frequently causes severe dysphonia. Various treatment options exist for this con- dition, with the type I thyroplasty being one of the more commonly performed surgical procedures for vocal rehabilitation. The Voice-Related Quality of Life (V- RQOL) Measure is a validated outcomes instrument for voice disorders. This study measured the V-RQOL of patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores to those of patients with untreated and uncompensated unilateral vocal fold paralysis and to normals. Treated patients had significantly higher domain and overall V-RQOL scores than untreated patients, but also scored lower than normals. These differences were true across gender and age. Patients who were more distant from surgery had lower V- RQOL scores than those who had more recently been treated. It is concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis. This study also demonstrates further the utility of patient- oriented measures of treatment outcome.
Longitudinal effects of botox injections on voice-related quality of life (V-RQOL) for patients with adductory spasmodic dysphonia (part II)
(American Medical Association, 2001-12) Rubin, A ; Wodchis, Walter P ; Spak, C ; Kileny, P R ; Hogikyan, N D
Objective: To investigate the longitudinal effects of botulinum toxin type A (Botox) injections on voice-related quality of life (V-RQOL) for patients with adductory spasmodic dysphonia. Design: Prospective study. Setting: Academic tertiary care referral center. Participants: Forty-two patients who presented to our institution with dysphonia and were diagnosed as having adductory spasmodic dysphonia during a 38-month period. Intervention: Patients received Botox injections into both thyroarytenoid muscles via the cricothyroid membrane. The typical starting dose was 1.0 U per vocal fold. If necessary, the dosage was adjusted in subsequent injections to reduce adverse effects or to enhance duration of benefit. Main Outcome Measures: Patients filled out questionnaires, including the V-RQOL Measure and a selfassessed overall voice rating, before each injection. Postinjection questionnaires were completed 6 to 8 weeks after each treatment. Mean pretreatment and posttreatment scores were calculated for each treatment. Results: The number of treatments per patient ranged from 1 to 7. Statistically significant improvements in mean total and domain V-RQOL scores were calculated for every injection (P.01) (no postinjection questionnaires were available for the seventh injections). The magnitude of the effect remained constant for later injections. Eighty-two percent of the population recorded at least 1 category of improvement in overall self-assessed voice rating with each injection. Conclusions: Botox has a significant beneficial effect on V-RQOL for at least 6 injection cycles. This study demonstrates the efficacy of Botox for treating patients with adductory spasmodic dysphonia and further illustrates the usefulness and validity of the V-RQOL Measure in evaluating patients with dysphonia.
Longitudinal effects of botulinum toxin injections on voice-related quality of life (V-RQOL) for patients with adductory spasmodic dysphonia
(Elsevier, 2003-04) Hogikyan, N ; Wodchis, Walter P ; Spak, C ; Kileny, P R
Adductory spasmodic dysphonia is a focal dystonia of laryngeal muscles. Patients with this disorder typically have severe vocal difficulties, with significant functional, social, and emotional consequences. There is no widely accepted cure for this condition, however, botulinum toxin injections of the thyroarytenoid muscles are considered by most voice clinicians to be the state of the art treatment. Based on extensive experience treating patients for adductory spasmodic dysphonia, we feel that traditional means of voice assessment do not adequately measure either the disease severity or the treatment outcomes. That is, listening to or acoustically analyzing limited phonatory samples does not capture the functional, social, and emotional consequences of this disorder. These consequences will be reflected in a patient's voice-related quality of life (V-RQOL). Using a validated voice outcomes instrument, the V-RQOL Measure, the purpose of this study was to quantify longitudinal changes in the V-RQOL of patients with adductory spasmodic dysphonia who are undergoing botulinum toxin injections. Twenty-seven consecutive new patients presenting with dysphonia to our institution during an 18-month period were diagnosed with adductory spasmodic dysphonia, and treated patients were evaluated prospectively using the V-RQOL Measure. Results indicated that (1) V-RQOL was initially very low for these patients, (2) botulinum toxin injections improved it significantly for each injection cycle studied, and (3) the magnitude of the treatment effect appears to change across injections.
Health-related quality of life measure based on the minimum data set
(Cambridge University Press, 2003-08) Wodchis, Walter P ; Hirdes, John P ; Feeny, David H
Objectives: To introduce a health-related quality of life measure for home care and institutional longterm care settings based on the Minimum Data Set (MDS) and the Health Utilities Index Mark 2 (HUI2). Methods: Health attributes of Health Related Quality of Life (HRQOL) were identified, and suitable constructs were determined. Items from the MDS were mapped to the HUI2. Scores for the Minimum Data Set Health Status Index (MDS-HSI) were calculated using the HUI2 scoring function. Measurement properties are examined and reported. HRQOL scores were compared across study populations and to an external reference population. Random samples were drawn from long-term care clients in private households (n=377), supportive housing apartments (n=80), two residential care facilities (n=166), and a chronic care hospital (n=274) in Ontario, Canada. All sampled residents were assessed for health-related items using the MDS. Results: The MDS-HSI results provide preliminary evidence of good validity. Institutional populations had lower overall HRQOL scores than community populations. Comparisons to existing Canadian national data support construct validity. Conclusions: The MDS-HSI provides a summary outcome measure and an indicator of health status in the six supporting attributes. Longitudinal research is required to assess the sensitivity of the measure to changes over time. Further research is also required to establish the consistency between the preference weights used in this application of the HUI2 and those thatwould be derived from a frail elderly population
Payer incentives and physical rehabilitation therapy for non-elderly institutional long-term care residents: evidence from Michigan and Ontario.
(Elsevier, 2004-02) Wodchis, Walter P. ; Fries, Brant E. ; Pollack, Harold
Objective: The purpose of this study is to examine the effect of payment incentives on the provision rehabilitation therapy to non-elderly nursing home residents. Design: Retrospective cross-sectional study. Participants and Setting: All non-elderly nursing home residents admitted to nursing homes in Michigan, U.S.A. or Complex Continuing Care facilities in Ontario, Canada in 1998 or 1999 (n=5,189) Main Outcome: The focus for the present study is the effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly therapy time for each therapy type. Results: A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private-insurance was associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared to private-pay residents. Global budget payment was associated with greater access to PT but less weekly minutes of OT and PT . Conclusions: Little information exists to describe the characteristics and treatment of non-elderly nursing home residents. This study finds that many of these residents receive rehabilitation and that residents whose care is paid for by more generous payers such as Medicare receive more therapy than those paid for by less generous payers.
Physical rehabilitation following Medicare prospective payment for skilled nursing
(Blackwell Publishing, 2004-10) Wodchis, Walter P
Objective: To examine the effect of the Medicare prospective payment system (PPS) for Skilled Nursing Facilities (SNF) on the delivery of rehabilitation therapy to residents. Data Sources: Resident-level data are based on the Resident Assessment Instrument Minimum Data Set for nursing facilities. All elderly residents admitted to SNFs in Michigan and Ohio in 1998 and 1999 form the study population (n= 99,952). Study Design: A differences-in-differences identification strategy is used to compare rehabilitation therapy for SNF residents before and after a change in Medicare SNF payment. Logistic and linear regression analyses are used to examine the effect of PPS on receipt of physical, occupational, or speech therapy and total therapy time. Data Extraction: Data for the present study were extracted from the University of Michigan Assessment Archive Project (UMAAP). One assessment was obtained for each resident admitted to nursing facilities during the study period. Principal Findings: The introduction of PPS for all U.S. Medicare residents in July of 1998 was associated with specific targeting of rehabilitation treatment time to the most profitable levels of therapy. PPS was also associated with increased likelihood of therapy but less rehabilitation therapy time for Medicare residents. Conclusions: The present results indicate that rehabilitation therapy is sensitive to the specific payment incentives associated with PPS.
The effect of Medicare’s prospective payment system on discharge outcomes of skilled nursing facility residents
(Excellus, 2004-12) Wodchis, Walter P ; Fries, B F ; Hirth, R A
In July 1998, the Centers for Medicare and Medicaid Services (CMS) changed the payment method for Medicare (Part A) skilled nursing facility (SNF) care from a cost-based system to a prospective payment system (PPS). Unlike the previous cost-based payment system, PPS restricts skilled nursing facility payment to pre-determined levels. CMS also reduced the total payments to SNFs coincident with PPS implementation. These changes might reduce quality of care at skilled nursing facilities and could be reflected in resident discharge patterns. The present study examines the effect of the 1998 policy change on resident discharge outcomes. The results indicate that PPS reduced the relative risk of discharge to home and to death for Medicare residents (compared to non-Medicare residents) and had no significant effect on hospitalizations or transfers.
Social inclusion as a fourth way: Reflections on HIV, HCV, and people who use illicit drugs in Canada
(2005) Allman, Dan
Atypical antipschotic drugs and risk of ischemic storke: population based retrospective cohort study
(BMJ Publishing Group Limited, 2005-01) Gill, S.S. ; Rochon, P.A. ; Herrmann, N. ; Lee, P.E. ; Sykora, K. ; Gunraj, N. ; Normand, S-L. T. ; Gurwitz, J.H. ; Marras, C. ; Wodchis, W.P ; Mamdani, M.
Objective To compare the incidence of admissions to hospital for stroke among older adults with dementia receiving atypical or typical antipsychotics. Design Population based retrospective cohort study. Setting Ontario, Canada. Patients 32 710 older adults ( ≥ 65 years) with dementia (17 845 dispensed an atypical antipsychotic and 14 865 dispensed a typical antipsychotic). Main outcome measures Admission to hospital with the most responsible diagnosis (single most important condition responsible for the patient’s admission) of ischaemic stroke. Observation of patients until they were either admitted to hospital with ischaemic stroke, stopped taking antipsychotics, died, or the study ended. Results After adjustment for potential confounders, participants receiving atypical antipsychotics showed no significant increase in risk of ischaemic stroke compared with those receiving typical antipsychotics (adjusted hazard ratio 1.01, 95% confidence interval 0.81 to 1.26). This finding was consistent in a series of subgroup analyses, including ones of individual atypical antipsychotic drugs (risperidone, olanzapine, and quetiapine) and selected subpopulations of the main cohorts. Conclusion Older adults with dementia who take atypical antipsychotics have a similar risk of ischaemic stroke to those taking typical antipsychotics.
A national study showed that diagnoses varied by age group in nursing home residents under age 65
(Elsevier, 2005-02) Fries, Brant E ; Wodchis, Walter P ; Blaum, Caroline ; Buttar, Amna ; Drabek, John ; Morris, John N
Objective: It is commonly held that those aged <65 in nursing homes (NHs) are substantially different from elderly residents. This study uses data gathered using the Resident Assessment Instrument’s Minimum Data Set (MDS) to describe these relatively rare residents. STUDY DESIGN AND SETTING, RESULTS, CONCLUSION Data: The study uses MDS assessments of close to three-quarter million residents in nine states from 1994-6. An algorithm resolved potentially incorrect ages caused by confusion between residents age < 15 from those 100-115. Methods: Residents are described within chronological age group (0-4, 5-14, etc.). Functional status, prevalence of chronic conditions and treatments are described for each group. Co-morbidity is examined using factor analyses and cross-tabulations. Results: Overall, pediatric residents appear substantially more physically and cognitively impaired than young adult residents. The youngest population primarily has diagnoses related to mental retardation and developmental disabilities, young adults have the highest prevalence of hemi- and quadriplegia, while older residents are typified by increasing prevalence of neurological diagnoses and more co-morbid conditions. Thirteen diagnostic factors describe nearly 85% of all NH residents and highlights differences between age groups. Conclusions: This study offers a first description of nearly all NH residents <65. The classification demonstrates significant differences within this population and between these residents and those 65+.
Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study
(BMJ publish group, 2005-02) Gill, Sudeep S ; Rochon, P.A ; Herrmann, N ; Lee, P E ; Sykora, K ; Gunraj, N ; Normand, S L ; Gurwitz, J H ; Marras, C ; Wodchis, Walter P ; Mamdani, M
Objective To compare the incidence of admissions to hospital for stroke among older adults with dementia receiving atypical or typical antipsychotics. Design Population based retrospective cohort study. Setting Ontario, Canada. Patients 32 710 older adults ( ≥ 65 years) with dementia (17 845 dispensed an atypical antipsychotic and 14 865 dispensed a typical antipsychotic). Main outcome measures Admission to hospital with the most responsible diagnosis (single most important condition responsible for the patient’s admission) of ischaemic stroke. Observation of patients until they were either admitted to hospital with ischaemic stroke, stopped taking antipsychotics, died, or the study ended. Results After adjustment for potential confounders, participants receiving atypical antipsychotics showed no significant increase in risk of ischaemic stroke compared with those receiving typical antipsychotics (adjusted hazard ratio 1.01, 95% confidence interval 0.81 to 1.26). This finding was consistent in a series of subgroup analyses, including ones of individual atypical antipsychotic drugs (risperidone, olanzapine, and quetiapine) and selected subpopulations of the main cohorts. Conclusion Older adults with dementia who take atypical antipsychotics have a similar risk of ischaemic stroke to those taking typical antipsychotics.
Skilled nursing facility rehabilitation and discharge to home after stroke
(Elsevier, 2005-03) Wodchis, Walter ; Teare, Gary ; Naglie, Gary ; Bronskill, Susan ; Gill, Sudeep ; Hillmer, Michael ; Anderson, Geoff ; Rochon, Paula
RT was given to more than 95% of residents for whom discharge was expected within 90 days and to more than 60% of residents for whom discharge was uncertain or not expected. RT increased the likelihood of discharge to the community for all groups except those expected to be discharged within 30 days. The dose-response relation was strongest for residents with either an uncertain discharge prognosis or no discharge expected.

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