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OBJECTIVES: To identify and explore areas where responsibilities may overlap between family health teams (FHTs) and public health units (PHUs); to identify facilitators or barriers to collaboration; and to identify priority areas for increased collaboration. DESIGN AND CONTEXT: Cross-sectional mixed-methods study of FHTs and PHUs in Ontario, Canada, consisting of a postal survey, key informant interviews and a roundtable meeting. RESULTS: The survey response rate was 46%. Direct client-based services such as giving immunizations, promoting prenatal health and nutrition, and counselling related to smoking cessation were identified as the top three areas of perceived overlap. The greatest interest in collaboration was expressed in the areas of emergency planning and preparedness, immunization, and prenatal health and nutrition. Good communication with a clear understanding of roles and functions was the most important facilitator, and lack of resources and absence of a clear provincial mandate and direction to collaborate were identified as significant barriers. CONCLUSIONS: Small, simple client-based projects of interest to both kinds of organization would be the best way to move forward in the short term. Improving communication between FHTs and PHUs, understanding of roles and functions, the use of shared or interoperable information systems and greater clarity from government on the ways in which these two key sectors of the healthcare system are intended to work together were identified as important for the success of increased collaboration.

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The precautionary principle has influenced environmental and public health policy. It essentially states that complete evidence of a potential risk is not required before action is taken to mitigate the effects of the potential risk. The application of precaution to public health issues is not straightforward and could paradoxically cause harm to the public's health when applied inappropriately. To avoid this, we propose a framework for applying the precautionary principle to potential public health risks. The framework consists of ten guiding questions to help establish whether a proposed application of the precautionary principle on a public health matter is based on adequacy of the evidence of causation, severity of harm and acceptability of the precautionary measures.

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BACKGROUND: All aspects of the heath care sector are being asked to account for their performance. This poses unique challenges for local public health units with their traditional focus on population health and their emphasis on disease prevention, health promotion and protection. Reliance on measures of health status provides an imprecise and partial picture of the performance of a health unit. In 2004 the provincial Institute for Clinical Evaluative Sciences based in Ontario, Canada introduced a public-health specific balanced scorecard framework. We present the conceptual deliberations and decisions undertaken by a health unit while adopting the framework. DISCUSSION: Posing, pondering and answering key questions assisted in applying the framework and developing indicators. Questions such as: Who should be involved in developing performance indicators? What level of performance should be measured? Who is the primary intended audience? Where and how do we begin? What types of indicators should populate the health status and determinants quadrant? What types of indicators should populate the resources and services quadrant? What type of indicators should populate the community engagement quadrant? What types of indicators should populate the integration and responsiveness quadrants? Should we try to link the quadrants? What comparators do we use? How do we move from a baseline report card to a continuous quality improvement management tool? SUMMARY: An inclusive, participatory process was chosen for defining and creating indicators to populate the four quadrants. Examples of indicators that populate the four quadrants of the scorecard are presented and key decisions are highlighted that facilitated the process.

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OBJECTIVES: To coordinate local responsibilities and identify options to enhance local health system capacity during a pandemic. The purpose of this paper is to illustrate the application of a Delphi exercise in an Ontario Public Health Unit as a first step in this complex planning task. Its strengths and weaknesses are presented. PARTICIPANTS: Stakeholders representing nine categories of health care organizations. SETTING: Public Health facilitated the Delphi process. INTERVENTION: The exercise occurred in three rounds. In round 1, stakeholders identified a series of questions pertaining to the subject. Round 2 involved formulation of issue-related statements outlining possible strategies or solutions. Level of agreement regarding the statements by panel members were indicated. In round 3, a facilitated face-to-face meeting allowed statements to be fed back to the panel, enabling discussion of their own and other panel members' previous statement views. OUTCOMES: Statements were formulated from questions generated by the expert panel, collated into categories and sent to all panel members. A total of 72 unique statements were developed. Agreement was obtained for 56 of the statements. CONCLUSION: The Delphi exercise proved to be an effective approach to commence planning a coordinated local health system response to a pandemic. This process permitted advancement of the planning exercise to Phase 2 which aimed to develop operational plans for primary assessment centres, alternate care sites and hospital surge capacity.

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STUDY OBJECTIVE: To describe trends in hospital utilization and surgical rates for endometriosis and to estimate the probability of hospital readmission over 4 years among women with early-stage disease. DESIGN: Population-based, retrospective cross-sectional and longitudinal analysis of 53,385 hospital admissions for same-day surgery or inpatient treatment of endometriosis from fiscal years 1994/95 through 2001/02 (Canadian Task Force classification III). SETTING: All hospital discharge records that listed endometriosis as the most-responsible diagnosis in the province of Ontario, Canada, from fiscal years 1994-1995 through 2001-2002. PATIENTS: Ontario female patients 15 years of age or older admitted to the hospital for treatment of endometriosis. INTERVENTIONS: Surgical treatments were classified as minor, intermediate, or major depending on the extent of the surgery. MEASUREMENTS AND MAIN RESULTS: Age-standardized annual discharge rates were calculated and trends in surgical treatment described. The records of 7993 women who received minor or intermediate surgery on their index hospital visit were linked, and the likelihood and predictors of readmission were calculated using survival analysis and logistic regression. During the observation period, the standardized discharge rates fell significantly from 172.9 per 100,000 women aged 15 to 70 to 137.1 per 100,000 (p<.05). Age-specific rates were highest for women aged 15 to 39 (approximately 200 per 100,000). The proportion of hospitalizations involving minor surgeries dropped (from 27% to 17%), and the proportion involving intermediate surgeries increased (from 40% to 53%). The likelihood of hospital readmission within 4 years for additional surgical treatment was 27% and of having a hysterectomy was 12%. CONCLUSION: Fewer women are being hospitalized for minor surgical procedures for endometriosis with hospital-based care being reserved for more extensive procedures. Nonetheless, about a quarter of women hospitalized for initial surgical treatment for endometriosis will undergo additional surgical treatment within 4 years, and one in 10 will have a hysterectomy.

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