Canadian Quality Circle pilot project in osteoporosis

Program description

The CQC project involved a broad coalition of stakeholders and was under the guidance of the CQC steering committee, which was composed of leading physicians and scientists, representatives from the Ontario College of Family Physicians, industry scientists, and representatives from OC. The protocol was approved by the Health Research Ethics Board and the St Boniface General Hospital Research Review Committee in Manitoba and a research ethics board in Ontario.

Recruitment

Three groups of physicians were recruited for the study: facilitators, osteoporosis specialists, and circle members. All participants provided written informed consent. Physicians were selected based on their interest in osteoporosis and the fact that their practices were focused on women’s health.

The CQC facilitators were local family physicians recruited and trained specifically to lead study meetings. They were chosen by the CQC steering committee for their skills in facilitating small-group activities, their known interest in chronic disease management, and their involvement in continuing professional development.

Physicians specializing in osteoporosis management were assigned to each QC to assist participants in addressing clinical matters. These specialists were recruited from the local referral network on the recommendation of the facilitators of each QC.

Circle members were family physicians recruited from specific geographic regions across Canada based on a list of names developed by the facilitator of each QC (ie, colleagues known to the facilitator). This list was supplemented with physicians from the membership lists of the provincial colleges of family physicians. Each potential member received an introductory letter and was invited to join the CQC project. Facilitators or the project manager followed up by telephone. Up to 15 physicians were enrolled in each geographic area.

Fifty-two circle members participated in the pilot project. Two dropped out of the study before follow-up data collection. The remaining physicians formed 7 QCs. Six were in Ontario: Toronto core (n = 6), Toronto east (n = 5), London (n = 8), Kingston (n = 11), Hamilton-Niagara (n = 7), and Ottawa (n = 7); and 1 was in Manitoba: Winnipeg (n = 6). About 36% of circle members were women, 69% of the physicians were between 40 and 59 years old, 39% came from solo practices, 42% came from group practices, and 11% came from family medicine units.

Overview of project phases

The project was divided into 2 parts: part 1 was the pilot study, and part 2 was the national study. The pilot study was conducted to assess the feasibility of the study design and to gather information necessary for implementing the national study. Based on results from the pilot study, the methodology of the national study was slightly modified to improve physician education and data collection and interpretation.

The pilot project had 3 phases: training and baseline data collection, the educational intervention and follow-up data collection, and a session on implementing strategies for care (Figure 1). Participants received 12 Mainpro-C credits or 24 Mainpro-M1 credits for participating. Mainpro^® credits are awarded by the College of Family Physicians of Canada to acknowledge participation in accredited continuing medical education. All phases of the pilot project incorporated QC meetings led by the facilitators. Before the meetings, train-the-trainer workshops were conducted to assist facilitators in their role as group leaders.

• Download figure
• Open in new tab

Figure 1

Three phases of the Canadian Quality Circle pilot project

Educational workshop

The QC Educational Intervention Workshop was developed by the Core Educational Committee, which consisted of members of OC, representatives from the Ontario College of Family Physicians, leading physicians and scientists, and industry partners. The “Breaking News for Breaking Bones” accredited workshop was developed over a period of 18 months. The workshop was based on a provincial learning needs assessment and data from focus groups of family physicians from each of the provinces to ensure the curriculum material would meet the needs of physicians across Canada. The 2002 OC guidelines were used as the main evidence-based reference for the program. The needs assessment consisted of a 10-item survey that was mailed to approximately 3500 family physicians.

The workshop facilitator presented an overview of osteoporosis and led a case discussion. For the first workshop, the facilitator selected 1 of 3 cases, the one that seemed best for meeting the educational needs of participants: case 1, “Managing osteoporosis in the older adult”; case 2, “Osteoporosis in the postmenopausal woman”; or case 3, “Osteoporosis in the 50-year-old healthy woman.” The case was selected based on a pre-evaluation questionnaire sent to individual QC members before the meeting.

Multifaceted educational intervention

Our educational intervention had 8 key components (Table 1). Studies have demonstrated that single-component interventions are unlikely to change clinical practice,14–16 and that combining various techniques into 1 multifaceted intervention could be more effective.17,18

Evaluation of the pilot project

Family physicians thought the CQC project was well designed, and the intervention plan was well received. The success of the intervention plan was due to several factors, including the train-the-trainer sessions for facilitators; the prior development of PowerPoint presentations summarizing the main points of discussion during each meeting; the materials for participants, such as binders to hold correspondence and profiles; and the ongoing reminders of meeting dates, venues, and agendas.

Providing participants with profiles summarizing their fracture-prevention treatment strategies appeared to be an effective approach, both to making physicians aware of their current practices and to allowing them to compare their practices with those of their peers. The database application successfully addressed challenges, such as authenticating and authorizing data, and other critical functions.

Suggestions for improvement

Although participants in the pilot project thought the study was successful and efficient, they did suggest ways to improve the project design for the national study. They suggested using the facilitators more effectively in the recruitment process to build on their local networking capabilities. They also suggested shortening the time between recruitment and baseline meetings to maintain enthusiasm and involvement in the project.

Facilitators in the pilot project recommended that the steering committee provide a more clearly defined role for the osteoporosis specialists in advance of meetings and have more face-to-face contact with the research team and their peers during the study, both in preparation for the meetings and as a debriefing exercise. Although most participants agreed that the CQC-form was easy to complete, they said that questions related to the use of pharmaceuticals were difficult to interpret and that efforts should be made to balance the amount of information required with the need to assess additional factors that influence treatment decisions.

With regard to the educational workshop, they suggested that too much information was provided and that the focus of the workshop should be narrowed. They also suggested that simpler and clearer QC profiles could help in interpreting findings from particular graphs. The methodology of the national study will be modified based on these recommendations.