Context Primary care is the ideal setting for chronic disease prevention and screening (CDPS); however, evidence-based approaches are inconsistently applied and physicians lack the time to adequately address CDPS. The BETTER coalition, informed by Ontario’s Chronic Disease Prevention and Management Framework, demonstrated the effectiveness of an approach to CDPS involving internal practice facilitation at the individual patient level through the use of a prevention practitioner (PP).

Objective To improve CDPS in primary care for cardiovascular disease, diabetes, cancer, and associated lifestyle factors. The desired long-term goals are improved clinical outcomes, reduction in the burden of chronic disease, and improved sustainability of the health care system through improved CDPS in primary care.

Design The program aims to transform practice in participating communities in Alberta, Ontario, Newfoundland and Labrador, the Northwest Territories, and Nova Scotia, through a patient-level intervention by the PP, a health care professional within the practice. This intervention 1) is personalized; 2) addresses multiple conditions; 3) is integrated with linkages to local, regional, or national resources; and 4) is longitudinal—assessing patients over time.

Target population The target patient population is adults aged 40 to 65 years. The BETTER program brings together primary care providers, policy and decision makers, and researchers to work toward improving CDPS in primary care.

Intervention Using the BETTER tool kit, the PP determines which CDPS maneuvers the patient is eligible to receive and, through shared decision making and motivational interviewing, develops a unique, individualized “prevention prescription” with the patient.

Outcome measures The program will be evaluated using qualitative and quantitative methods. A composite measure of CDPS effectiveness will be made using a summary quality index. The summary quality index is a ratio of the number of CDPS maneuvers that are met at follow-up divided by the number a patient is eligible to receive as determined at baseline. The RE-AIM framework will also be used to evaluate the program.

Conclusion The BETTER project is a collaborative approach grounded in practice and built from existing work; that is, “integration not creation.” The findings to date provide an understanding of an approach that is effective for CDPS within primary care and that could be adapted to become sustainable in the nonresearch setting.

Context There is a paucity of research regarding the specific kind of experiences and challenges health care providers encounter in the adoption and implementation of electronic medical records (EMRs). While some studies report organizational impacts and system-level changes affecting provider roles and responsibilities, others suggest improved communication between care providers, which has important implications for an interdisciplinary care setting and potentially for an academic teaching clinic.

Objective To investigate how a newly implemented EMR was implemented and integrated into 3 family medicine academic teaching units at the University of Manitoba.

Design We assessed the experience during the first year of EMR implementation using a qualitative approach to explore salient events and common themes regarding the user experience.

Participants Members of the Department of Family Medicine interdisciplinary teaching teams and residents.

Instrument An electronic questionnaire was distributed at 1, 3, 6, and 9 months postimplementation, and focus groups were conducted at each site.

Outcome measures Participants were asked to reflect on their experiences with EMR training, functions, and challenges, and effects on work flow, resident training, and patient care.

Results and findings The EMR implementation experiences of health care providers at the teaching clinics align very closely with previously described adoption frameworks. We also found unique implementation challenges such as changes in documentation scope, communication and continuity, and the effect within a training environment.

Conclusion Our study describes the process of managing a considerable change in clinician practice that has not been explored or detailed in the literature. Clearly understanding how digitization affects clinician practices will have ongoing value as the digital environment, including EMRs, continues to evolve.

Context There is a perception that not having a family physician is a major determinant for seeking medical attention at walk-in clinics as well as emergency departments. Similar studies assessing determinants of urgent care clinic use are very rare compared with those for emergency department and routine walk-in clinics.

Objective This study assessed the determinants of urgent care clinic use in a city with 4 regular walk-in clinics and a community hospital-based emergency department.

Methods A 9-item questionnaire was administered to 300 patients attending the urgent care clinic. Data (nominal) were analyzed using z statistics or χ² tests.

Results Two hundred ninety-three surveys (98%) were completed. Only 31 patients (11%) had chosen the urgent care clinic over other clinics for specific medical reasons. On a scale of 1 to 10, a majority (58%) of patients perceived their problem to be of high acuity (score of 7 to 10; P < .0001) versus moderate (score of 5 to 6; 23%) or low acuity (score of 1 to 4; 17%). Sixty-three percent of patients (n = 184) had family physicians (P < .0001), but only 68 (37%) called their family physicians’ offices (P < .0001). Of these, 60% (n = 41) could not get an appointment (busy line, 15%; physician away, 27%; no opening, 19%). Eighteen patients (26%) got an appointment considered remote. Of those who did not call their family physicians (n = 116), 54 (47%) assumed unavailability and 31 (27%) assumed that appointments would be remote. Interestingly, assumptions of physicians’ unavailability and remote appointments were not far from reality (P = .1 and P = .9, respectively).

Conclusion The urgent care clinic was being used as any other walk-in clinic. Most of the patients considered their ailments to be of high acuity. A large majority of patients presenting at the urgent care clinic did have family physicians, hence not having a family physician did not seem to be a main determinant. However, perceived and real unavailability of their physicians or timely appointments were major determinants of clinic use.

Context Continuing medical education (CME) for FPs seeks to promote positive practice change and improvement. Research suggests interactive techniques, small group learning, interrupted learning formats, and commitment-to-change statements support practice improvement. However, few studies have used actual practice data to measure CME outcomes. Workshops on HIV testing measure CME outcomes using HIV testing data, offering more rigorous evaluation of CME features that support practice improvement.

Objective To determine whether FPs who attended routine HIV testing workshops subsequently increased HIV testing in their practices; to identify specific features of the workshops that supported change.

Design A mixed methods approach was used to evaluate the program, incorporating analysis of participants’ HIV testing data with preworkshop and postworkshop surveys and field notes.

Participants Forty-six FPs from Vancouver, BC, who attended 1 of 4, 2-part workshops on routine HIV testing.

Intervention A preworkshop needs assessment survey served to tailor workshops to each small group cohort. The first workshop employed “ask the expert,” role-play, and discussion. Participants completed a commitment-to-change statement, outlining specific objectives for practice improvement. Support tools were offered, including in-practice support and individualized reports on HIV tests ordered. A 2-month integration period followed, with opportunity to implement routine HIV testing into practice. At the second workshop participants had opportunities to share reflections on integration period experiences.

Outcome measures Comparison of number of HIV tests performed before and after the workshops. Preworkshop and postworkshop surveys, written reflections, and field notes captured CME features that supported change.

Results and findings Participants’ HIV testing numbers increased significantly following their attendance at the workshops (P < .001). Self-report survey data and field notes indicated that the integration period, role-play, small group discussion, provision of useful tools and resources, and hearing colleagues’ experiences were particularly effective in promoting practice change.

Conclusion Participants’ HIV testing increased following the workshops. Interactive, small group CME with an integration period, commitment-to-change statements, and provision of resources can be effective for FPs in achieving practice improvement. The success of the workshops has contributed to provincial expansion of the initiative. Future work will explore maintenance of practice change.

Context In 2010, the College of Family Physicians of Canada approved the Triple C Competency-based Curriculum. The goal of this initiative is to produce family medicine graduates who will be ready to practise comprehensive family medicine in any community in Canada with the competencies that reflect the changing needs of Canadians. To ensure that the Triple C Competency-based Curriculum meets its goals, a working group of the College of Family Physicians of Canada has focused on designing and piloting a series of surveys and process inventories. This study reports on the design and preliminary results of the first survey (2 other surveys will be developed and administered to track residents over time).

Objective To determine the best questions to ask to establish baseline data about our current residents.

Design Multiple-site survey design (online and paper administration).

Participants First-year family medicine residents across 5 family medicine residency programs (n = 317; response rate 70%).

Instrument Entry survey that included questions about background demographic characteristics, family medicine–related experiences in medical school, intentions to practise, and confidence in dealing with various patient populations.

Outcome measures Preparedness to practise family medicine, experiences (positive and negative) with family medicine, and intentions to practise (geographic, patient populations, and comprehensiveness of care).

Results Design and piloting of the survey went through multiple iterative processes. The final wording and content of the surveys was finalized in the spring of 2012 and administered to the incoming cohort in mid- to late July. Respondents indicated varying levels of exposure to described patient populations, but almost all respondents indicated low levels of exposure to palliative or end-of-life care and care of vulnerable populations. At total of 92% of respondents reported positive or highly positive attitudes toward family medicine; 63% of residents planned to practise comprehensive care.

Conclusion Collecting baseline data about residents entering family medicine programs can contribute to decisions about curriculum experiences to be offered. Further, similar surveys will be administered at the end of residency and after the first 3 years in practice. Tracking resident attitudes, confidence, and self-perceived competence over time will allow us to determine if the Triple C curriculum is having the intended effects.

Context Visual art has been used in medical education to improve learners’ observation and diagnostic skills. Less work has been done using visual art in a narrative fashion; that is, mining the ambiguity and emotion inherent in artistic representations to explore clinical relationships.

Objective To determine how directed study of visual art influences medical educators’ attitudes about the value of art experiences in student development and in patient care.

Design Workshop followed by retrospective preworkshop and postworkshop self-assessment obtained through an electronic questionnaire.

Participants Medical educators and clinicians in an interdisciplinary conference on humanities in health care at the University of Calgary.

Intervention We designed a workshop around a painting entitled “Sticky,” which portrays a woman covered with labels such as poor, unloved, fat, etc. After a didactic session on how to “read” a painting, participants viewed “Sticky” independently and then discussed it in small and large groups, followed by a question-and-answer session with the artist. Two months after the workshop, participants were invited to complete a postworkshop questionnaire.

Outcome measures Self-assessed attitudes about how the observational and interpretive skills exercised in the viewing of visual art can improve student skill and patient care.

Results and findings Respondents were almost unanimous in rating the workshop as valuable. Individual viewing of the artwork, facilitated small group discussion, and the question-and-answer period with the artist were ranked as the most useful aspects of the workshop. Changes in self-assessed attitude were analyzed using the Wilcoxon rank sum test. Significant changes were observed in the degree to which participants believed observational and interpretive skills involved in viewing art were relevant to patient care, and in the degree to which participants believed visual art should be used in medical education to improve students’ observational skills, narrative skills, and empathy.

Discussion Directed art experiences positively influence the degree to which educators and clinicians believe the skills involved in interpreting visual art can be used to influence student clinical skills and empathy. Improving educator comfort with these humanities skill sets might open up new possibilities in medical mentorship and in protecting students’ engagement during medical enculturation.

Context Discontinuation of secondary prevention medications post–ST-elevation myocardial infarction (STEMI) is common and associated with increased mortality.

Objective To test a scalable intervention aiming to improve long-term adherence to cardiac medications post-STEMI.

Design Pragmatic, cluster-randomized controlled trial with blinded outcome assessment.

Participants Post-STEMI patients from one health region in Ontario were enrolled. Patients with the same family physician received the same intervention to avoid contamination.

Intervention An automated system that sends recurrent, personalized, educational reminders to patients, their family physicians, and their pharmacists urging long-term use of secondary prevention medications. Reminders are sent by mail at 1, 2, 5, 8, and 11 months after discharge.

Outcome measures The primary outcome is the proportion of patients taking all 5 guideline-recommended classes of cardiac medications (acetylsalicylic acid, second antiplatelet, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, statin, and β-blocker). Interim 3-month results are reported, along with data from an embedded process evaluation.

Results A total of 861 eligible patients were randomized (intervention = 415, control = 446); 89% in the intervention arm and 88% in the control arm completed 3-month follow-up. Baseline characteristics in the 2 groups were balanced. Of patients taking 5 of 5 medication classes at discharge (n = 221 in intervention and n = 252 in control), 73.8% of intervention and 70.2% of control patients were still taking 5 of 5 classes at 3 months (absolute difference in persistence = 3.6%). The process evaluation found that 59% of patients remembered receiving the intervention and 53% of those took it for discussion with their providers. Patients reported that discontinuation happened more commonly at the direction of the internist or cardiologist than the family physician.

Conclusion DERLA-STEMI demonstrates the feasibility of recruiting and randomizing all eligible patients from a health region to a quality improvement initiative. Preliminary results suggest low persistence to all 5 cardiac medication classes at 3 months. A small absolute difference in medication persistence between the groups after only 3 months indicates the promise of this readily scalable and sustainable intervention. Long-term follow-up is ongoing.

Context There are currently 31 primary care memory clinics in Ontario, led by family doctors and supported by interprofessional health care providers (including geriatric specialists). In these memory clinics, the health care team reorganizes care processes using standardized assessments and optimizes use of interprofessional care through structured collaboration and integrated patient-centred care. The model uses co-active team-based case management rooted in family practice.

Objective To explore the barriers and facilitators to adapting and extending the current memory clinic model to integrate care for conditions such as heart failure, falls, and chronic obstructive pulmonary disease, with the goal of improving outcomes for older adult patients with complex chronic conditions and increasing the efficiency of health care utilization.

Design The study design involves a mixed-method approach to obtain stakeholder perceptions on current barriers and facilitators to integrated primary care and the potential effects of expanding the memory clinic model.

Participants Physicians currently working in memory clinic teams (n = 30) and supporting physician specialists (n = 9) were recruited as survey participants. Telephone interviews were conducted with a sample of lead physicians (n = 18). Participants had a range of experience as memory clinic physicians, including length of time in their role.

Instrument and outcome measures Online surveys and telephone interviews were used to obtain data regarding physician perceptions and recommendations on memory clinic expansion and the role of physician specialists as consultants.

Results and findings Survey results provided descriptive statistics, and qualitative data were coded to identify key themes. Results indicate high satisfaction rates with the current memory clinic model and overall support for expanding the model to integrate care for other complex conditions. Funding and staffing resources were reported as key barriers to facilitating integration, including limited remuneration for physician leads and supporting specialists. Facilitators included structured training, a successful team approach, and access to supporting specialists.

Conclusion Identified facilitators and barriers will inform the design, implementation process, and pilot testing of an expanded memory clinic care model to manage other complex chronic conditions of seniors.

Context Publicly funded nursing home care is delivered in for-profit, non-profit, and publicly owned facilities, and previous literature has determined that facility ownership influences resident outcomes. When nursing home residents are ill or injured, they are frequently transferred to the hospital emergency department (ED). Higher rates of ED transfers lead to higher rates of hospital admissions, putting residents at risk of further decline and greater risk of iatrogenesis.

Objective To examine the association of nursing home facility ownership with ED transfer rates, describe how facility organizational characteristics are distributed across ownership groups, and explore the association of these characteristics with ED transfer rates.

Design A retrospective observational cohort study using secondary administrative data linked to facility size, ownership, and cross-sectional survey–derived facility organizational characteristics.

Participants Residents admitted to any of the 48 for-profit, non-profit, and publicly owned nursing homes in the Vancouver Coastal Health region of British Columbia (N = 13 140).

Outcome measures Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis.

Results Crude ED transfer rates (transfers per 100 resident years) were 69, 70, and 51 in for-profit, non-profit, and publicly owned facilities, respectively. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared with for-profit (incidence rate ratio = 0.65, 95% CI 0.59 to 0.71) and non-profit ownership (incidence rate ratio = 0.68, 95% CI 0.62 to 0.74). Higher total direct-care nursing hours per resident day, and presence of allied health staff, disproportionately present in publicly owned facilities, were associated with lower transfer rates.

Conclusion Nursing home residents in publicly owned facilities have fewer transfers to hospital EDs when compared with residents in for-profit and non-profit facilities. Other organizational factors, some of which are disproportionately present in publicly owned facilities, are also related to ED transfers.

Context In 2012 to 2013 Vancouver Coastal Health, a regional health authority in British Columbia, implemented a pilot program to offer intranasal live attenuated influenza vaccine (LAIV) to children aged 2 to 17 years old within its annual influenza immunization campaign. Children could receive intranasal LAIV or intramuscular inactivated split virion trivalent influenza vaccine (TIV).

Objective An evaluation was undertaken to explore parent and health care provider acceptance of LAIV in the context of an increasing number of influenza vaccine options and in order to guide implementation in subsequent seasons.

Participants Participants included 460 parents and children eligible to receive influenza vaccine as well as 52 health care providers working in public health immunization clinics and participating family physician offices.

Design The evaluation involved an audit of chart records in pilot clinics, a client survey, and a health care provider survey.

Intervention and instrument Client surveys were developed and then administered to clients or parents following vaccine administration. Health care provider surveys were developed and then administered online or via telephone.

Outcome measures Outcome measures included overall LAIV acceptance rate, factors affecting vaccine choice, experiences of clients receiving the vaccine, and health care providers’ experience with the product.

Results Most clients chose LAIV (75%) and an overwhelming majority of those (96%) would choose it next year. Younger age of vaccine recipients and providing sufficient information about LAIV at the clinic appear to be the most important factors associated with LAIV acceptance. Health care providers were enthusiastic about offering LAIV and believed it had an overall positive effect on clinic flow. Parents preferentially chose LAIV over TIV to avoid needles and pain and because it is an easier procedure. Surprisingly, few parents (17%) chose LAIV because it protects better than TIV. Variability in acceptance rate by site might be explained by differences in information offered.

Conclusion The evaluation demonstrated the feasibility of offering LAIV to children in public health influenza clinics or to children immunized at their family physicians’ offices. Lessons learned will guide implementation in subsequent years not only in Vancouver Coastal Health but also for the rest of the province.

Context Individuals with incarceration experience (IIEs) face multiple barriers in accessing primary health care. Negative prison and community health care experiences are major barriers; however, there is a lack of interventions to address this in Canada.

Objective To pilot and describe the impact of an interactive technique addressing communication and relationships between IIEs and health care providers (HCPs).

Design Community-based research, interpretive descriptive methods.

Participants Twenty-one men and women with incarceration experience living in BC, and 6 men and women HCPs or HCPs-in-training.

Intervention The intervention was designed by the project team, including members with incarceration experience, and community partnerships. A trained facilitator led an interactive theatre “Rainbow of Desire” (RD) technique with IIEs and HCPs (including family physicians) to explore underlying issues, including fear, stigma, and mistrust, relating to their negative health care interactions. Additionally, a presentation and manual with resource information about HCPs was also presented to IIE participants before the RD technique.

Outcome measures Focus group interviews with IIE and HCP participants yielded qualitative data regarding workshop relevance, efficacy, and impact. Interview transcripts were coded and thematically analyzed collaboratively by all co-authors including IIEs.

Results and findings Consistent with existing literature, participants reported previous negative experiences with HCPs as a major barrier to seeking primary health care. Both IIE and HCP participants reported that the RD technique helped them become aware of, understand, and empathize with the other side’s perspective. The IIE participants shared specific ways to prioritize and self-advocate for their health after the workshop. The HCP participants emphasized the need for HCPs to be trained in empathetic communication to improve health care interactions between IIEs and HCPs.

Conclusion This intervention brought HCPs and IIEs together to engage them in a mutually educational experience that demonstrates the potential of the RD technique in improving their health care interactions. Both IIEs and HCPs reported benefiting from seeing the other side’s perspective and ways of overcoming communication barriers in a health care setting. In terms of sustainability, several IIEs will acquire RD theatre facilitator training to conduct similar workshops with medical students and IIEs. Furthermore, the benefits of this type of emphatic communication training can potentially translate to HCPs working with other marginalized and medically underserved populations.

Context The number of family physicians providing maternity care continues to decline despite societal need and the College of Family Physicians of Canada’s requirement to train residents who are competent in full-scope maternity care. While the challenges of sustaining family medicine (FM) obstetrics are well recognized, little is known about how Canadian residency programs strive to train residents who are competent and willing to provide intrapartum care in the future.

Objective To explore maternity care education leaders’ perceptions of success within FM training programs across Canada: How is success understood in FM maternity care education? What environmental factors affect success?

Design Semistructured telephone interviews with education leaders in FM maternity care from 6 Canadian university residency programs. Departmental leaders identified program or site directors from maternity care programs deemed to be “successful.” Interviews were audiorecorded and transcribed verbatim. Thematic analysis was conducted by team members.

Setting Purposive sample of 6 FM programs from 5 provinces.

Participants Eighteen departmental leaders and program directors.

Findings Participants described the importance of addressing process-related elements of a supportive clinical learning environment for the sustainability of FM obstetrics. They revealed strategies used to create supportive environments for today’s learners, who are predominantly female and interested in models of care that allow for flexibility. Strategies included role modeling (of competence, sustainable models of care, work-life balance, and enjoyment of maternity care), as well as mentorship during residency and throughout the first 5 years of practice. Underlying these threads of discussion, participants described the tension between the requirement to demonstrate and teach continuity of care and the reality of the current maternity care practice environment.

Conclusion Educational leaders confirmed the importance of a supportive clinical learning environment, role modeling, and mentorship. Strategies that maximized success considered variations in local culture as well as learner preference.

Objective A multidisciplinary research team conducted a lifestyle intervention to assist class I and II obese patients in the management of their condition. The multisite Healthy Eating, Active Living for Tomorrow’s Health (HEALTH) study was conducted in 4 separate sites: 2 rural and 2 urban.

Design A cross-sectional pre- and post-study design was utilized for patients with a body mass index (BMI) between 30 and 40 kg/m². The patients were either referred to the study by their physician or they self-referred.

Participants A total of 146 people enrolled in the study; more women than men enrolled (85%). The mean age was 50 years with a mean BMI of 37 kg/m² (class II).

Intervention The intervention consisted of 1-hour physical activities 3 times a week and a biweekly nutritional education seminar for the duration of 6 months; 2 of the 4 groups received biweekly group-mediated cognitive behavioural intervention.

Results Attrition rates were lowest for the sites where participants received biweekly group-mediated cognitive behavioural intervention. Physically, participants showed significant improvements in resting heart rate, systolic blood pressure, neck and waist circumferences, and BMI. They also showed a reduction in triglyceride levels, high-density lipoprotein cholesterol levels, and the ratio of total cholesterol to high-density lipoprotein cholesterol, despite the fact that participants attended, on average, 75% of the physical activity sessions.

Conclusion Class I and II obese patients benefited from a community-based, low-participation-threshold, moderate physical intensity intervention program. Inclusion of behaviour modification sessions decreased program dropout. Although a 6-month intervention does not cure adult obesity, it can help obese adults establish a healthier obese phenotype. The intervention can be logistically delivered in both urban and rural community settings with equal effectiveness.

Context Family history (FH) reflects genetic and environmental factors influencing health but it is often absent or limited. Family history is a basic genomic test, aiding in risk stratification and personalized management, and possibly motivating behaviour change. Patient-completed FH questionnaires are gaining attention with evidence of completeness and accuracy.

Objective To assess the feasibility of collecting FH using mailed, self-completed health surveys (SCHS); prevalence of elevated familial risk of type 2 diabetes, coronary artery disease, breast cancer, and colorectal cancer (CRC); accuracy of FH from SCHS compared with electronic medical records (EMRs); and appropriate screening for familial risk.

Design Baseline data were used from the BETTER (Building on Existing Tools to Improve Chronic Disease Prevention in Family Practice) project, a randomized controlled trial to assess the effect of patient and practice facilitation interventions on primary prevention and screening.

Participants Randomly selected patients from 8 family practices (Ontario and Alberta) were invited to participate.

Intervention Participating patients were mailed surveys including an SCHS. Baseline FH and screening data were obtained from the SCHS or EMR on all enrolled patients.

Outcome measures Feasibility of completing the SCHS, proportion of participants with presence of FH from SCHS and EMR, comparison of presence of FH from SCHS or EMR using Cohen κ, differences between elevated- and low-risk patients regarding screening using χ², and predictors of screening using logistic regression.

Results Overall 789 of 1260 (63%) accepted participation in the study; 775 of 789 (98%) completed the SCHS. Mean age was 52.5 years; 72% were female. Estimated proportions of patients with presence of FH from SCHS versus EMR are as follows: diabetes 36% versus 24% (κ = 0.466); coronary artery disease 22% versus 35% (κ = 0.225); breast cancer 22% versus 21% (κ = 0.241); CRC 14% versus 12% (κ = 0.510); showing moderate agreement for diabetes and CRC. Presence of FH was a significant predictor of diabetes screening (OR = 2.6, 95% CI 1.0 to 6.6). Recent immigrants were less likely to have had CRC screening (OR = 0.15, 95% CI 0.03 to 0.72).

Conclusion A moderate prevalence of FH was found for 4 conditions where screening recommendations vary with familial risk. Patient self-completed FH was feasible; questions about accuracy and completeness from self-report and EMR remain. Strategies linking familial risk to appropriate screening are needed.

Context Family physicians are often left out of the follow-up of their cancer patients at the treatment phase. Little is known about FPs’ collaboration and communication with the oncology team.

Objective To compare patients’, their family caregivers’, and their FPs’ perceptions of continuity of care at the beginning of cancer treatments.

Design Survey.

Methods A total of 206 patients recently diagnosed with inoperable lung cancer, 131 family caregivers (63.6% participation rate), and 152 FPs (86.4% participation rate) completed validated questionnaires regarding their respective perception of continuity of care (relational, informational, and management continuity) and of collaboration between FPs and the oncology team. Univariate and bivariate analyses were conducted.

Results Although both patients and FPs indicate satisfactory relational continuity of care, FPs report higher mean scores compared with patients regarding the comprehensive knowledge of the patient (4.3 out of 5 vs 3.5 out of 5; P < .0001) and the partnership with the patient and confidence (4.4 out of 5 vs 3.8 out of 5; P < .0001). At baseline, only 113 patients had seen their FPs since their cancer diagnosis. Among them, 20.4% of patients and 18.3% of their family caregivers reported some problem in management continuity, compared with 48.3% of FPs (P < .0001). Patients, family caregivers, and FPs frequently mentioned difficulties in informational continuity (68.6%, 50.7%; patients compared to family caregivers: P = .02, and 73%; patients compared to FPs: P = .24). Although respective scores of global collaboration between FPs and the oncology team are statistically different between patients, family caregivers, and FPs, their perception seems quite similar (3.2 out of 5, 3.5 out of 5, and 3.6 out of 5, respectively; P < .0001). There is a discrepancy between patients and FPs regarding their respective perception of FP involvement in shared care with the oncology team, as 56.6% of FPs report being engaged in this type of care, compared with only 26.7% of patients perceiving that FPs are involved (P < .0001).

Conclusion Problems of informational continuity seem to regularly occur even at the beginning of cancer treatments. These results support the implementation of an intervention to improve communication and collaboration between FPs and the oncology team.

Context Polypharmacy is a well-known risk factor for increased morbidity and mortality, especially for frail elderly patients in residential care, but in BC these patients are prescribed an average of 9 medications each. Recent studies suggest reducing polypharmacy might decrease morbidity, mortality, and cost, but there is little research into GPs’ beliefs regarding minimizing medications and their current approaches.

Objective To explore the views and practices of GPs working in residential care facilities regarding the practice of medication minimization.

Design A descriptive quantitative survey of GPs in Vancouver, BC.

Participants All GPs who self-identified as the most responsible physician for 10 or more frail elderly patients in residential care facilities in Vancouver were invited to participate (N = 49).

Instrument The survey was developed in consultation with experts in the field of elder care and was distributed by e-mail and in person to GPs caring for frail elderly patients in residential care.

Outcome measures Self-reported practices and challenges of medication minimization and factors contributing to reluctance to discontinue medications.

Results The response rate was 61%, with 30 GPs completing the survey. The majority (75%) of respondents denied reluctance to discontinue medications. Challenges to deprescribing were multifactorial, including family unavailability (89%), time constraints (83%), and patient cognition or dementia (82%), as well as concerns about causing an adverse event (71%) and worsening symptoms (64%). Two-thirds of respondents reported they did not feel pressured to follow chronic disease management guidelines in frail elderly patients. Only 48% reported a consistent approach to deprescribing.

Conclusion Despite the high prevalence of polypharmacy among frail, elderly long-term care residents in Vancouver, GPs report they are not reluctant to discontinue medications in these patients. This study identifies some of the most common challenges to deprescribing while affirming that most GPs lack systematic approaches to discontinuing medications in this patient population. These barriers need to be targeted to facilitate optimal prescribing and reductions in polypharmacy among frail elderly patients in Vancouver.

Context Patient-reported outcomes (PRO) are becoming increasingly important for identifying illnesses and risk factors and as outcomes in clinical trials. While single assessments of PROs are susceptible to recall bias and other errors, more frequent assessment of PROs provides less biased and more representative sampling of patient symptoms, functioning, health status, and quality-of-life indicators.

Objective To report on the development and implementation of an integrated electronic health record (EHR) and Web-based patient portal platform that provides opportunities for longitudinal and frequent measurement of PROs for basic research and clinical practice.

Design Survey.

Participants A sample of 120 patients, aged 50 years and older, was recruited from a private practice using an online consent procedure. The consent procedure included a brief multi-item quiz regarding the major points of consent prior to giving consent to ensure full understanding of the study purpose and procedures.

Instrument Web-based baseline and 7 daily surveys included items from standardized measures of health and functioning (SF-36 Short Form Health Survey), well-being, stress, affect, physical activity, and premorbid cognition.

Outcome measures We examined impacts of within-person variation in aspects of health on daily positive and negative affect. Secondary analyses focused on premorbid cognition, the informed consent quiz, and participant feedback on the system.

Results Patients reported significant daily variability in health subscales, activity, and well-being outcomes. Daily positive and negative affect were related to physical activity, stress, and all 8 SF-36 health subscales such that a better health state was associated with higher positive and lower negative affect. Better health was reported by participants who indicated more daily physical activity and fewer daily stressors. Participant feedback demonstrates interest in this research and 97% willingness to be involved with similar future projects.

Conclusion The EHR-based patient portal is an effective tool for clinical and basic research data collection, permitting frequent assessments with minimal burden to the clinician, researcher, or patient. Regular use of such a system by practitioners will provide beneficial information regarding health and consistent health changes, as well as engage patients in awareness of their health and health care.

Context Individuals with incarceration experience (IIEs) have a higher prevalence of HIV and AIDS than the general population. Prevention and treatment of HIV in prison faces many barriers. A community-based research project currently being conducted with IIEs has revealed formerly and currently incarcerated men as an underserved subpopulation interested in HIV prevention. This has implications for primary care, because “throughcare” and “aftercare” for incarcerated individuals is crucial for improving health outcomes of this population as they transit through the correctional system.

Objective To determine whether an HIV prevention program developed in collaboration with IIEs and piloted outside prison, is effective in improving health knowledge and HIV prevention behaviour of currently incarcerated men.

Design Community-based research using interpretive descriptive methods: survey data (demographic characteristics, pre- and post-program health knowledge and behaviour); focus group data; and program evaluation.

Participants Phase 1: 17 men and 11 women with incarceration experience, living in British Columbia, invited by snowball sampling by 3 community-based research IIEs. Phase 2: 100 men currently incarcerated in a federal correctional institution. Voluntary participation was through word-of-mouth and poster invitations.

Intervention Two workshops included context (rates, harm reduction, accessing services) of HIV in prison, HIV prevention (primary and secondary), self-care, and personal accounts from an HIV-positive IIE.

Outcome measures Feedback through focus groups in phases 1 and 2 to evaluate content and structure satisfaction and exit surveys and interviews to evaluate impact on health knowledge and behaviour.

Findings In phase 1 the following themes emerged: workshop was useful, participants will share information, importance of getting tested, previous misinformation clarified (regarding infectivity, viral load, prognosis), information coming from an HIV-positive IIE extremely effective, people inside prison will find useful, and necessary to educate juvenile offenders. In phase 2 it is anticipated that involvement in workshops will improve health knowledge regarding HIV, decrease stigma, and increase the adoption of available HIV prevention tools.

Conclusion The information provided and the format of community-based workshops were successful. Participants indicated the need for similar programs inside prisons. Participants will radiate knowledge to their peers, families, and communities, as well as to the BC health organization; Canadian correctional institutions will adopt project recommendations, leading to improved HIV prevention for incarcerated men.

Context Formal standards are of critical importance in determining what will be valued and emphasized in training programs, significantly shaping curriculum and assessment. These formal requirements change over time to reflect changing program goals, intentions, and needs. Detailed analysis of how family medicine standards are framed can provide family medicine educators with better understanding of ways to support desired curricular changes.

Objective The objectives of this research project were 1) to identify the dominant discourses in the newly adopted (2013) College of Family Physicians of Canada (CFPC) accreditation standards and Triple C curriculum framework; and 2) to identify potential leverage points within formal standards that might be used to better embed the teaching and practice of compassionate care in family medicine residency training.

Design A critical social science theoretical framework and Foucauldian critical discourse analysis methodology were used. Accepted critical discourse analysis principles and methodologic approaches were followed, notably familiarization with the literature; assembling an archive of texts; analyzing the archive to identify key statements, words, and metaphors; analyzing links between the identified discourses; identifying links between identified discourses and dominant discourses in health profession education internationally; and describing the effects and implications of identified discourses on educational practices.

Archive The primary textual archive consisted of the Triple C curriculum framework and CFPC 2013 accreditation standards. The secondary textual archive included additional recent CFPC formal reports on the CFPC website, and the CFPC 2006 accreditation standards.

Findings We identified an emphasis on a need for change. The rationales for these changes were positioned discursively in terms of accountability, efficiency, and ensuring proper identity development of trainees as family physicians. This created a less explicit focus on humanistic values such as compassionate care than existed in the 2006 standards.

Conclusion It is important to pay attention to the effects of highlighting particular priorities, as others then become less visible. If formal documents do not sufficiently emphasize fundamental aspects of the discipline of family medicine, such as the provision of compassionate care, there is risk that these values might inadvertently get lost.

Context Medical trainees’ empathy level declines throughout training. Accordingly, the medical education community has implemented reflective writing exercises that foster critical analysis capacity and the understanding of patient perspectives. Recently, the REFLECT rubric (Wald et al, 2012) was developed to address the challenge of assessing medical student reflections.

Objective To demonstrate the reliability and construct validity of REFLECT.

Design Five raters evaluated reflections written by clinicians and medical students using REFLECT. Reliability across rubric domains was determined via interrater agreement. Construct validity was determined by way of the rubric’s ability to differentiate inexperienced (student) reflections from experienced (clinician) reflections.

Results Interrater agreement was fair overall but low for rubric subdomains. The rubric did not differentiate between groups.

Conclusion The REFLECT rubric lacks reliability and validity characteristics. However, the results suggest the rubric has utility in guiding feedback concerning written reflection.

Context Traditional or standard follow-up (SFU) after medical abortion with methotrexate and misoprostol requires ultrasound and in-person assessment. This method poses serious concerns regarding the accessibility of abortion services, is resource-intensive, and is associated with a high noncompliance rate.

Objective To determine whether remote follow-up (RFU), using telephone follow-up and serum β–human chorionic gonadotropin (β-hCG) testing, is a feasible, safe, and effective method of follow-up after medical abortion, compared with standard care.

Design Prospective cohort study.

Participants A total of 116 pregnant women requesting medical abortion at 2 clinics. Participants met eligibility criteria to undergo medical abortion, had an intrauterine sac confirmed by ultrasound, and were less than 7 weeks’ gestational age.

Intervention Eligible subjects who elected to participate in the SFU group received in-person follow-up, including a transvaginal ultrasound and bimanual examination. Decline in serum β-hCG was calculated for participants in the RFU group, who then received telephone follow-up focusing on symptoms of retained products of conception and ongoing pregnancy, and complications such as infection. Both groups completed an acceptability survey and were contacted by telephone after follow-up to screen for the occurrence of late complications.

Outcome measures Percentage of women who chose RFU, percentage of women who completed successful follow-up within 3 days of the scheduled date in each group, percentage of serious adverse events in each group.

Results Preliminary results are as follows: Eighty participants (69%) chose RFU and thirty-six (31%) chose SFU. The number of women compliant with follow-up did not differ significantly between the 2 groups (48 of 80 RFU vs 23 of 36 SFU, P = .8371). One serious adverse event occurred in the RFU group; however, it was identified before the follow-up appointment. No serious adverse events occurred in the SFU group.

Conclusion Remote follow-up using telephone contact and serum β-hCG testing was the preferred method for follow-up after medical abortion. While noncompliance with follow-up remains a concern, the overall safety and compliance rates are similar for each of the 2 different methods of follow-up.

Context The Canadian Primary Care Sentinel Surveillance Network provides information on chronic disease managed by primary care physicians.

Objective To investigate the association of cardiovascular and lifestyle risk factors with low back pain using data from a network’s Canadian Primary Care Sentinel Surveillance Network database. Clinically this association is of importance because it raises the question of whether or not back pain itself is a potential harbinger of cardiovascular disease.

Participants Data were obtained from the Edmonton, Alta, regional database September 2012 extraction (July 2007 to July 2012). After excluding patients younger than 18 years of age, the total number of patients analyzed in the study was 20 866.

Outcome measures Generalized estimating equations analysis was used to obtain estimates of relative risk (RR) and their respective 95% confidence intervals for the association of factors—including age, sex, body mass index greater than 30 kg/m², and any history of smoking, in addition to chronic diseases including depression, hypertension, and diabetes—with back pain.

Results Statistically significant associations with a back pain encounter visit were found for age (P < .001; RR = 1.02), obesity (P < .023; RR = 1.13), depression (P < .001; RR = 1.52), any history of smoking (P < .001; RR = 1.29), and taking antihypertensive medication (P < .005; RR = 1.26). In contrast, statistically significant associations with a back pain health condition were found only for age (P < .001; RR = 1.02), hypertension (P < .029; RR = 1.42), and any history of smoking (P < .001; RR = 1.93).

Conclusion To our knowledge, our study is the first to publish a risk estimate between having a diagnosis of depression and seeking care for acute low back pain. Patients with any history of smoking had both an increased risk of seeking care for acute low back pain (RR = 1.29) and an even greater risk of having back pain listed as a chronic health condition (RR = 1.93), implying the possibility of causality in the etiology of chronic back pain.

Context As part of provincial primary health care reforms, the Quality Improvement and Innovation Partnership, now amalgamated with Health Quality Ontario, implemented a primary health care quality improvement program using the Institute for Healthcare Improvement Learning Collaborative model. One of the areas of focus of these collaborations was access to care.

Objective To assess the impact of the Quality Improvement and Innovation Partnership learning collaboratives on access to care.

Methods A mixed methods evaluation was conducted. For access-to-care outcomes this included key informant interviews and a survey of participating and control practices.

Participants A total of 34 participating physician practices and 34 matched controls.

Outcome measures Access model (traditional, open, advanced), time to third-next available appointment, methods used to improve access, and barriers to or facilitators of change.

Intervention Learning collaborative consisting of 3 learning sessions, 2 action periods, and 1 congress. Teams were supported by quality improvement coaches.

Results Survey completion rates were excellent (91% for intervention practices, 94% for controls). Intervention practices showed greater adoption of advanced access at the end of the study period (44% vs 28% of practices not using advanced access already) and a 1-day difference in time to third-next available appointment. These differences were not statistically significant. The qualitative component identified barriers to full implementation of advanced access, particularly in rural areas.

Discussion Access to care and adoption of advanced access improved in both intervention and control practices, with intervention practices showing greater but not statistically significant gains compared with controls. This might be owing to the emphasis on improving access at this time within the province of Ontario, the use of nonparticipating physicians from practices within the same family health team as controls, and the limited sample size.

Contexte le recours aux échantillons de médicaments présente des bienfaits potentiels, mais peut poser des problèmes de gestion entraînant des risques pour la santé des individus. Cette recherche vise à évaluer la qualité des pratiques en matière de gestion des échantillons dans les Unités de médecine familiale (UMF) du Réseau de recherche en soins primaires de l’Université de Montréal (RRSPUM). L’objectif général est de décrire les politiques, les pratiques de gestion et l’utilisation des échantillons de médicaments.

Méthodologie étude descriptive transversale menée dans les 16 UMF du RRSPUM. La population étudiée est composée de tous les professionnels remettant des échantillons (utilisateurs, n=295) et ceux responsables de la gestion globale des échantillons (gestionnaires, n=22). La collecte des données est effectuée à l’aide de deux questionnaires autoadministrés, développés par les chercheurs.

Résultats des 16 UMF participantes, 12 ont des armoires à échantillons. Aucune des UMF ne dispose d’une politique écrite de gestion des échantillons, mais huit ont une politique de leur Centre de santé et de services sociaux (CSSS). Dans plusieurs milieux, l’infirmière assure la gestion (9/12) et fait aussi la commande des échantillons (5/12). L’accès au lieu de rangement des échantillons est non contrôlé (7/12) et le personnel administratif (8/12) ainsi que le représentant pharmaceutique (5/12) ont accès aux armoires. Il ressort que 76% des répondants utilisent des échantillons et plus de la moitié ne savent pas si leur UMF ou CSSS dispose d’une politique écrite de gestion. La moitié des utilisateurs remette aux patients un échantillon même si celui-ci n’est pas leur premier choix de molécule (46%). Seul 60% des utilisateurs inscrivent une note au dossier quand ils remettent un échantillon. Le tiers des utilisateurs (33,3%) déclarent ne jamais référer le patient à son pharmacien communautaire lors de la remise de l’échantillon au patient.

Discussion cette recherche a permis de dresser un portrait de la gestion des échantillons dans nos UMF. Elle montre une défaillance dans la gestion optimale des échantillons distribués. Les résultats de cette étude permettront de développer des lignes directrices qui serviront à guider l’utilisation éthique et sécuritaire des échantillons.

Context Current communication systems between hospital and family physicians have considerable deficits. North York General Hospital in Ontario initiated the Physician Notification Project (PNP) to address this issue. The PNP is a novel approach to information transfer utilizing fax notifications to family physicians and it allows physicians access to the hospital electronic medical record from their community-based offices.

Objective To investigate family physicians’ perspectives about PNP as compared with the pre-existing system of information transfer.

Design A mixed-methodology study was designed using a modified grounded theory approach. Both qualitative focus groups and a quantitative survey were used in an iterative process to identify important themes.

Participants A convenience sample, consisting of the 20 family physicians involved in PNP, was used to participate.

Intervention Participants were invited to complete 1 quantitative survey and attend 1 focus group. The focus groups were conducted using a semistructured interview guide.

Findings The PNP was seen as an improvement over the pre-existing system in that it consistently provided fax notifications of patient emergency department visits, admissions, discharges, and deaths. However, participants had many concerns about PNP. Emerging themes included the need for timely information transfer, consistency in information transferred, and concerns about technology (access, usability, efficiency). The PNP did not improve involvement of the family physician in the care of patients in the emergency department, in the inpatient wards, or after discharge. Participants did not feel that there was an improvement in interprofessional communication with PNP. Participants also expressed concerns about possibilities of new medicolegal issues arising from PNP.

Discussion All efforts to improve transfer of information between hospitals and family physician offices should be welcomed. Study of the PNP revealed many issues of concern regarding the process and methodology of information transfer that had not previously been identified.

Conclusion The findings provide important information for the development of future initiatives that seek to improve transfer of information across the care continuum in Canada. New protocols must address known concerns. The need for collaboration between in-hospital and community-based physicians is key to the success of future programs.

Context More than 2800 youths across the province of Quebec live in custodial facilities. These teens are at high risk of health problems. Several organizations have proposed standards of medical practice for youths in care (American Academy of Pediatrics, Child Welfare League of America, Canadian Paediatric Society). Upon admission, often these youths are not evaluated. There is no common or standardized procedure or tool to evaluate their health needs.

Objective To describe the health problems and to assess the health care and service needs of youth in custodial facilities.

Design Cross-sectional; self-reported questionnaire about youths’ health status, problems, and needs. Evaluation grid completed by a nurse and a doctor, with a physical examination within 2 to 4 weeks. A list of health needs and problems was established for each youth.

Participants A total of 93 adolescents aged 14 to 17 years (mean age 15.5 years) in 13 custodial facilities from 7 urban and rural regions in Quebec.

Results Self-evaluation of youth health status is below what we expect, with only 31% of girls and 55% of boys grading their health as very good or excellent. Many reported physical complaints. Overall, 56% of youth were taking a medication the week before admission (including 32% taking psychostimulants and 21% taking atypical antipsychotics). As for sexual health issues, 80% were sexually active—36% rarely or never used a condom, and 55% used a condom the last time they had intercourse; 14% of the girls had been pregnant; and 9% of the girls and 5% of the boys were involved in prostitution. There was a high prevalence of self-reported mental health problems (49%) and history of violence (47%). A total of 34% of girls and 14% of boys had attempted suicide in the previous year. Most youth had health problems (mean of 3.6 health problems per youth); 77% had at least 1; 41% had more than 4; and 6% had at least 1 chronic problem.

Conclusion The results support the findings from the literature showing that the majority of youths living in custodial facilities have health problems and have more than 1 such problem. Many of these problems are chronic and are not addressed. This confirms the need to improve the rehabilitation process of youths living in custodial facilities by an early and global evaluation of their health.

Context Research shows that understanding the student experience of learning and teaching improves educational practice. In Canada, the topic of residents’ views on which roles and tasks are effective for their growth and development in becoming a competent physician is not yet part of the research discourse. Ensuring that the competency-based curriculum objectives are aligned with well-defined competencies and evaluation methods is critical to building a curriculum that will produce competent physicians.

Objective This research reports on residents’ views of the current orthopedic surgery “experiment” in delivery of a curriculum that is solely competency based. The residents’ views were specifically explored about which CanMEDS roles and entrustable professional activities would be important to track and develop in order for them to become competent physicians.

Intervention and participants This study employed a mixed methodology of individual resident interviews and a survey. The individual interviews were performed with volunteers from the competency-based curriculum orthopedic surgery program. The survey was sent to the orthopedic residents in the regular time-based program and the competency-based program. Using grounded theory, the data sets were explored iteratively to show what residents viewed as important to their training.

Findings The data are rich in illustrating what residents value. While residents noted that medical expertise is very highly valued, they also indicated an understanding for developing the need for a broad base of intrinsic role competencies.

Conclusion This research provides a better understanding of the resident experience so that educational practice and residency education can influence decisions around the curriculum design in postgraduate competency-based medical education programs.

Context As massive open online courses begin permeating medicine, we tested effects of the world’s first free, accredited courses, including courses in clinical medicine and public health, of potential interest to family physicians.

Objective To determine the effects and uptake of free online health sciences training offered for university credit in 4 pilot sites in preparation for our global testing of a family medicine residency with more than 10 000 family physicians in Sudan.

Design and participants In Canada, Colombia, and the United States, we tested 3 courses from NextGenU.org (the first provider of free and accredited massive open online courses): emergency medicine (EM), environmental health (EH), and physical activity counselling (PAC). Using national, concurrent, and historical comparison populations and pretest and posttest evaluations, we tested EM with senior US medical students at the University of Missouri (intervention, n = 167; control, n = 163) and the Uniformed Services University of the Health Sciences (intervention, n = 35; control, n = 415), EH with Master’s of Public Health students at Canada’s Simon Fraser University (intervention, n = 9; control, n = 130), and PAC with PAC students at the Universidad Pedagógica Nacional in Bogota, Colombia (intervention, n = 11; control, n = 26).

Results NextGenU users and control students trained in traditional EM programs performed almost identically on the national EM test. In the NextGenU Colombian PAC pilot, those voluntarily adding the NextGenU training and certificate learned more than twice as much as traditionally trained students. The NextGenU EH course rated a 4.7 out of 5 for “Overall I would rate this course as excellent,” versus prior years’ scores averaging 4.0 out of 5, and there were no significant differences (P = .72) between NextGenU flipped classroom and traditional lecture-based cohorts’ knowledge scores.

Conclusion NextGenU courses have been widely adopted, and students performed as well as or better than those in courses offered in some of the world’s most-resourced traditional settings. This bodes well for this approach and helps answer global calls for rapid, high-quality health care work force expansion, especially at the primary care level.

Context The longitudinal, comprehensive nature of primary care settings allows them to facilitate behaviour change, treatment entry, and follow-up for people using alcohol or drugs. Unfortunately, Screening, Brief Intervention, and Referral for Treatment (SBIRT) implementation has been suboptimal, and little is known about best practices for SBIRT in disadvantaged settings with additional barriers to patient engagement.

Objective The goals of this project were to develop and evaluate a set of SBIRT and patient engagement knowledge translation (KT) resources designed to enhance the capacity of physicians to effectively intervene with low-socioeconomic-position patients engaging in substance use.

Design Nonrandomized 2-group, pre-post, quasi-experimental intervention design.

Participants Family and emergency medicine physicians and residents.

Intervention A partnership of researchers, clinicians, KT experts, inner-city agencies and residents, and policy makers oversaw the project. The core team hired an inner-city community member to optimize information sharing and project relevance. Information sources for resource development included a literature review, local pilot studies, and needs assessments. Physician KT resources included workshops, point-of-care tools, e-modules, addiction medicine champions, and inner-city orientations.

Outcome measures Self-reported frequency of SBIRT use at 12 months after enrolment.

Results A total of 131 physicians were assigned to the intervention (n = 78) or control (n = 53) condition according to their usual location of practice. A total 39 intervention and 25 control participants were available for follow up at 12 months. Uptake of KT resources ranged from 25% for e-modules to 63% for point-of-care reminders; when used, the majority found these resources useful. After adjusting for age, sex, years in practice, discipline, baseline comfort, and baseline assessment behaviour, intervention physicians trended toward increased screening and brief intervention behaviour (P = .069).

Conclusion A community-based patient engagement and SBIRT KT strategy was favourably received by participants and associated with early changes in physician assessment behaviour. Other mediators of physician behaviour might need to be considered to encourage sustained physician behaviour change in a real-world setting.

Context Global health researchers are increasingly called upon to deliver ever more participatory and sustainable health improvement programs in developing countries. However, evaluation of the impact of such programs remains challenging owing to linguistic and cultural barriers.

Objective To determine how indigenous community health workers in Ecuador learn, by using ethnography and developmental evaluation to measure knowledge uptake.

Design Qualitative description.

Participants Nine female, indigenous community health workers from 4 villages: all were between the ages of 17 and 59 years; 50% were illiterate; 2 family were physician teachers or researchers.

Intervention The study took the form of a “developmental evaluation,” documenting the emerging process of the development and negotiation of the curriculum, as well as data on the knowledge uptake itself.

Outcome measures Data sources came from ethnographic methods, combining observations of real-life behaviour, supported by interviews and documents, including facilitator reports, interviews with participants and facilitators, and ethnographic field notes of the educational intervention itself. The qualitative data were analyzed thematically to document patterns through an inductive process.

Findings The study showed ethnography to be a robust method to document the development of substantive learning. Participants previously conveyed fear and frustration at being “tested” in the use of traditional evaluation methods (pre- and post-course surveys, knowledge surveys, and multiple choice questions). The ethnographic methods, negotiated among the participants, showed that open questions at various stages of the teaching process, particularly through role-play, can provide an independent source of information on the level of learning of substantive content.

Conclusion Developmental evaluation offers a powerful approach to monitoring participatory research projects. Ethnography is a valuable and underexplored tool to assess educational projects in complex dynamic systems such as global health contexts.

Context Chronic pain was identified by PACE Society members as a common phenomenon not well understood among survival sex workers. Previous studies have characterized survival sex worker access to primary care, yet no study has evaluated it in the context of chronic pain.

Objective To understand the experience of chronic pain among female survival sex workers.

Design Phenomenologic design using semistructured interviews.

Participants Inclusion criteria consisted of age greater than 18 years, being a current or former survival sex worker who self-identified as female, being a member of PACE Society, and being known to experience chronic pain through previous disclosure to support workers. Participants were excluded if they did not speak English fluently or were actively psychotic. Fifteen participants were identified aged 40 to 65 years, 6 of whom identified as aboriginal.

Instrument Semistructured interviews were conducted, audiorecorded, and transcribed. The investigators met to read the transcripts and discuss emerging themes. The process continued until no new themes were observed.

Outcome measures Key themes achieving saturation.

Findings Eleven of 13 interviews were analyzed for themes. Drug use for pain management was the most important theme. Poverty and a lack of stable housing were barriers to adequately addressing the source of chronic pain. Participants felt judged for living in the Downtown Eastside, for being a drug user, or for being aboriginal, and only 2 participants had been referred to a pain specialist. All participants were involved in support networks made up of other sex workers and all spoke of a sense of community and survival. The 2 interviews not analyzed for themes were with actively psychotic women who were unable to communicate the issues they had with their barriers to chronic pain management. Two participants did not arrive for their interviews.

Conclusion The experience of chronic pain among female survival sex workers is unique to each individual, but the main themes expressed were the use of illicit drugs to manage pain, stigma, barriers to care, and lack of communication with health workers. Efforts must be made by the medical community to listen to each individual voice without judgment, recognizing sentiments of displacement, abandonment, and ultimately of empowerment and survivorship.

Context The purpose of this study is to compare mortality rates between aboriginal and nonaboriginal people infected with HIV who were receiving care at an inner-city health centre in Vancouver, BC, to determine if the previously demonstrated HIV mortality gap has narrowed between aboriginal and nonaboriginal patients over this time period.

Methods We conducted a retrospective cohort study of HIV-infected patients receiving primary care and highly active antiretroviral therapy at an inner-city health centre in Vancouver, during the period of January 2007 to December 2012. We constructed the Cox proportional hazards model to estimate all-cause mortality hazard ratios, considering self-identified aboriginal ethnicity, sex, baseline age, CD4 cell count, and HIV RNA level as potential confounders.

Results Of the 290 study patients, 60% were aboriginal. We observed 44 deaths: 45% were HIV related. In multivariable models, aboriginal patients experienced similar all-cause mortality rates (hazard ratio 1.72, 95% CI 0.83 to 3.55, P = .147) compared with nonaboriginal patients. The HIV-related mortality rate for aboriginal patients decreased over this time, with the highest of 5.88 per 100 person-years in 2008 and the lowest of 0.78 per 100 person-years in 2012 (Spearman correlation coefficient −0.943, P = .005).

Conclusion Aboriginal patients with HIV receiving highly active antiretroviral therapy had similar all-cause mortality to nonaboriginal patients, and decreasing HIV-related mortality rates over this time period. These are promising outcomes, compared with other studies on a similar population in Canada. Further research should examine reasons for the observed better survival of aboriginal patients receiving primary and HIV-related care in this inner-city health centre to improve interventions for these vulnerable populations.

Objectives This study sought to validate 8 chronic disease electronic medical record (EMR) diagnostic algorithms developed by the Canadian Primary Care Sentinel Surveillance Network (CPCSSN); and to refine these diagnostic algorithms to improve sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Design CPCSSN developed case definitions for hypertension, diabetes mellitus, depression, chronic obstructive pulmonary disease, osteoarthritis, dementia, epilepsy, and Parkinson disease from readily available EMR information, including diagnoses, billing data, laboratory tests, and medications. We retrospectively reviewed a random sample of EMR charts from 6 of the 10 CPCSSN networks. We oversampled for persons older than 60 years with epilepsy or Parkinson disease. All chart abstractors were blinded to the CPCSSN diagnosis during the chart review process.

Primary outcome measures Sensitivity, specificity, PPV, and NPV for each disease with the associated 95% confidence interval.

Results Data from 1870 charts were obtained from 6 networks located in British Columbia, Alberta, Ontario, Nova Scotia, and Newfoundland and Labrador. These data were obtained from 4 EMR systems. For the total sample, sensitivity ranged from 78% (osteoarthritis) to more than 95% (diabetes, epilepsy, and Parkinson disease); specificity was greater than 94% for all diseases; PPV ranged from 69% (dementia) to 93% (hypertension); NPV ranged from 86% (hypertension) to more than 99% (diabetes, dementia, epilepsy, and Parkinson disease). Depression and chronic obstructive pulmonary disease had sensitivity greater than 80% and specificity greater than 94%. Dementia was also very sensitive (94%) and specific (98%); however, PPV (69%) was limited. Osteoarthritis lacked sensitivity (78%) but had excellent specificity (95%), PPV (88%), and NPV (90%). Variation in PPV was found across the networks and different EMR systems.

Conclusion The CPCSSN diagnostic algorithms demonstrated excellent sensitivity and specificity for hypertension, diabetes, epilepsy, and Parkinson disease. The CPCSSN data can now be used for public health surveillance, primary care, and health services research and to inform policy for these diseases. The algorithms for the other 4 diseases have room for modest improvement.

Context Metabolic syndrome increases the risk of stroke and heart attack 3-fold and the risk of type 2 diabetes 5-fold. Further, metabolic syndrome increases the risk of cardiovascular events by 1.5 to 2 times.

Objective The purpose of this study was to determine the impact of including the diagnosis of metabolic syndrome in the assessment of cardiovascular risk.

Methods A retrospective chart review of 100 patients at a family medicine centre in London, Ont, was completed. Men aged 40 to 65 and women aged 50 to 65 with low or moderate cardiovascular risk as diagnosed with the Framingham risk assessment tool were included in the study. All patients with high cardiovascular risk were excluded from the study. Participants diagnosed with metabolic syndrome, as determined using International Diabetes Federation criteria, had their Framingham risk scores multiplied by 1.5 to 2 to account for further cardiovascular risk due to the syndrome.

Results In total, 54 males and 46 females with low and moderate cardiovascular risk were included in the study. Of the 100 participants, 26 were identified as having metabolic syndrome. Framingham risk assessment scores of these 26 participants were multiplied by 1.5 to 2 to account for the impact of metabolic syndrome. It was found that 7 of the 26 patients with initially low cardiovascular risk became moderate risk. Further, 17 of the 26 patients with initially moderate cardiovascular risk became severe risk. The remaining 2 out of 26 patients diagnosed with metabolic syndrome did not change risk category after the calculation.

Interpretation Combining the diagnosis of metabolic syndrome with cardiovascular risk in family practice might increase cardiovascular risk screening sensitivity and might identify more people who are at risk.

Context The majority of cancer patients begin their journey with their FPs in primary care. The International Cancer Benchmarking Partnership is exploring FPs’ perceptions in 12 jurisdictions in an attempt to explain different 1-year survival rates of cancer in different countries.

Objective Describe the view of Manitoba FPs regarding their beliefs, behaviour, and office systems as they relate to the investigation of suspected cancer.

Design Web-based survey developed by the International Cancer Benchmarking Partnership using a postal invitation to a stratified random sample of rural and urban FPs.

Participants Family physicians selected from the College of Physicians and Surgeons of Manitoba membership list, with a representative sample of 500 invited, with an equal number of urban and rural doctors.

Instrument The survey comprised 3 different parts: 1) core questions, exploring early diagnosis and screening, administration, training and education, and access to investigations; 2) vignettes exploring how the FP would manage a patient when presented with a specific scenario; and 3) Manitoba-specific questions targeting the use of local programs.

Outcome measures This survey assessed systems and resources available to physicians in the diagnosis and management of breast, colorectal, lung, prostate, and ovarian cancers. It also used Likert scales to determine physician attitudes toward early diagnosis and health care system efficiency. Results from urban and rural Manitoba physicians were compared.

Results There were a total of 228 responders (47% response rate). Anticipated results from this study will report simple frequencies of responses with cross-tabulations of connected data. Initial analysis reveals that rural physicians perceive better direct access to endoscopy procedures, shorter wait times, and quicker results than do urban physicians. There were no significant urban-rural attitudinal differences. Final survey results will be linked with local initiatives that aim to improve the cancer journey experience.

Conclusion Manitoba FPs report good access to investigations in general, but poorer access to direct-to-test referrals for endoscopy than do FPs in other jurisdictions. This finding is more apparent among urban than rural physicians. Whether this difference in access translates to cancer outcomes is unknown.

Context Canadian cesarean section rates are at an all-time high, and for the first time maternal and perinatal mortality rates are rising. Rates of postpartum depression and posttraumatic stress disorder range from 16% to 20% for childbearing women. Our research has demonstrated that women have substantial knowledge gaps and uncertainties about birth interventions, which has major implications for informed decision making during childbirth and for mental and physical health for themselves and their babies.

Objective To evaluate the impact of educational methods developed by our group in “bridging the gap” between what women need to know to make informed decisions and current knowledge gaps.

Design Randomized controlled study.

Participants Women approaching their first birth. Pilot data indicated a sample size of 626 women was needed to detect a 10% difference in knowledge improvement between 2 study groups.

Intervention Interactive, educational materials that engage expectant women in accessing evidence-based, online information about common maternity interventions. These tools were developed by our group (established obstetrical, family practice, midwifery, and decision-analysis experts) based on emerging evidence in the decision sciences about the use of Web 2.0 in disseminating health care information as part of informed decision making.

Outcome measures A validated 2-part questionnaire was used to measure women’s knowledge and attitudes about childbirth approaches and interventions.

Results Pilot data showed significant change in women’s attitudes toward more appropriate and defined use of technology after using our educational interventions, compared with the control group (3.61 control vs 3.83 experimental, P = .032). There was a slightly larger increase in knowledge in the experimental group, but no statistically significant differences in the change in knowledge between the control and experimental groups (8% change in control vs 12% change in experimental, P = .358).

Conclusion Our pilot randomized controlled study has shown that Web-based educational materials can lead to knowledge and attitudinal change, improving women’s ability to make informed birth choices.

Context Family medicine research is the foundation that supports the discipline of family medicine in Canada.

Objective To develop a blueprint that outlines the steps needed to ensure that research becomes a core component of family medicine training, scholarship, and clinical practice.

Design and participants In 2012, the College of Family Physicians of Canada’s (CFPC’s) Section of Researchers (SOR) held a 4-day, facilitated strategic planning meeting with more than 50 leading family medicine researchers, clinicians, educators, and teachers from across Canada. An electronic survey was sent to participants in advance of the meeting to help focus the discussion. At the meeting, the participants were tasked with developing a vision and plan, which would be implemented over the following 5 years (2013 to 2017). The summary chart, strategic objectives, and key activities underwent SOR executive and council review, and a revised blueprint was approved in principle by the SOR council in April 2013. The blueprint was widely reviewed by the CFPC board and other stakeholders in 2013 for implementation.

Results The SOR blueprint was developed in collaboration with the CFPC’s overall strategic planning process, thereby ensuring alignment and the broader adoption of the blueprint by the CFPC leadership. Participants developed a vision; a mandate; 5 areas of strategic focus, each with an achievement indicator; 18 strategic objectives; and 42 key activities that were specific, measurable, realistic, and time based. Each activity was tagged with a time frame for completion.

Conclusion An SOR blueprint has been created to guide the strategic activities of the SOR in its mandate to make research valued as a core component of family medicine and the CFPC within 5 years. Implementation of the new SOR blueprint requires a carefully prioritized and detailed work plan. It will involve new action groups that will engage members in carrying out the plan, articulated governance structures, adequate staffing, departmental reorganization, and additional budgetary support.

Context In Canada, approximately 25 000 children have mothers behind bars; these children are more likely to encounter extreme poverty, trauma, and grief and to be victims of violence. The incarceration of mothers is a self-perpetuating cycle: 40% of women in Canadian jails were separated from their own parents because of incarceration; 50% of their teenage children have already been in youth custody. In the United States, more than 2.5 million children have an incarcerated parent, and most live below the poverty line. In Nepal, children are sent with their mothers to grow up behind bars because no one else can raise them. An estimated 60% of incarcerated Canadian women were unemployed at the time of arrest, and 82% of federally sentenced women and 90% of federally sentenced aboriginal women have experienced physical or sexual abuse. The vast majority of incarcerated women have experienced neglect, violence, and a legacy of child abuse, often leading to survival strategies that result in imprisonment. These include drug abuse, sex work, stealing food to feed their children, welfare fraud, and civil disobedience.

Intervention A University of British Columbia Peter Wall Institute International Roundtable Discussion occurred May 5 to 10, 2013, when 20 delegates from 6 countries met with 10 mothers with lived prison experience, to explore how equity-focused approaches can help protect the health and bonding of incarcerated mothers and their children.

Findings Findings of the roundtable were presented at Family Medicine Forum 2013, including a documentary that portrays children’s narratives. The opportunity for children to express themselves in their own way is critical to their healing. Children of incarcerated parents collectively house expert knowledge and their perspective is crucial to transforming the correctional system. Both the mothers and their children face multiple barriers that inhibit their ability to access the resources they need.

Conclusion This endeavour increases understanding of this issue through film and personal narratives; it will lead to discussion of ways that FPs might advocate for the health of Canadian children whose parents are incarcerated.

Objective To examine whether elderly alternate level of care (ALC) patients cared for by an interdisciplinary team on a transitional care unit (TCU) achieve better clinical outcomes and lower costs when compared with those who received standard hospital care (SC).

Design Before-and-after structured retrospective chart audit.

Setting St Joseph’s Hospital in Comox, BC.

Participants All consecutively admitted patients older than 70 years designated ALC during 5-month periods before (n = 49) and after (n = 86) opening an on-site TCU.

Results Among 86 postintervention ALC patients, 66% (n = 57) were admitted to the TCU. Comparable data were collected from postintervention ALC patients who remained on acute care units. Length of stay reduction occurred during the acute portion of the hospital stay (14.0 days postintervention, 22.5 days SC; P < .01). Discharge home increased (30% postintervention, 12% SC; P < .01). Activities of daily living improved for patients in the postintervention group. Patients’ ability to transfer improved (55% postintervention, 14% SC; P < .01). At discharge, 48% in the postintervention group were able to transfer independently, versus 17% in the SC group. Hospital-acquired infections decreased during the acute portion (14% postintervention, 33% SC; P = .008) and in the ALC portion (21% postintervention, 41% SC; P = .011) of the hospital stay. Antipsychotic prescriptions decreased (45% postintervention, 66% SC; P = .026). Despite greater use of rehabilitation services, TCU costs per patient were lower ($154/d postintervention, $273/d SC).

Conclusion The ALC patients on a new interdisciplinary TCU experienced improvements in health and function and did so at reduced cost.

Context In the 2009 Commonwealth Fund survey, 45% of Canadians were able to access a health care provider the same or the next day, and 33% of Canadians waited 6 days or more to be seen by a primary care physician or nurse. An innovative approach to optimizing practice management, open-access or advanced access scheduling, has been proposed as a method to address access to providers. Through improved access to one’s interprofessional (IP) health team, continuity of care has been shown to increase, with a subsequent decrease in repeat demand for the provider. By combining the advanced access concept with IP collaboration we expect an increase in health care access and improvement in patient clinical outcomes and satisfaction.

Objective A study team at the Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont, has been working to expand and evaluate this model to an IP health care team that includes chiropractors. This study aimed to evaluate open-access scheduling feasibility for all providers; the “max-packing” concept for patients requiring IP health care interventions (providing multiple services and providers on the same day); and the impact of open access on patient satisfaction for both family physician and chiropractic provider practices.

Methods This mixed-methods project involves implementation of open access to health care providers, both physicians and chiropractors, at the St Michael’s Hospital Department of Family and Community Medicine. This involves measurement of practice metrics of the third-next available appointment and appointment supply and demand. Patient satisfaction surveys were collected for both chiropractic and family physician practices. Focus groups were also conducted to gather provider perspectives.

Results Preliminary results have indicated that open-access scheduling has reduced the wait times for patients requiring rapid access to their providers and has shortened the time period for the third-next available appointment. Initial results have also indicated an improvement in both patient and provider satisfaction with this model of delivery.

Conclusion Through the use of open access in interprofessional care, we envision significant benefits, including improved and timely access to health services, increased comprehensive health care, and decreased health care resource use such as emergency and walk-in clinic care.

Context Moral distress is viewed as a predictor of burnout and is associated with poorer patient and provider outcomes. Although growing in importance in the formal care sector, the role of moral distress among informal family caregivers of individuals with dementia has not been explored.

Objective The goal of this is project was to develop a psychometrically valid tool for the early identification of moral distress in family caregivers through family physicians.

Methods Findings from reviews of the published and gray literature on caregiver stress, burden, and moral distress were synthesized with those from focus groups with family caregivers to create a preliminary 21-item scale. The scale measures decisional distress in the areas of health care and impact on family and caregiver. Data using the scale items were collected online from 150 family members through various dementia support services.

Results A principal component factor analysis (no rotation) was conducted, resulting in a 4-factor solution that accounted for 74.2% of the variance. Only 8% of the residual correlations in this solution were 0.15 or higher. Cronbach reliability (total scale-item) analysis revealed an overall α of 0.857 for the scale, indicating good reliability. The next phase of the study will explore the validity of the scale and individual scale items in predicting caregiver moral distress.

Context Research skills empower family physicians to produce and appraise new knowledge, and to evaluate improvements in their clinical work. The Section of Researchers of the College of Family Physicians of Canada views research as a core component of training, scholarship, and clinical practice. This context is the impetus for developing a theoretically based program for building research culture and capacity in family medicine (BRCC-FM).

Objective To describe barriers and facilitators and to develop a formal strategy for BRCC-FM in Western University’s Department of Family Medicine. The strategy will use as a framework both the Cooke and the Farmer and Weston conceptual models, which focus on individual, departmental, institutional, career stage, and system factors.

Design Descriptive qualitative pilot study. A collaborative approach will be employed to the design of a local research capacity development initiative.

Setting Department of Family Medicine at Western University in London, Ont.

Participants Clinicians and leaders engaged and not engaged in research; research and clinic staff.

Instrument Key informant interviews will be conducted and qualitatively analyzed, exploring barriers and facilitators to clinical faculty research, and the success and limitations of research capacity development initiatives already in place.

Outcome measures Ultimately, enhanced research culture, measured by increased research interest, skills and confidence, and institutional support; and increased research productivity, measured by publications and presentations.

Anticipated results The qualitative analysis will validate the extent to which barriers, facilitators, and initiatives described in the literature for building research culture and capacity are confirmed by interviews. These results will be used in a deliberative process to design a strategy for strengthening research capacity among clinical faculty.

Conclusion This pilot will support the design of a BRCC-FM approach in Western University’s Department of Family Medicine, and will also act as a pilot for expanding this work across departments of family medicine in Canada.

Context Palliative care has traditionally focused on the care of cancer patients, and most palliative care units have a disproportionately high number of cancer patients. However, patients with noncancer diagnoses also have a high burden of distressing symptoms at the end of life and benefit from palliative care. Multiple barriers prevent noncancer patients from accessing palliative care.

Objective To compare the admission characteristics, palliative performance scales, and lengths of stay of patients with noncancer and cancer diagnoses admitted to a palliative care unit, with the aim of understanding the differences in these groups and improving how we offer palliative care to patients with noncancer terminal illnesses.

Design Retrospective chart review.

Participants All patients admitted to the palliative care unit at Baycrest Hospital in Toronto, Ont, between September 1, 2011, and September 1, 2012. A total of 307 patients were reviewed, 62 of them (20%) with a noncancer diagnosis (average age 84.0 years, 40% males) and 245 (80%) with a cancer diagnosis (average age 77.1 years, 44% males). The most common noncancer diagnostic categories were cardiac (34%), dementia (21%), and “other” (45%).

Instrument Electronic hospital records were reviewed.

Outcome measures Demographic characteristics, admission palliative performance scale (PPS) scores (a functional performance assessment), lengths of stay, and origin of admission.

Results Patients with a noncancer diagnosis were more likely to come from hospital (and less likely from home) relative to cancer patients. They were older and had lower PPS scores at the time of admission. Lengths of stay did not differ statistically between the cancer (30.3 days) and noncancer (19.2 days) groups. Lengths of stay of a week or less were common, occurring in 53% of the noncancer patients. Patients with dementia had shorter lengths of stays and lower PPS scores than those with other noncancer diagnoses.

Conclusion These results show that noncancer patients have poorer functional status at the time of admission than cancer patients and are often admitted very near the end of life. On this palliative care unit patients with noncancer diagnoses do not place a greater burden on resources with longer lengths of stay, and it might be possible to optimize patient care by admitting them at an earlier point in the illness.