Context Current guidelines do not recommend routine use of urinary cultures for managing uncomplicated urinary tract infections (UTIs) in premenopausal, nonpregnant women. Complicating factors include atypical presentation, structural abnormalities, or recent recurrent infection or antibiotic use.

Objective To determine the number of urine cultures ordered for women who presented to the emergency department (ED) with symptoms of uncomplicated UTI, and whether a culture result affected subsequent management.

Design Retrospective medical record review.

Participants Women aged 18 to 39 presenting to 1 of 2 academic EDs with a discharge diagnosis of uncomplicated UTI from January to December of 2014. Patients were excluded if any of the following were documented: pregnancy, fever, immunocompromised state, diabetes mellitus, absence of lower urinary tract symptoms, ED administration of intravenous antibiotics, a previous UTI treated with antibiotics in the past 90 days, and 2 weeks postpartum or postinstrumentation.

Main outcome measures Proportion of patients who had urinalysis or urine cultures, and the results of these investigations.

Results Of the 512 charts included in the analysis, 494 (96.5%) patients had urinalysis, of which 463 (93.7%) had results positive for leukocyte esterase and 90 (18.2%) had results positive for nitrites. Of the 370 patients (72.3%) who had urine cultures performed, 236 (63.8%) results were positive. More than 500 patients (505 [98.6%]) received antibiotics (53.9% nitrofurantoin, 22.6% ciprofloxacin, 15.0% sulfamethoxazole and trimethoprim, 6.7% other, and 1.8% not documented). Only 7 (1.9%) cultures grew organisms resistant to the prescribed antibiotic; 2 (0.5%) patients received new prescriptions.

Conclusion For most young female patients with uncomplicated UTI, urine cultures did not change management. Almost all of these patients had a positive leukocyte esterase result and were treated with antibiotics, yet approximately 40% of the patients tested did not return positive urine culture findings, suggesting that better algorithms for the diagnosis of UTI in the ED are required. Unnecessary treatment with antibiotics is expensive, contributes to the development of multidrug-resistant organisms, and exposes patients to the unnecessary risks of possible allergic reactions, drug interactions, and side effects.

Context The relationship between patients and primary care providers is the foundation of a sustainable health care system (Starfield, 2009) and therefore should be the focus of primary care measurement. We hypothesized that quality measured this way should be associated with lower costs.

Objective To measure primary care quality in a way that reflects the patient-provider relationship and test its relationship to per capita health care costs.

Design Observational study of patient experience survey, electronic medical record, and administrative data contributed to Data to Decisions (D2D), a summary of primary care data currently available, comparable, and meaningful to practices working to improve the quality of care for their patients. We generated a composite quality measure according to the importance of each component to patients in their relationship with their providers. We analyzed reliability and conducted multivariate regression of the relationship between the composite quality measure and per capita cost.

Participants More than 100 teams (N = 137 or 74% of all Association of Family Health Teams of Ontario members invited to participate) voluntarily contributed practice characteristics and performance data, describing care for approximately 2 million patients (15% of Ontario’s population).

Main outcome measures Relationship between primary care quality and per capita health care cost.

Results The measure incorporated 14 indicators balancing patient priorities (eg, patient involvement in decisions) with system priorities (eg, emergency department visits, access to same or next day appointment; Cronbach α = .516). Higher quality was associated with lower per capita health care costs, explaining approximately 50% of variation in costs, taking patient complexity and rural locale into account. Patients in the study were less likely to be immigrants and to have a large number of comorbidities, and were more likely to be older and live in rural, higher-income settings compared with provincial means.

Conclusion It is possible for front-line providers to measure quality in a way that reflects providers’ priorities, considers what matters to patients regarding the patient-doctor relationship, and contributes to health care system sustainability. The composite quality measure represents a feasible alternative for front-line providers disenchanted with body-part measures. For policy makers, it also represents a promising option for measurement and support of primary care performance that can lead to increased health care system sustainability.

Context Frail older people are among those most likely to use acute care, yet they are the least likely to benefit from it; most are likely to experience harm from such services. A number of home-based primary care programs have been developed to address this. However, there are relatively few evaluative studies on such programs.

Objective To assess a home-based primary care program (Home Visits for Vancouver’s Elderly [Home ViVE]) in Vancouver, BC, by examining rates of emergency department (ED) visits and hospital admissions.

Design Before-and-after time series study with matched controls. We assessed the Home ViVE effect by linking cases and controls to their hospital ED visit and discharge abstract records.

Participants Cases comprised all individuals in Home ViVE between April 2010 and June 2013. Controls selected were individuals older than 55 years of age receiving long-term home support over the same period who were not clients of Home ViVE. We matched cases to controls (1:2 ratio) on functional and medical complexity variables. There were 246 cases and 492 controls.

Main outcome measures Number of ED visits and number of hospital admissions.

Results The control group was similar to the cases on all matched characteristics except age, where a higher proportion of cases versus controls were older than 90 years of age (33.3% vs 25.4%, P = .02). Cases demonstrated a decrease from the before-to-after period in both crude ED visit rates and crude hospital admission rates: 4.12 to 3.66 visits per 1000 patient days and 2.29 to 2.19 hospital admissions per 1000 patient days, respectively. Controls showed an increase in both ED visit and hospital admission rates: 3.00 to 3.99 visits per 1000 patient days and 1.31 to 1.87 hospital admissions per 1000 patient days, respectively. We used multivariate Poisson regression to further assess the effect of Home ViVE on our outcome measures and the results are forthcoming.

Conclusion The Home ViVE program had a protective effect on cases compared with controls for both ED visits and hospital admissions.

Context The importance of the social determinants of health is well established. Administrative data, while providing valuable information on population-based health service use, have traditionally not included the social determinants other than ecological measures of income. This study provides a new perspective for family doctors to understand their patient populations.

Objective To develop measures of the social determinants of health using the data available in the 70 linkable databases in the Population Health Research Data Repository held at the Manitoba Centre for Health Policy.

Design Retrospective analyses of administrative data.

Participants The databases included 1 159 761 unique residents of Manitoba whose data were collected between 2010 and 2013; 53.1% were female.

Results We developed 11 new indicators to describe social determinants of health: children in care, teen mom, child of a teen mom, social housing resident, low income quintile, income assistance, special needs education funding, newcomer, child of a newcomer, high residential mobility, and involvement with the justice system. More than half of the population (52.4%) has at least 1 social determinant. The lowest income quintile group includes approximately one-fifth of the population, by definition (19.7%). The next most prevalent determinant, high residential mobility (3 or more moves in a year), includes 17% of the population. Less than 15% of the population has more than 2 determinants, and 3.3% have 5 or more.

Conclusion The availability of social data in population health repositories provides new opportunities to understand the distribution of social determinants of health among care providers and the effect of each on the health of populations. This can support focused interventions to address specific social risk factors.

Context While administrative health records provide a unique population-based perspective, electronic medical records (EMRs) can address many of the limitations of administrative data by providing clinical information. Linking EMR prescribing data to pharmacy dispensing data can improve the accuracy and completeness of available information. The Manitoba Primary Care Research Network extracts clinical information and prescription data from primary care EMRs. These data can be anonymously linked to the Population Health Research Data Repository held at the Manitoba Centre for Health Policy, which includes the Drug Program Information Network database containing information on prescriptions filled by community pharmacies, as well as patient and provider characteristics. The subsequent comparison and analysis can provide a fundamental understanding of drug initiation and adherence behaviour on a population scale. Cardiovascular disease remains a leading cause of death in Canada, despite many medications that can reduce the risk of mortality and morbidity. An essential component to achieving improvements in prevention and treatment is addressing medication adherence.

Objective To compare prescribing patterns in EMRs to pharmacy dispensation data.

Design A retrospective comparison between linked EMR and population-based drug dispensing data—prescriptions for cardiovascular disease (antihypertensives, diuretics, antiarrhythmics, and statins) written between April 1, 2012, and December 31, 2013, were included. Multivariate logistic regression models were used to determine the influence of patient and practitioner factors on the proportion of prescriptions being filled at pharmacies.

Setting Manitoba.

Main outcome measures Proportion of written prescriptions that were filled and delays in filling prescriptions.

Results From our sample of 117 600 prescriptions, 69 302 prescriptions (59%) were eventually filled. A total of 25 252 (21%) prescriptions were delayed (filled 30 to 90 days after prescriptions were obtained). Analyses are ongoing to describe the patient and provider features that are associated with the likelihood that a prescription will be filled.

Conclusion Less than 60% of prescriptions were filled within 90 days. Future investigations will primarily focus on further understanding the patient and clinician factors that affect adherence, as well as how to inform interventions to support quality improvement.

Context Previous examinations of wait times have focused on the time between seeing a specialist and starting treatment. Less is known about patients’ waits from referral to initial visit.

Objective To assess the feasibility of collecting wait time data through a chart audit study in order to understand wait times between patients’ referrals and visits.

Design Retrospective chart audit conducted at 3 primary care clinics in Ontario, selected using purposive sampling. Extracted data elements included dates the patient was referred to and seen by the specialist; specialty type; whether or not the referral was urgent; whether the referral was for a procedure; whether the primary care provider received any follow-up either after the referral was sent or after the patient saw the specialist.

Setting Three primary care clinics in Ontario.

Participants We systematically sampled 100 specialist referrals per clinic between October 2014 and January 2015.

Main outcome measures The primary outcome was wait time, defined as the time between the patient’s referral to a specialist and the specialist visit.

Results A total of 275 referrals (91.3% of total) were included in the analysis. In 13.4% of referrals, there was no indication the patient had seen the specialist after 1 year. The median wait time for all nonurgent and urgent referrals was 86.5 (interquartile range 45 to 184) and 57 (interquartile range 28.5 to 91) days, respectively. The most popular referral specialties were gastroenterology (12%), general surgery (11%), otolaryngology (9%), and orthopedics (8%). Dermatology and orthopedics had the longest median wait times for all nonurgent referrals (152 and 98 days, respectively) while general surgery had the shortest median wait time (36 days). Procedure referrals equaled 27.6% of referrals. After the patient was initially referred to the specialist, there was evidence of communication back from the specialist’s office in 17.8% of referrals. After the patient saw the specialist, there was evidence of follow-up from the specialist in 90.7% of cases.

Conclusion Findings from this pilot study suggest that wait times are excessive and longer than previously reported. Wait times vary substantially by referral urgency and specialty type. This will be relevant to policy makers interested in reducing wait times.

Context Increasing demand for primary health care services has led to the development of clinic-based multidisciplinary teams that include pharmacists.

Objective To characterize and evaluate referrals to a pharmacist in a primary care clinic (PCC).

Design Prospective cross-sectional study. Data were collected from the PCC electronic medical record.

Setting A PCC based in Chilliwack, BC.

Participants Included were all patients (N = 122) referred to a PCC pharmacist during a 12-month period (May 2015 to April 2016). Median age was 64 years (range 21 to 92 years) and 59% were female. Nineteen patients (16%) canceled their appointments without rescheduling or were no-shows.

Main outcome measures Source of and reason for referral, patient characteristics, and number and category of identified drug therapy concerns (DTCs) were examined using descriptive statistics.

Results Fifty-eight percent of patients were referred via new patient intake using a Medication Risk Assessment Questionnaire, 29% were referred from other PCC providers, and 13% were referred from community family physicians. The most common reason for referral was a medication review (84%). Median number of medical problems per patient was 7 (range 1 to 18) including chronic pain (61%), hypertension (53%), and dyslipidemia (49%). Median number of medications per patient was 11 (range 1 to 33). Common medication classes included antihypertensives (64%), gastric acid suppressants (50%), and benzodiazepines or hypnotics (49%). Relatively few patients (≤ 20%) were receiving high-alert medications such as anticoagulants, antihyperglycemics, and immunosuppressants. In total, 412 DTCs were identified (median 4 per patient, range 0 to 12), of which 33% were a medication without an indication and 29% were an untreated indication.

Discussion The most reliable source of referrals to a PCC pharmacist was for medication reviews of new patients. Most referred patients had multiple medical problems and polypharmacy, and few were referred for disease-specific management. A limited number were receiving high-alert medications; therefore, these patients should be proactively targeted by the PCC pharmacist. The number of DTCs per patient varied, and most related to either initiating or discontinuing a medication. Despite polypharmacy being commonplace, almost one-third of patients had an untreated indication.

Conclusion The Medication Risk Assessment Questionnaire was the most effective method for identifying pharmacist referrals in a PCC. Generally, patients referred to a pharmacist had multiple comorbidities and medications; however, many still had indications for additional therapy.

Context In Ontario, approximately 50% of the opioid-dependent population in treatment has co-occurring mental health issues. In an ideal setting, mental health and addiction treatment services can be delivered in a coordinated fashion. However, it is far more common that addiction medicine and mental health services are provided discordantly. A factor contributing to the separation of services is the challenge of providing coordinated care across a large geographic area. Understanding the unique needs of the opioid-dependent population, and how these patients access mental health services is an important step toward developing a coordinated model of care.

Objective To evaluates how opioid-dependent patients are accessing mental health care and for which purposes.

Design We conducted a retrospective cohort study using an administrative database for patients who commenced opioid agonist therapy between 2008 and 2014 who also interacted with the mental health system in Ontario. Patients were stratified by primary mental health treatment model. Treatment models were defined as mental health treatment by a family physician or pediatrician, a psychiatrist, coordinated care (primary care provider supported by a psychiatrist), or telemedicine.

Setting Ontario.

Participants Patients starting opioid agonist therapy between 2008 and 2014 who also interacted with the mental health system.

Main outcome measures Proportion of mental health care provided by primary care, psychiatrists, shared care, and telemedicine.

Results Mental health provided by primary care accounted for 19 458 patients (0.81% of all mental health delivered by primary care), psychiatrists provided care to 11 455 patients (1.10% of mental health delivered by psychiatry), shared care provided mental health services to 7682 patients (7.92% of appointments by shared care), and telemedicine was used to deliver services to 9077 patients (17.61% of all telemedicine-delivered mental health appointments).

Conclusion Shared care and telemedicine models are being used disproportionately to care for opioid-dependent patients with co-occurring mental health conditions.

Context Metabolic syndrome (MetS) is a cluster of risk factors related to increased insulin resistance, which increases the risk of developing cardiovascular disease, stroke, diabetes, and cancer. Controlled studies have shown that diet and exercise can reverse MetS and improve outcomes related to these diseases. We designed an evidence-based diet and exercise program aimed at reducing the components of MetS in primary care: The Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) program.

Objective To determine if the team-based CHANGE program was feasible in a primary care setting and resulted in a reversal of MetS at 12 months and a reduction in long-term risk of myocardial infarction.

Design Prospective study. Eligible patients were screened and educated about the nature and risks of MetS. They had follow-up visits with the family physician every 3 months over the year, and weekly visits with the dietitian and kinesiologist for the first 3 months and monthly thereafter.

Participants A cohort of 305 patients with MetS were enrolled from 3 large Canadian primary care clinics over 2 years. Eligibility criteria were designed to enrol adult patients that met the criteria for MetS according to the unified criteria. Patients incapable of participating for safety or medical reasons were excluded.

Results Of the 305 patients enrolled, 293 met the inclusion criteria at baseline and 228 had 12-month bloodwork done. Median compliance with dietitian and kinesiologists visits over the 12 months was 86% and 76% respectively. At 12 months, at least 16% to 20% of eligible patients had MetS reversal. The average expected PROCAM 10-year risk of a cardiovascular event decreased at 12 months by 1.5% (P < .0001) from a baseline of 8.5%, a relative risk reduction of 18%, with patients at the highest risk at baseline showing the most improvement.

Conclusion The CHANGE lifestyle intervention program is feasible in a Canadian primary care setting, and compliance with this program is associated with significant MetS reversal and reduction in the 10-year risk of a cardiovascular event. Efforts are in place for the widespread dissemination and adoption of the program across Canada.

Context Government legislation allowing medical assistance in dying received royal assent in June 2016. For the first time, patients in Canada have the right to be granted an assisted death within their own country.

Objective To explore the experiences of patients who asked for an assisted death after February 6, 2016, the initial deadline set by the Supreme Court of Canada to have federal legislation in place.

Design Qualitative design using semistructured interviews and thematic analysis.

Participants Patients who had a consultation regarding assisted death through the Hemlock AID clinic in Vancouver, BC, or through other physicians in British Columbia.

Methods Semistructured interviews by 2 family practice residents exploring the decisions the patients had made, the discussions patients had had with physicians and family members, barriers they faced, support they had received, how their feelings had changed over time, and what they wanted from health care providers. They also discussed basic demographic characteristics for context.

Main findings The subjects had a variety of medical and psychiatric conditions that they all found intolerable, ranging from imminently life-limiting to chronic illnesses. Main themes for requesting assisted death included unacceptable quality of life, most commonly due to loss of autonomy, physical functioning, and the ability to communicate. Some expressed fear of future suffering and future disability. They talked about the barriers they encountered, including accessing assisted death and paternalism. The patients in our study were confident in their decisions, but this might be because they had barriers to overcome and might have been among the more persistent ones requesting assisted death. This might change as our society gains experience with assisted death and it becomes widely accessible.

Conclusion We are learning more about the experience patients have when requesting an assisted death. We also learned more about our own reactions and biases.

Context Our department developed a series of explicit benchmarks in family medicine (FM): 29 for first-year residents and 32 for second-year residents. These benchmarks became stems for core FM in-training evaluation reports (ITERs) implemented in July 2013. The action-based ITER evaluation scale had 4 parameters: not observed nor not applicable; off trajectory for this benchmark (action required); on trajectory for this benchmark (minimal or no action required); attained this benchmark (no action required). Such an assessment system permitted an appreciation of just when during residency each of these benchmarks was attained.

Objective To determine the timing and consistency of competency attainment for predetermined benchmarks in FM training.

Design We retrospectively analyzed the aggregated ITER data contained in our online assessment system (1 WebEval) over the academic years 2013 to 2014 and 2014 to 2015. Using the data in one sorted by resident with sequenced FM rotations, we were able to determine the timing and consistency of competency attainment for each of the 61 predetermined benchmarks.

Participants A total of 85 preceptors completed ITERS for 149 first- and second-year residents in 2014, and 102 in 2015.

Main outcome measures We grouped the competencies into 6 educational categories for simplicity, and determined the point in core FM blocks when each competency and each group of educational categories was attained by 50% of residents.

Results We examined results from trainees’ assessments, which showed an expected consistent increasing trend toward benchmark attainment over the sequence of ITERs. The 2014 to 2015 results ranged from 25% of first-year residents who attained the benchmarks after 1 FM block, to 71% after 5 blocks. Increases in second-year residents were similar, ranging from 55% to 87%. More important, we demonstrated stability of when this occurred from year to year for each item and there were no statistically significant differences in percentage of residents who attained benchmarks between cohorts.

Discussion Although addition of a third year of data will provide more reliability, we believe that the use of action-based resident assessment and big data approaches have provided a tool to determine expectations about attaining competency.

Conclusion Having developed an indirect approach to longitudinal benchmarks, we now can more readily recognize which residents need early attention because their educational progress is off the expected trajectory.

Context A 3-hour mandatory workshop (mindfulness in clinical practice) was developed and piloted for the 2012 to 2013 academic year at the University of Ottawa in Ontario, and has since remained as part of the curriculum. This workshop was incorporated into the existing third-year family medicine rotation of the clerkship curriculum for both the Anglophone and Francophone streams.

Objective The main objective of this teaching innovation is to improve the MD program by introducing a mindfulness-based practice that students can use to enhance both their personal and professional lives by increasing self-awareness, compassion, empathy, and resilience, and thus the quality of medical care.

Design A qualitative research project was designed to explore the students’ ideas of this teaching innovation, as well as the barriers encountered when trying to incorporate a curriculum in mindfulness.

Setting University of Ottawa.

Participants The students consenting to the research study (N = 14) were invited to participate in an interview during the week following the workshop and subsequently 12 weeks later.

Methods Data were analyzed using thematic content analysis. The raw transcribed data were coded for recurrent and emergent themes within the predetermined areas of inquiry.

Main findings Preliminary findings of 6 out of the total 14 participants revealed that students preferred informal mindfulness practices (breathing, walking, eating, and listening awareness) over formal practice (sitting or lying), likely owing to time mentioned as the main barrier. Stress was the most important motivation to engage in mindfulness practice, and participants reported reduced stress as the main benefit. Students expressed their desire to have more resources and experiential sessions and both a mandatory and an elective mindfulness curriculum during their undergraduate training.

Context Simulated office orals (SOOs) are used by the College of Family Physicians of Canada (CFPC) to evaluate family medicine resident readiness for clinical practice. The ability to use residents’ performance on the practice examinations conducted during their training to predict their final Certification examination score would be useful for residency programs.

Objective To determine if performance on practice SOO sessions conducted during residency training could be used to help predict performance on the SOO component of the final Certification examination.

Design Prospective cohort study.

Setting University of Ottawa (U of O) in Ontario.

Participants Family medicine residents enrolled at the U of O between July 1, 2012, and June 30, 2014, who were eligible to write the CFPC Certification examination in the spring of 2014 and who had participated in all 4 practice SOO examination sessions. There were 23 residents who met these criteria.

Intervention Practice SOO sessions at U of O were standardized using a modification of the CFPC’s SOO examination standardization process. The scores generated on 4 practice SOO examination sessions conducted during the 2-year residency training program were used to generate the data presented in this study.

Main outcome measures Scores on practice SOO sessions during fall 2012, spring 2013, fall 2013, and spring 2014; the SOO component score on the spring administration of the CFPC Certification examination.

Results Weighted least squares regression analysis using the 4 practice SOO session scores significantly predicted final certification examination SOO score, with an adjusted R² value of 0.29 (P < .05). Additional analysis suggested that the mean scores for the cohort generated at each time point were statistically different from each other and that the relationship over time could be represented by either a linear relationship or a quadratic relationship, with a plateauing effect at 16 months. A generalizability study generated a relative G coefficient of 0.63.

Conclusion Our results confirm the utility of practice SOOs as a progress test and demonstrate their feasibility to predict final scores on the SOO component of the CFPC’s Certification examination.

Context Primary care reform has introduced different models of service provision and provider remuneration. Very little evaluation of the quality care provided by clinicians in different models of care has been published.

Objective To determine the relationships between the model of primary care service delivery and quality-of-care indicators in an urban population.

Design Retrospective administrative data analysis. We created general linear mixed models to describe the relationship between each model of primary care and the dominant, traditional fee-for-service (FFS) model for health services use, while controlling for a variety of primary care provider (PCP) and patient factors, including patient social complexity.

Setting Two FFS and 3 alternatively funded models of primary care service delivery in Winnipeg, Man, were studied.

Participants We allocated all Winnipeg residents who had at least 3 visits to any PCP at any Winnipeg clinic between 2010 and 2013 to the most responsible PCP (N = 626 264). We then allocated each PCP to a model of primary care service delivery.

Results Patient social complexity was associated with poorer crude rates for many of the indicators. There were no differences among the models for hospital readmission within 30 days or specialist referral by the assigned PCP. Hospitalizations for ambulatory care sensitive conditions were higher for one alternatively funded model (odds ratio = 1.98, 95% CI 1.38 to 2.83), while nonindicated low back x-rays were lower for a different alternatively funded model (odds ratio = 0.14, 95% CI 0.03 to 0.59). Ambulatory care visits to any PCP were lower for all 3 alternatively funded models than the 2 FFS models. The family medicine academic teaching sites had lower rates of continuity of care (P < .5) conclusion overall, and no model of primary care consistently outperformed the others. The FFS models had higher rates of visits, but appeared to satisfy patient needs better (less frequent use of telehealth services following visits). Teaching sites appeared to sacrifice continuity of care potentially to support other academic activities. Controlling for social complexity was associated with a reduction in the differences between models in indicator outcomes.

Context Ideal management of alcohol withdrawal syndrome incorporates a symptom-driven approach, whereby patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol, Revised [CIWA-Ar]) and treated according to severity. Among the domains assessed by the CIWA-Ar, tremor is the most objective indicator of withdrawal severity. However, the ability of clinicians to reliably quantify tremor is highly dependent on experience.

Objective To prospectively validate an objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application.

Design Prospective, observational cohort study.

Participants Patients 18 years of age and older presenting to an academic emergency department in alcohol withdrawal from October 2014 to August 2015.

Intervention An objective, reliable tool to standardize and quantify the severity of alcohol withdrawal tremor using the built-in accelerometer of an iOS application.

Main outcome measures Assessments were videotaped by a research assistant and subsequently reviewed by 3 clinical experts blinded to the primary clinical assessment. Tremor severity was scored using the 8-point CIWA-Ar scale (0 = no tremor to 7 = severe tremor). Accelerometer-derived results were compared with expert assessments of each video. Interrater agreement was estimated using Cohen κ statistics.

Results A total of 76 patients with 78 tremor recordings were included. Accelerometer-derived tremor scores matched exactly with expert assessor scores in 36 (46.2%) cases, within 1 point for 73 (93.6%) cases and differed by 2 or more points in 5 (6.4%) cases. The overall κ for agreement within 1 point for tremor severity was very good: 0.92 (95% CI 0.86 to 0.99).

Conclusion Assessment of the tremor component of the CIWA-Ar score using the iOS accelerometer is reliable and has potential to more accurately assess the severity of patients in alcohol withdrawal. We anticipate this resource will be easily disseminated and will affect and improve the care of patients with alcohol withdrawal.

Context Well-child care (WCC) includes preventive care, anticipatory and health education, and vaccinations to infants and children in primary care. In Canada, family physicians and pediatricians perform most WCC, but in many developed countries, registered nurses (RNs) provide WCC. As team-based primary care expands across Canada, family physicians need new approaches to collaborating and sharing responsibility for the growing demands of practice. Shared WCC could be an effective and efficient way to maximize nursing scope of practice while maintaining the patient-physician relationship with families.

Objective To develop and pilot a collaborative, shared-care approach to WCC by nurses and family physicians.

Design Feasibility study to test implementation and data collection, and acceptability to providers and families.

Setting A family health team (FHT) in Ottawa, Ont.

Participants Two RNs and 5 family physicians in a multidisciplinary FHT, and 20 to 30 healthy children ages 2 months to 2 years.

Intervention A shared-care approach to WCC, with visits alternating between the child’s family physician and the RN, was developed based on the following steps: searching international literature examples; establishing standards of care for WCC; matching the scope of practice of an Ontario primary care RN to the activities of routine WCC; and consultation with FHT physicians and RNs to identify an approach that optimized the nursing scope of practice, maintained continuity of care with patients and families, and promoted collaboration and communication between the nurse and the physician caring for a child.

Main outcome measures Acceptability of shared-care model by FHT physicians and RNs.

Results Family physicians and RNs found the proposed shared-care model acceptable and the Rourke Baby Record was chosen as the standard of care for providing WCC by all providers.

Conclusion This project developed and implemented a novel shared-care approach to WCC with good buy-in from providers. Ongoing data collection will assess WCC outcomes and parental and longitudinal provider satisfaction with this approach.

Context Between 2005 and 2012, there was a 300% increase in quetiapine prescriptions in Canada, most of which were written by family physicians. Prescribing data indicated high off-label use; for example, in sleep or anxiety disorder. Factors informing family physicians’ prescribing decisions, and practices relative to quetiapine safety, are unknown.

Objective To explore quetiapine prescribing practices from the perspective of the family physician, with a view to designing an educational intervention.

Design Qualitative study, informed by a constructivist understanding of prescribing. By this we see prescribing as a complex, socially situated process—physician knowledge and use of medication is affected by a range of factors, such as health care organization and systems, personal experience, and patient factors.

Participants To solicit a range of physician experiences (male, female, suburban, vulnerable populations, old, young), participants were selected purposively. After obtaining consent, 18 family physicians were interviewed using semistructured interviews, which were recorded and transcribed.

Analysis Data were analyzed using template analysis, a flexible form of thematic analysis. By reading and re-reading the transcripts, a hierarchical template consisting of vertical and horizontal codes and themes was constructed, which was refined repeatedly, as data collection was iterative with analysis. An external critical friend with expertise in qualitative research in prescribing helped critically interrogate the data and enhance template development.

Main findings Four themes were identified: decision making in patients with mental health problems; use of quetiapine; prescribing practices; and influences. Two integrative themes crossed the data set and related to patient complexity and use of quetiapine as an alternative to benzodiazepines. Family physicians were holistic in their approach to mental health issues. Off-label use of quetiapine tended to be for patients with more than 1 mental health problem, often complicated by social factors—mental health plus. An important factor favouring quetiapine use was to avoid risk of addiction, tolerance, or abuse associated with benzodiazepines. Few physicians monitored patients for movement disorder or weight gain, nor did they perform laboratory work.

Conclusion This qualitative study highlights the complexity of prescribing. We have identified a number of teaching points that can be used to inform high-quality safe prescribing of quetiapine.

Context Most Canadians with mental health problems seek care for these issues first from their family physicians. Specialty mental health care is often not readily available to patients owing to long wait times, finances, stigma, and lack of access to services. Integrated primary care models like the Behavioural Health Consultation program (BHC) are designed to overcome some of these obstacles by providing brief, evidence-based behavioural and mental health interventions to patients directly in family practice settings.

Objective To assess the effectiveness of the BHC intervention by comparing symptom severity, mental health functional changes, patient and physician satisfaction, and number of physician visits before and after the BHC intervention.

Design Data were collected in the context of a program evaluation before intervention and at 4-month follow-up within a 22-month period, and analyzed comparing means before and after intervention using a paired-sample t test.

Participants Data from 186 patients in an urban family practice setting with 5 physicians and 1 psychologist were analyzed (102 women, 84 men, mean age of 42, and a range 12 to 96 years of age). At total of 101 patients identified as Caucasian, 35 did not disclose their ethnicity, 25 identified as Asian, 8 as South Asian, and the remaining patients identified as aboriginal (n = 3), mixed (n = 2), and Middle Eastern (n = 2).

Intervention The intervention consisted of 4, 15- to 25-minute behavioural health consultation visits with a psychologist BHC in an integrated primary care family practice setting.

Main outcome measures A variety of measures were used, including the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7-item scale (GAD-7), Health-Related Quality of Life (HRQOL) scale, patient and physician satisfaction ratings, as well as evaluation of physician visits 16 weeks before and 16 weeks after the start of the BHC intervention.

Results The data suggest that brief BHC interventions decreased mental health symptoms such as depression (PHQ-9: P < .0002; GAD-7: P < .0001), decreased physician visits from 3.54 visits in the timespan of 16 weeks before to 2.73 visits in the timespan of 16 weeks after the start of the BHC intervention (P < .0001), and increased mental health-related quality of life (HRQOL-MH: P < .0087).

Conclusion Integrated BHC intervention showed promising results for providing effective, accessible, and timely behavioural and mental health care with few barriers for patients in family practice settings.

Context People with developmental disabilities are living longer and are more likely to have multiple and complex medical problems. Lack of appropriate transition of care from a well coordinated pediatric service to more fragmented adult services renders this group vulnerable to health care disparities. Family physicians provide ongoing primary care to people with severe and profound developmental disabilities but this can be challenging, especially as the family physician is rarely involved in their care as children. The development of the patient-physician relationship might be different in this population and could influence the provision of appropriate ongoing care. Further research about this relationship could help inform and support family physicians as they embark on these relationships.

Objective The primary objective of phase 1 of this study is to explore how the patient-physician relationship develops between adult patients with severe or profound development disabilities and their family physicians as perceived by their caregivers.

Design Qualitative-grounded theory.

Participants Primary caregivers of patients with severe and profound developmental disabilities.

Instrument Using semistructured interviews developed from the research questions, participants were asked about their experience with the development of this relationship.

Main findings The patient-physician relationship in this context is complex and the importance, intensity, and role of the close bond between the caregiver and the patient with severe and profound developmental disabilities was realized. Various steps in the process of relationship development are described. These steps result in the creation of the patient-caregiver-physician dynamic triangular relationship. Four models of this relationship are then described: the upfront knowledge acquisition, familiarization over time, stable and functional resource, and physician-centred models. The model of relationship affects the delivery of true patient-centred care.

Conclusion The effect of the different types of relationships in each of these models on the well-being of the patient, caregiver, and family physician is considerable. Appropriate transfer of this knowledge to family physicians to help develop positive, enduring relationships with these patients is essential to ensure the ongoing provision of appropriate primary care.

Context Many family medicine (FM) residency programs have eliminated overnight on-call shifts owing to concerns about patient care and resident fatigue. However, some argue that this reduces exposure to acute patients and eliminates a valuable educational experience.

Objective To assess the number, urgency, and perceived learning value of pages received by FM residents on call overnight.

Design Prospective observational study.

Participants Family medicine residents in their first (n = 9) and second (n = 4) years at the Chilliwack General Hospital, a 140-bed community hospital in British Columbia.

Main outcome measures First, residents were asked to score the learning value of each page on a scale of 0 (not at all valuable) to 10 (extremely valuable). Second, residents were asked to record the patient’s complaint and key physical examination features, which was then coded using the Canadian Triage and Acuity Scale (CTAS).

Results Residents recorded 544 pages (505 after exclusions) from October 16 to December 17, 2014. We observed a mean of 12.32 pages per shift (range 4 to 26) or 0.95 pages per hour. The most common pages were for general and minor issues (53.7%), which includes medication requests (28.9%). The next most common complaints were cardiovascular (14.1%), gastrointestinal (7.1%), and respiratory (6.5%). Pages were categorized (with mean [M] learning scores) as nonurgent (44.6%, M = 1.41), less urgent (19.2%, M = 3.37), urgent (22.8%, M = 4.17), emergent (11.7%, M = 6.44), and resuscitation (1.8%, M = 7.78) according to the CTAS. Mean learning scores significantly increased as the CTAS urgency increased (linear trend, P < .0001). Fewer pages occurred after midnight (30.5%), but the proportion of pages categorized as less urgent or nonurgent did not change significantly (P = .53 and P = .09, respectively).

Conclusion Urgent pages have more perceived learning value; however, a large portion of the pages received by residents were not urgent. Residents were paged less frequently after midnight, but the likelihood that they would be paged for nonurgent issues did not change. Further research should investigate perceived learning value in other settings, including daytime clinics that residents might miss owing to call.

Context Family medicine (FM) identity development is an important goal of residency training programs with implications for education, practice patterns, and colleague interactions. Research in undergraduate medical education settings suggests that longitudinal curriculum structures have effects on professional identity formation; however, these innovations have not been studied in postgraduate settings.

Objective To explore how the FM identity of residents develops in a longitudinal curriculum and explore factors that affect this process.

Design This was a qualitative, phenomenologic study that employed semistructured individual interviews and thematic analysis.

Participants Six final-year FM residents in a distributed community training site with a longitudinal curriculum structure.

Main findings Participants described key experiences that supported their developing identity as family doctors: clinical activities typical of FM, independence and ownership for patient care, and meaningful patient relationships. Curriculum factors supporting these key experiences included having an FM home base, curriculum flexibility, and breadth of experience over time. Noncurriculum factors such as community training setting, preceptor teaching style, and preceptor scope also affected participants’ identity development.

Conclusion Based on the personal accounts of residents, these findings identify features of the longitudinal curriculum that influence the developing identity of FM residents. This adds to our understanding of how curriculum innovations in FM affect resident experiences and support identity development.

Context Traditional medical education assessment approaches tended to focus on measuring medical knowledge and procedural skills. Competency-based assessment approaches carry with them an underlying assumption that, while static knowledge and procedural skills are important, the ability to apply knowledge, communicate effectively, practice patient-centred care, and conduct oneself in a professional manner are also essential elements that must be assessed. In 2010, we implemented the Competency-Based Achievement System (CBAS). Our goal in switching to the CBAS was to broaden the assessment of our residents to capture all competencies of an effective physician. In this study, we compared assessment data before and after implementation of the CBAS.

Objective To evaluate whether assessment information after CBAS implementation is more detailed and informative, addresses multiple competencies beyond medical knowledge and procedural skills, and shows evidence that residents had an opportunity to self-assess, compared with pre-CBAS assessment information.

Design Secondary data analysis intervention (data sources).

Main outcome measures In-training evaluation reports (ITERs) and summative progress reports (PRs) from de-identified resident assessment files for 4 years before and 5 years after CBAS implementation. Random sample of 25% of files for each cohort (total N = 164). Content, length, and quality of comments, as well opportunities for residents to self-assess, on ITERs and PRs.

Results The PR results confirmed our hypothesis: after CBAS implementation, comments were detailed and specific, resident self-assessment was more evident, and learning plans were found more consistently. For ITERs, comment length did not change, but accuracy in identifying concerns about resident progress increased. Additionally, post-CBAS ITERs showed more alignment between comments and the score given to the resident.

Discussion The CBAS facilitated the collection of better assessment information about residents than was found before implementation. The emphasis shifted from medical knowledge to a broad assessment of all competencies identified by our program as essential. The CBAS also shifted the focus from rankings to narrative about resident competence, which provided greater information about resident strengths and weaknesses. Finally, an emphasis on guided self-assessment encouraged residents to self-assess, based on the assessment evidence in the CBAS.

Conclusion Adopting a system (CBAS) that emphasizes workplace assessment and formative feedback resulted in better assessment information.

Context In our experience, complaints of ankle swelling are more common in the summer, often from patients with no obvious cardiovascular, venous, or lymphatic disease. Surprisingly, this observation has never been reported in the literature.

Objective To determine any seasonal pattern in the general public’s interest in ankle swelling.

Design Our data were obtained from Google Trends and consisted of the frequency of all Google searches related to ankle swelling in the United States from January 4, 2004, to January 26, 2016, and in Australia from August 29, 2010, to January 26, 2016.

Results Consistent with our expectations, Internet searches for information about ankle swelling are highly seasonal (P < .0001), with peaks of search volume occurring in the summer. Seasonality explained 86% of the search volume variability in the United States and 73% of the variability in Australia.

Conclusion The public’s interest in ankle swelling is highly seasonal and might reflect underlying physiological trends in body fluid volume.

Context Atrial fibrillation (AF) contributes to approximately 25% of ischemic strokes in the elderly, underscoring the importance of oral anticoagulation for stroke prevention. Inconsistent therapeutic effectiveness of warfarin and the burden of frequent international normalized ratio testing have resulted in a surge in the use of the novel oral anticoagulants (NOACs). However, these medications require dose adjustments for renal insufficiency or failure, which is prevalent in the elderly. Primary care providers rely on community laboratory reported estimated glomerular filtration rate (eGFR) based on the MDRD (Modification of Diet in Renal Disease) formula, which does not use the actual patient’s weight and has been shown to overestimate GFR in the elderly. This provided rationale to assess discrepancy of GFR between the MDRD and the Cockroft-Gault (CG) formula (which uses actual body weight), and its potential effect on NOAC dosing.

Methods A retroactive chart review was undertaken in 10 primary care practices.

Participants Inclusion criteria were as follows: patients 75 years of age and older with a confirmed diagnosis of AF who were taking NOAC therapy; availability of NOAC dosing details; and at least 1 serum creatinine (Scr) and 1 body-weight measure during the study year. Exclusion criteria were as follows: patients younger than 75 years of age; unavailable Scr or body-weight data; lack of NOAC dosing details; long-term care residents (lack of data in electronic medical record).

Main outcome measures We calculated GFR by CG and compared this with the laboratory reported MDRD eGFR. We assessed potential and real dosing discrepancy of NOACs in these patients relative to eGFR.

Results Charts for 210 patients 75 years of age and older were identified: 32 had a confirmed AF diagnosis; 12 were taking warfarin (excluded); 20 were taking NOACs, meeting the study criteria. Mean (SD) age was 82 (5) years; mean (SD) Scr was 90 (23); mean (SD) MDRD eGFR was 67 (19) vs 60 (20) for CG-GFR (P = .09; non-significant on Kruskal-Wallis test). The MDRD overestimated GFR in 16 cases, but NOAC dose discrepancy was noted in only 8 patients—6 underdosed, 2 overdosed (P < .05 for all differences on ² tests).

Conclusion The MDRD formula overestimated eGFR compared with the CG formula. Unexpectedly, we noted that underdosing exceeded overdosing, which could undermine stroke prevention. Drug monographs for NOACs suggest using eGFR based on CG, which should be followed for appropriate dosing and safety in clinical practice.

Context Office procedures are an important part of the comprehensive care package provided by family physicians. Every family physician cannot feasibly perform every office procedure. A cadre of family physicians drawing upon each other’s procedural skills has the potential to improve patient care and enhance physician satisfaction.

Objective A mixed methods approach was used to explore the potential clinical and educational roles of a formalized referral network for office procedures in Newfoundland and Labrador.

Design A descriptive quantitative study using a self-administered survey and a subsequent descriptive qualitative study using focus groups of family physicians.

Participants Family physicians practising in Newfoundland and Labrador. Quantitative sampling frame was 597, with an eligible survey response rate of 22.11%. Qualitative study participants (n = 20) were divided into 4 focus groups composed using a purposeful sampling strategy.

Main findings In the quantitative study, family physicians identified that, while there are procedures being performed in family practice, there is a discrepancy between the demand for and the performance of office procedures. Respondents also identified interest in colleague referral for office procedures. In the subsequent descriptive qualitative study, participants suggested that colleague referral would be beneficial if supported by the entire medical community, accepted by patients, and implemented effectively.

Conclusion Family physicians recognized that there is both a need and a desire for a formalized referral network that incorporates the following: encourage office procedures in family practice; connect colleagues to address discrepancies between the demand for and performance of office procedures; improve physician, patient, and health authority satisfaction with colleague referral; and address family physician concerns through effective implementation.

Context Collaborative care integrating primary and specialist mental health care has been increasingly highlighted as a way to improve psychiatric services in Canada and internationally. The family practice unit at Sunnybrook Health Sciences Centre in Toronto, Ont, in collaboration with the department of psychiatry, has operated a shared care program since 2008, providing joint family medicine–psychiatry consultations for patients within the family medicine clinic. The program has also aimed to provide teaching for residents and family medicine staff to build capacity to manage psychiatric illnesses in a primary care setting. However, the program has not undergone formal evaluation since its inception.

Objective To evaluate whether the shared care program was meeting the needs of health care team members and to look for opportunities for improvement.

Design A qualitative study design using a combination of in-depth interviews and focus groups to understand the views of family practice and psychiatry team members on the shared care program.

Setting The shared care program in the family practice unit at Sunnybrook Health Sciences Centre in Toronto.

Participants Family medicine and psychiatry residents and staff, registered nurses, social workers, office coordinators, and program coordinators were sampled to elicit a range of perspectives on facilitators and barriers to the goals of the program.

Methods A qualitative content analysis approach was used to iteratively code the interview and focus group transcripts and derive themes.

Main findings Themes included continuity of care, formalization, educational goals, attitudinal shifts, communication issues, and program strengths. The participants indicated that the value added by family medicine’s longitudinal relationships with patients was lost when shared care appointments were scheduled with physicians who had not previously met the patient. Trainees also noted that a more structured approach to the program would help clarify roles of the learners and other health care team members. Many participants thought that the program was succeeding for patients and clinicians by offering timely access to psychiatric care and helpful feedback, respectively.

Conclusion Alterations to the structure of the shared care program could help improve the educational experience of the trainees. Formalization might lead to less uncertainty regarding responsibility for follow-up, clearer expectations, and better longitudinal care.

Context Chronic disease accounts for a substantial proportion of morbidity and mortality worldwide. Four out of 5 Canadians are at risk of chronic disease, and the burden of these conditions will only increase unless strategies are implemented to mitigate these risks. HealtheSteps (HeS) is a healthy lifestyle program targeted at improving risk factors (physical inactivity and unhealthy diet) known to contribute to chronic disease.

Objective To explore the potential effectiveness of the HeS program at improving physical activity and unhealthy diet in individuals at risk of chronic disease.

Design This study was a pilot pragmatic randomized controlled trial.

Participants Individuals 18 to 85 years of age, with 1 or more self-reported or measured risk factor for chronic disease (body mass index ≥ 24.9 kg/m², exercise ≤ 150 minutes a week, sitting ≥ 3 hours a day, consuming ≤ 8 fruit and vegetable (F&V) servings per day, diagnosis of metabolic syndrome or type 2 diabetes) were eligible to participate in the study.

Intervention Over the 6-month program (4, 45-minute sessions), participants worked with a HeS coach to develop healthy lifestyle prescriptions for physical activity and healthy eating.

Main outcome measures Physical activity (average steps per day), healthy eating (Starting the Conversation [STC] scored 0 to 16 [0 = most healthful eating]; Modified DINE [higher number indicates greater consumption]), and weight were assessed at baseline and 6 months.

Results Participants were randomly assigned to either the HeS intervention group (N = 59) or a wait-list control group (N = 59). Baseline characteristics were similar between groups: mean (SD) or median (interquartile range) for age 57.7 (3.5) years; weight 85.6 (22.5) kg; steps per day 5608 (4057); STC score 6.0 (3.0); Modified DINE F&V score: 2.8 (2.5). At 6 months, the HeS group increased their physical activity more than the control group did: difference between groups in mean steps per day (control is reference) was 3057 (95% CI 1924 to 4189 steps, P < .001). Healthy eating improved more in the HeS group compared with the control group (STC −1.50 [95% CI −2.40 to −0.59], P = .001; Modified DINE F&V score 0.67 [95% CI 0.06 to 1.28], P = .03). There were no differences between groups in mean weight change.

Conclusion The HeS program has the potential to improve physical activity and healthy eating in individuals at risk of chronic disease. More research is warranted.

Context Effective communication between health care providers and patients is thought to be an important factor for improving various outcomes, such as patient understanding, adherence, and health outcomes. Interventions seeking to promote patient participation can improve communication, yet most study interventions are resource intensive and few studies have rigorously evaluated these interventions’ effects.

Objective To assess the effect of a Web intervention promoting patient participation in communication, recall of medical information, and health outcomes in patients suffering from chronic diseases as compared with usual care.

Design This study used a 3-arm randomized control trial, randomizing participants into usual care, the Web intervention (e-Learning), and combined Web intervention and workshop (e-Learning and workshop). Physicians, coders, and research assistants assessing charts were blinded to patient allocation.

Participants Participating in the study were 322 adults selected from primary care clinics in Ontario who had at least 1 disease among hypertension, type 2 diabetes, and dyslipidemia not meeting target goals according to Canadian guidelines. Participants spoke English and could access the Web. The e-Learning group completed a Web intervention that focused on 4 modules, based on the PACE approach of Cegala: prepare for the medical interview, ask questions, check understanding, express concerns. Participants in the combined group benefited from an additional workshop that involved role-playing the previously mentioned skills. Communication was assessed objectively using 2 validated communication coding schemes, MEDICODE and RIAS. Recall was assessed through questionnaire answers compared with audio recordings, and health outcomes, such as meeting target goals for recommended blood pressure, glycated hemoglobin levels, and lipid profiles were assessed through analysis of medical records.

Results A total of 221 participants came to their follow-up appointments, which were audiorecorded. Participants who used the website had richer information exchanges with their physicians, recalled more information about their medications (odds ratio for e-Learning vs usual care = 1.564, 90% CI 1.058 to 2.312), and had a greater likelihood of meeting their treatment goals (relative risk for e-Learning versus usual care = 1.52, 95% CI 1.008 to 2.30).

Conclusion Although results must be evaluated with caution owing to attrition, this trial provides evidence that accessible websites such as discutonssante.ca are important tools that might have direct positive effects on clinically relevant outcomes.

Contexte Dans nos milieux universitaires, les médecins-patrons travaillent de manière quotidienne avec les résidents en formation. Ces interactions complexes soulèvent d’importants questionnements juridiques sur le plan de la responsabilité médicale.

Objectifs Exploration des aspects juridiques de la relation entre le médecin-patron et le résident dans le système de justice québécois. Type d’étude : Essai juridique rédigé dans le cadre d’une Maitrise en Droit de la Santé.

Instrument La jurisprudence de 1980 à aujourd’hui a été relevée. C’est 23 causes pertinentes qui ont été entendues devant nos tribunaux québécois. La doctrine a aussi été relevée de 1980 à aujourd’hui. Enfin, 11 articles d’auteurs renommés ont été étudiés.

Paramètre à l’étude En premier lieu, les lois ont été étudiées afin de déterminer les obligations du résident, du médecin-patron et de l’établissement. Par la suite, la jurisprudence a été explorée sur l’interprétation des lois par les tribunaux. Finalement, la doctrine a été analysée; les grands auteurs québécois ont été lus et critiqués.

Constat La faute du médecin patron a été entrainée dans de multiples circonstances; notamment pour son devoir d’enseignement, son devoir d’obtenir un consentement, sa délégation d’actes médicaux et son rôle au sein d’un hôpital universitaire. Le résident fautif va entrainer la faute de son médecin-patron pour le fait d’autrui s’il prodiguait des soins médicaux et la faute de l’établissement s’il prodiguait des soins hospitaliers. Le résident peut aussi entrainer sa faute propre déontologique.

Discussion Le débat juridique sur le commettant principal du résident a été exploré. Il nous semble que l’acte en luimême n’oriente pas sur le commettant, mais bien le contexte dans lequel il est posé. Lorsque les juristes explorent la faute d’un résident, ils doivent départager si l’acte médical a été posé en contexte de soins hospitalier ou de soins médicaux.

Conclusion Les relations entre le médecin-patron et le résident sont complexes. Il s’agit de trouver un équilibre entre l’apprentissage des résidents et la sécurité du patient.

Context Generalism is believed to be a widely held fundamental value in medical education. The Faculty of Medicine at the University of Toronto in Ontario is currently engaged in preclerkship curriculum renewal. The new curriculum is purported to be based on generalist principles. However, in the course of curriculum review, it became apparent that perspectives on generalism held by faculty and other stakeholders were varied and unclear.

Objective To systematically review all aspects of the midlevel design of the new proposed undergraduate curriculum for evidence of generalist principles and to recommend modifications.

Design In response to the apparent discord among faculty and stakeholders, an environmental scan of the literature and accreditation documents relevant to generalism in undergraduate medical education was undertaken. An evidence-informed tool, incorporating the key elements of generalism, was developed and applied in a systematic review process to all aspects of the midlevel design of the new proposed curriculum.

Methods The environmental scan, literature review, tool development, and curriculum review were conducted by the authors. The generalism tool was systematically applied to all aspects of the midlevel design of the new curriculum. Each section was reviewed by a minimum of 2 faculty members and consensus was achieved.

Main findings Application of the tool revealed a conspicuous lack of evidence for the inclusion of generalist principles in the new curricular documents. Detailed feedback and suggestions for change were provided to course and curriculum developers reflecting on the presence or absence of these principles. The results of the review process were highly valued and are being used to inform the evolving high-level curriculum design. The continued application of the tool will allow for ongoing assessment of the lived curriculum through a generalist lens.

Conclusion Development of an evidence-informed tool supported a generalist lens through which we were able to provide institutional guidance in the implementation of a new undergraduate curriculum. This process can be applied by other institutions wishing to review their curriculum regarding generalist principles.

Context The issue of residents in difficulty is of concern for all residency programs. In any program, there is a 6% to 10% rate of occurrence of residents encountering difficulty at any time. In addition to causing stress for the resident, programs encounter considerable costs in time and resources. Often, residents in difficulty are not identified until late in their programs, and efforts to address gaps meet with minimal success. Early interventions are often more successful, as poor attitudes or dysfunctional behaviour have not yet become ingrained habits. Improving identification of residents in difficulty benefits both the programs and the residents.

Objective In this study, we examined the extent to which an intervention to increase comments on assessments led to earlier detection of residents in difficulty.

Design Secondary data analysis. Archived de-identified resident assessment data were mined (3 years before and 3 years after the intervention; total N = 393).

Main outcome measures Rotation and progress report flags were used to identify residents in difficulty. Total numbers of comments were counted, as were words within comments. Content analysis of the comments was conducted to determine the degree to which comments gave residents specific information about where and how they could improve.

Results Significantly more comments were present on assessment forms after the intervention compared with before the intervention, as determined by ANOVA (F_5,384 = 8.8, P < .005). Content analysis revealed that the comments were more informative. Comments specified areas where residents were encountering difficulty and how they could improve their performance. Numbers of flags increased after the intervention, but residents were flagged earlier in their program, and fewer residents required formal remediation.

Conclusion Creating a residency program assessment culture that emphasizes informative comments on assessment forms facilitates earlier identification of residents encountering difficulty. There is more information contained in comments than can be determined from rankings or ratings of residents. Residents encountering struggles were more likely to have more frequent, longer, and detailed comments on assessment forms. This information meant that targeted interventions could be designed for these residents to help them address gaps and gain knowledge and skills needed to successfully complete residency. Comments on assessment forms are crucial to identifying and helping residents in difficulty.

Context Several organizations, including Choosing Wisely Canada and the Public Health Agency of Canada, have identified antimicrobial stewardship as a priority for optimizing antimicrobial prescribing in the outpatient setting. Nonetheless, large gaps remain in understanding how antibiotics are prescribed in primary care settings for various infectious syndromes, including urinary tract infections, pneumonia, pharyngitis, cellulitis, acute sinusitis, otitis media, bronchitis, and upper respiratory tract infection. In order to design interventions to improve antibiotic prescribing trends, more information is needed to assess how these medications are being used in primary care settings.

Objective To establish a baseline frequency of antibiotic prescribing for common primary care diagnoses in Manitoba. In addition, we attempted to identify patient and prescriber factors that were associated with potentially inappropriate antibiotic prescribing in order to design interventions to address improvements in care.

Design A retrospective database review was conducted using the Manitoba Primary Care Research Network Repository, which contains electronic medical record data from 35 clinics, more than 200 primary care providers, and nearly 200 000 patients.

Intervention A definition of potentially inappropriate antibiotic prescriptions was created for targeted diagnoses. Diagnosis-prescription pairings for a 2-year period from 2013 to 2015 were reviewed for appropriateness. Prescriber and patient factors were assessed using multivariate logistic regression.

Results Of the 1293 unique antibiotic prescriptions reviewed for likely bacterial diagnoses, 30% were not prescribed in an ideal manner, 52% owing to incorrect length of therapy as defined by evidence-based recommendations. There were 55 004 occurrences of likely viral diagnosis, of which 5.5% had an associated antibiotic prescription. This represented 3014 potentially inappropriate courses of antimicrobial therapy. Patient age, sex, and number of visits all had statistically significant correlations to potentially inappropriate prescribing. There were no prescriber factors in our model that led to greater likelihood of appropriate prescribing.

Conclusion Current antimicrobial prescribing patterns in Manitoba primary care practices appear to be less than ideal. This study lays the groundwork for further antimicrobial stewardship programs in primary care, which are urgently needed to curtail the overuse of antibiotics in the setting where most are dispensed.

Context It is estimated that 15% to 50% of patients with a mild traumatic brain injury (mTBI) diagnosed in the emergency department (ED) will develop postconcussive syndrome (PCS). Although expert consensus recommends cognitive rest and graduated return to usual activities, these interventions are not based on prospective clinical evidence.

Objective To determine if patients randomized to graduated return to usual activity discharge instructions have larger decreases in their Post-Concussion Symptom Scale (PCSS) score 2 weeks after mTBI compared with patients who received usual care mTBI discharge instructions.

Design Pragmatic randomized controlled trial.

Participants Adult (18 to 64 years) patients presenting to an academic ED (annual census 65 000) with chief complaint “head injury” occurring within 24 hours of ED visit.

Intervention Graduated return to usual activity and cognitive rest discharge instructions.

Main outcome measures Primary outcome was change in PCSS score 2 weeks following ED discharge. Secondary outcomes were change in PCSS score at 4 weeks, time off work or school, and number of physician follow-up visits.

Results A total of 118 patients were enrolled in the study (58 in the control group and 60 in the intervention group). Mean (SD) age was 35.2 (13.7) years and 43 (36.4%) patients were male. There was no difference with respect to change in PCSS score at 2 weeks (10.5 vs 12.8; difference = 2.3, 95% CI 7.0 to 11.7) or 4 weeks after ED discharge (21.1 vs 18.3; difference = 2.8, 95% CI 6.9 to 12.7) for the intervention and control groups, respectively. The number of follow-up physician visits and time off work or school were similar when the groups were compared. At 2 weeks and 4 weeks, 64.4% and 41.2% of patients, respectively, continued to experience symptoms (PCSS > 8).

Discussion Results from this study suggest graduated return to usual activity discharge instructions do not affect the rate of resolution of mTBI symptoms 2 weeks after ED discharge, yet most patients continue to experience symptoms. These findings are consistent with studies evaluating the effect of strict rest on symptoms following mTBI.

Conclusion Given that patients continue to experience low to moderate symptoms 2 weeks after mTBI, more investigation is needed to determine how best to counsel patients with postconcussive symptoms.

Context International guidelines recommend routine mental health screening in prenatal care. However, fewer than 20% of North American prenatal care providers conduct routine mental health screening in pregnant women owing to a number of barriers. E-screening, if acceptable to women, might address some of these provider barriers.

Objective One objective was to determine whether women’s perceptions of the benefits and risks of disclosure of mental health concerns differ between those who receive paper-based and e-screening of psychosocial health.

Design A randomized controlled trial with computer-generated randomization (1:1) to allocate pregnant women to e-screening or paper-based screening using the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale. Following randomization, women completed the screening tools and a baseline questionnaire, including the Disclosure Expectations Scale. Research assistants blinded to screening results conducted a Mini-International Neuropsychiatric Interview 1 week after recruitment.

Participants English-speaking pregnant women from 3 family medicine clinics, 1 obstetrics clinic, and prenatal classes at 2 community hospitals in Alberta were recruited consecutively.

Results Among the 636 participants, 23.3% indicated they would feel moderately or very vulnerable disclosing mental health information to their prenatal doctor or nurse, and 63.3% indicated it would be moderately or very beneficial to talk to them about personal or mental health concerns. Nulliparous women were more likely to see both the risks (adjusted odds ratio = 1.75, 95% CI 1.19 to 2.58) and the benefits (less likely to have a low benefit score; adjusted odds ratio = 0.59, 95% CI 0.37 to 0.94) of disclosure. No significant differences between screening groups were found in the mean levels of perceived risk (t₆₂₉ = 0.22; P = .82) or perceived benefit (t₆₂₉ = 0.19; P = .85) of disclosure of mental health information to the provider.

Conclusion Women find the risks and benefits of mental health screening similar using either traditional paper-based or e-screening. Therefore, clinicians can use the method that fits within their practice and enables implementing international guidelines to conduct routine mental health screening in pregnancy.

Context Tai chi is an ancient Chinese exercise that has been described as moving meditation. A surprising amount of research has now been done on tai chi that could inform physicians’ assessments of it.

Objective To summarize the evidence on tai chi as a form of physical fitness and as a therapeutic intervention.

Design A review of systematic reviews and recent clinical trials. PubMed and the Cochrane Collaboration Database on Systematic Reviews were searched for systematic reviews and randomized controlled trials of tai chi. Evidence for its fitness benefits as well as its therapeutic benefits for more than 20 conditions were then assessed and summarized into 3 categories: consistent evidence of benefit, preliminary or equivocal evidence of benefit, or little to no evidence of direct benefit.

Results More than 100 systematic reviews on tai chi were identified. Tai chi is a gentle exercise that can improve balance, aerobic capacity, and strength, especially in middle-aged and elderly adults who have become deconditioned. There is consistent evidence that tai chi has a therapeutic effect on osteoarthritis, cognitive capacity, chronic lung disease, Parkinson disease, and preventing falls in community-based older persons. There is preliminary or equivocal evidence that tai chi has a therapeutic effect on anxiety, quality of life in cancer patients, coronary artery disease, depression, fibromyalgia, hypertension, stroke, osteoporosis, and sleep disorders. There is some evidence that tai chi has no direct therapeutic effect on type 2 diabetes, rheumatoid arthritis, chronic heart failure, and preventing falls in frail institutionalized older persons. There were no studies that found that tai chi worsened a condition. A recent systematic review on the safety of tai chi found adverse events were typically minor and primarily musculoskeletal; no intervention-related serious adverse events have been reported.

Conclusion Physicians can now offer evidence-based recommendations on tai chi noting the various levels of evidence and benefit. Tai chi is still an area of active research, and patients should continue to receive medical follow-up for any clinical condition.

Context Clinical teachers generally identify problem learners readily, but they are often reluctant to act upon their impressions in the absence of clear or familiar subsequent steps. In particular, a need has been identified to support clinical teachers for the identification and remediation of clinical reasoning difficulties, as these difficulties are prevalent and have important implications for patient care. We hypothesized that an algorithmic application could be helpful to guide clinical teachers through the diagnosis and remediation of clinical reasoning difficulties.

Objective We aimed to evaluate the perceived utility, acceptability, and feasibility of this mobile tool.

Design The research design was an interpretive description. Semistructured interviews were conducted before and after a 3-month trial with the application. Interviews were analyzed deductively using predetermined categories, and inductively using emerging categories.

Participants Twelve emergency physicians in 2 academic hospitals were recruited through volunteer sampling.

Main findings The application was seen by participants as particularly useful to put the right words on learners’ clinical reasoning difficulties. Overall, using this application was considered helpful and feasible during shifts in the emergency department. The mobile format was considered instrumental in allowing participants to use this tool in the field.

Discussion These findings suggest that the tool could be of interest as a faculty development resource, requiring little time or few resources, while allowing experiential and cumulative learning to take place. It is hypothesized that the mobile and algorithmic format of this tool promoted access to educational information by allowing information to be accessed “just in time,” in a format that mirrors the habitual clinical problem-solving practices of clinical teachers.

Conclusion This mobile application could be especially useful to better identify the clinical reasoning difficulties of learners, in a format that is both acceptable to clinical teachers and feasible in a context known for its high clinical pressure. These observations suggest that just-in-time access to information in an algorithmic mobile format could be of interest for knowledge transfer in medical education.

Context Patients with diabetes and poor glycemic control are at higher risk of complications. Provider continuity is often cited as an important factor for improving outcomes for people with chronic disease, although evidence in diabetes populations is conflicting.

Objective We determined the association between sociodemographic and clinical characteristics, and time-varying primary care attachment and poor glycemic control.

Design Longitudinal cohort study using linked administrative and laboratory data from Alberta Health and the Alberta Kidney Disease Network.

Participants We created a provincial cohort of adults with prevalent diabetes and a measure of hemoglobin A_1c that occurred at least 1 year following the date of diagnosis. We used the Usual Provider of Care index to define attachment to both primary care physician and practice. Over 2 years, we categorized patients’ frequency of use as never (no visits), infrequent (1 or 2 visits), or frequent (≥ 3 visits) and level of attachment as high (> 75% of visits to 1 primary care physician or practice), medium (50% to 75%), or low (< 50%).

Main outcome measures The primary outcome was poor glycemic control, defined as at least 2 consecutive hemoglobin A_1c measurements of 10% or greater, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between patient factors and time-varying primary care attachment and poor glycemic control.

Results In this cohort of 169 890 patients, younger age was significantly associated with poor glycemic control: hazard ratio of 3.08 (95% CI 2.79 to 3.39) for patients aged 18 to 39 years compared with those 75 years of age or older. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, a history of substance abuse, a mood disorder, cardiovascular disease, albuminuria, and a high low-density lipoprotein cholesterol level were also associated with poor glycemic control. The hazard ratio for primary care physician attachment was 1.15 (95% CI 1.10 to 1.21) for low and 1.10 (95% CI (1.04 to 1.14) for medium, compared with high attachment. Physician attachment dominated practice attachment.

Conclusion These findings demonstrate the complexity associated with poor glycemic control and indicate a need for tailored interventions. Physician attachment as opposed to practice attachment was an important predictor of glycemic control, which speaks to the importance of the provider-patient relationship in achieving good health outcomes.

Context Funding agencies’ research agendas are typically set in meetings with senior researchers and agency leaders, sometimes with representation from junior researchers and sometimes from members of the public. This approach has left large gaps in the evidence base that practitioners need.

Objective To derive research agenda priorities from gaps in evidence that practitioners identify in real time, rather than from researchers’ preferences or abstract surveys of practitioners.

Design Prospective observational study, collecting questions asked by practitioners. Questions were compiled and grouped thematically.

Participants Family physicians and other professionals attending evidence-based medicine–oriented continuing professional development meetings.

Main outcome measures Two lists of questions: those for which no or inadequate evidence exists (ie, gaps in evidence) and those that come up often despite the existence of evidence (ie, gaps in knowledge translation [KT]).

Main findings Fifteen evidence gaps were identified on topics practitioners face regularly, where either no studies exist or only weak studies that do not provide sufficient guidance for practice are available; 131 KT gaps were also identified. Three illustrative examples are as follows: What is the effect of FODMAP-restricted diets for irritable bowel syndrome? (Existing studies are too small and not well done; a high-quality randomized controlled trial is needed.) How long after injury can minor wounds requiring suturing be closed? (There are many rules of thumb but few data exist.) Honey for cough is known to benefit children at night, but does it help during the day, and does it help adults? Two typical KT gaps were as follows: For whom (high-risk patients, women, elderly patients) is ASA for primary prevention useful? Is there any value in home glucose monitoring for patients taking oral hypoglycemics?

Discussion Practitioners’ questions readily identify gaps in evidence and KT of direct, practical importance that would have considerable effects on large numbers of patients. Research that addresses these gaps might be more readily taken up by practitioners, as they already perceive a need for the information. These gaps are often not identified by expert committees.

Conclusion Funders should prioritize support for research that addresses demonstrated gaps in evidence in community practice.

Context Physicians’ practices for using chaperones vary, and professional recommendations for their use differ between Canadian provinces and territories, and between countries. However, chaperone use is important for patient-centred care and for the protection of both patients and physicians.

Objective To perform a scoping review of the published literature and identify main themes regarding chaperone use during intimate examinations.

Design Arksey and O’Malley’s (2005) 5-stage scoping review methodology was used. Relevant electronic databases of peer-reviewed literature and gray literature were systematically searched using keywords and MeSH terms. Articles were also identified by snowball sampling. Key information collected included study design, date, country, and physician or patient perspective. Main themes were identified and narratively described.

Results The peer-reviewed literature yielded 549 articles after duplicate removal; 81 were selected based on title and abstract screening. The 81 articles underwent full text review and 62 were included for data extraction, with a further 4 articles identified through snowball sampling. The gray literature search yielded 2 articles and 1 article through snowball sampling. In total, 69 articles were used for data extraction. Publication dates ranged from 1981 to 2015; 83% were solely questionnaire-based. Most articles were from the United Kingdom (52%) or the United States (23%); only 4% were from Canada. Only 7% focused exclusively on family practice patients and 13% on family practice physicians. Physicians believe that chaperones should be offered and used for intimate examinations, but this does not routinely occur. Documentation of chaperone use is poor. Male physicians are more likely to offer and use chaperones than female physicians are. Female patients are more likely to want a chaperone, particularly with male physicians. Physicians and patients have a different understanding of the use and effects of chaperones. Patients would like the offer of a chaperone and value the conversation with their physician.

Conclusion There is paucity of Canadian literature, and chaperone research in family practice is limited. Both patient and physician sex might influence chaperone use. Discussion with patients is important to ensure a common understanding and shared decision making. Physician documentation can be improved.

Context Adverse childhood experiences (ACEs)—including physical, sexual, or emotional abuse; neglect; or household dysfunction—are prevalent. The ACE study estimated that 75% of people have experienced at least 1 event and 17% have experienced 4. Such experiences have a lifelong effect on many aspects of physical and mental health; however, little examination of the FP role in providing trauma-informed care has been undertaken.

Objective To explore patient experience of health care and ideas around ideal health care delivery in the context of chronic disease and a history of ACEs.

Design Qualitative phenomenologic study using in-depth interviews and thematic analysis carried out on transcripts using NVivo 10.

Setting An academic family health team in Kingston, Ont.

Participants Participants were identified using purposive sampling through chart review. Telephone interviews confirmed 26 eligible female patients at least 21 years of age with 2 or more non-psychiatric conditions and an ACE score of 4 or more.

Methods In-depth interviews were conducted using an interview tool looking at the experience of primary health care, including FP care, allied health care, structure and layout of care, administrative interactions, triggering experiences, and perceived ideal care.

Main findings Participants were frequent users of health care services and denied being asked about ACEs by their FP. They believed ACEs were important for their health and that providers should be aware. Participants were generally happy with their primary health care despite this gap. Triggers related to past experiences included certain interventions (Papanicolaou smears, dental work), patronizing or authoritative FP behaviour, and inadequate explanations about procedures and recommendations.

Conclusion A positive and consistent relationship between patient and FP is fundamental to ensuring safety among women with a history of ACEs. Family physicians should learn to ask about patients’ experiences, as patients consider these to be important to their health and health care.

Context While heart failure (HF) is a leading cause of death worldwide, there is little information about how community-based patients living with end-stage HF are cared for by family physicians.

Objective This study sought to understand the family physician’s role in and contribution to the HF care team surrounding the care of HF patients.

Design A constructivist grounded theory approach,

Methods Fifty patients with New York Heart Association class III or IV HF were interviewed at 5 study sites in 3 Canadian provinces and asked to identify key members of their care team. Twenty-nine family physicians identified by their patients were interviewed. Analysis within and across these patient–family physician dyads was conducted using a constant comparative approach to identify key themes.

Main findings The overall description of family physicians’ activities in their role was vast, but each family physician made choices about which activities to engage in. We characterized this variability of purposeful activity as arising from complex factors such as expertise and interest; from professional and personal philosophy; from system pressures and affordances; and from their relationship with the patient or patient wishes and needs. Patients were rarely aware of the scope of activities family physicians engaged in on their behalf beyond the in-person consultations with their family physicians, but still described their family physician as their pivot. Regardless of their activities of care, the family physicians consistently brought an understanding of the patient as a person, of their family and their community, of their past, and of their likely future to the larger health care team.

Conclusion The family physician role in the care of patients with complex chronic conditions such as HF is not characterized by uniform activity but rather develops as an outcome of multiple interactions and complex factors. Viewed through the lens of any single disease, this variability threatens our notions of standardized team care. A deeper understanding of the nature of and influences on variable practice activities among family physicians might have important implications for health system planning and health care team functioning.

Context The IMPACT (Innovative Models Promoting Access-to-Care Transformation) research program is a Canadian-Australian collaboration aiming to improve access to primary health care (PHC) for vulnerable populations in 3 Canadian and 3 Australian communities. Regional partnerships between stakeholders (consumers, policy makers, academics, and providers) in each of the communities guided the realist reviews.

Objective To inform the design and implementation of locally relevant interventions to improve access to PHC for vulnerable populations in the Canadian communities: Ottawa, Ont, Montérégie, Que, and North Lethbridge, Alta.

Design Rapid realist reviews conducted via a collaborative and iterative process involving stakeholders in each community who provided local context and guided the researchers who conducted the reviews. Analysis was based on the RE-AIM framework.

Target population Locally defined vulnerable populations (eg, unattached patients, patients living in high-deprivation neighbourhoods, or patients with mental illness).

Interventions Alberta: Community coalition and mobile (pop-up) services for underserved residents. Ontario: Organizational and individual behaviour change among PHC practice staff to accurately assess the needs of its vulnerable patients and refer them to community resources. Quebec: Community health worker (CHW) attached to PHC practices to help vulnerable patients navigate health, social, and community services and support physicians agreeing to enrol a predetermined number of new vulnerable patients.

Main findings Process and contextual factors affecting the interventions. Emerging themes include the following. Ontario: How to train providers about available community resources, how a local innovator within a practice can enhance referrals, how electronic health records can enhance referrals, and specific processes that affect referral. Alberta: Tailoring services to decrease barriers to primary health care, offering services at events or locations where community members are already gathered increases the reach of the interventions, partnerships or collaborations between key stakeholders lead to positive health outcomes and implementation, and design and reporting elements affecting effectiveness. Quebec: How training affects effectiveness, the importance of building trusting relationships, the influence of patients and CHW sharing similar characteristics, potential methods to reach out to patients, and considerations for CHW activities in the intervention design.

Conclusion Rapid and collaborative realist reviews can help guide the development of targeted PHC interventions.

Context Erectile dysfunction (ED) can be a sentinel marker for future cardiovascular disease and has been described as providing a window of curability for men to receive targeted cardiovascular risk assessment.

Objective To determine whether the prescription of phosphodiesterase type 5 inhibitors (PDE5is) for ED leads to the detection and treatment of previously undiagnosed cardiometabolic risk factors.

Design We performed a retrospective, population-based cohort study of residents of British Columbia, using linked health care databases from 2004 to 2011. An individual-level time series analysis with switching replications was used to determine changes in drug use for hypertension, hypercholesterolemia, and diabetes in men 40 to 59 years old. The observation window for each patient was 720 days before and 360 days following the index date.

Setting British Columbia.

Participants Male residents of British Columbia aged 40 to 59 years old.

Intervention First prescription of a PDE5i.

Main outcomes measures The primary outcome was changes in prescriptions for antihypertensives, statins, and oral antidiabetic drugs, with secondary outcomes being laboratory test results for plasma cholesterol and glucose levels.

Results We included 6702 men aged 40 to 59 years newly prescribed a PDE5i in the analysis. We found a sudden increase in prescriptions for antihypertensives (28 per 1000, P = .03), statins (15 per 1000, P < .001), and antidiabetics (18 per 1000, P = .002) in the 90 days following a new prescription for a PDE5i. Relevant screening tests for both hypercholesterolemia and diabetes performed in the 30 days following PDE5i prescription were responsible for this change. Only 11% and 13% of men who did not have a screening test for cholesterol or glucose, respectively, in the year prior to their PDE5i prescription went on to have one in the following 30 days.

Conclusion Treatment for ED with PDE5is can be a trigger, or “gateway drug,” for the early detection and treatment of cardiometabolic risk factors provided physicians perform the requisite screening investigations. The paucity of screening tests observed in our study suggests that physicians should be educated on the recommended screening guidelines for men newly diagnosed with ED.

Context Excessive alcohol use is an important cause of preventable morbidity, mortality, and injury. In 2005, 7.7% of all deaths among those aged 0 to 64 years old in Canada were attributed to alcohol consumption. Leading causes of alcohol-related deaths were cancer, degeneration of the nervous system, digestive diseases, and injury. Only 20% of electronic medical record (EMR) systems in Alberta had documentation pertaining to alcohol use. Standard data entry related to alcohol consumption will improve understanding of alcohol risks, prognoses, and potential for comorbidities. Many patients that might positively respond to practice management and prevention strategies likely go unnoticed by primary care providers.

Objective To identify the proportion of EMR-documented alcohol use in Manitoba, and describe patient- and prescriber-associated factors. In particular, patient comorbidities, age, sex, and frequency of visits, as well as practitioner type, practice size, age, location, funding model, and EMR familiarity are predicted to be associated with EMR documented alcohol use.

Design A retrospective database review was conducted using the Manitoba Primary Care Research Network Repository. The EMR data were assessed using multivariate logistic regression to determine the relationship between alcohol consumption recordings and patient and practitioner factors.

Results Both patient and practitioner factors appear to be associated with documented alcohol use in Manitoba EMRs. Practitioner factors played a large part in Manitoba EMR documented alcohol use, with higher rates of documentation associated with practice size (7.3 times higher in small practices), location (substantially less in small towns), and years of EMR use (10.3 times higher). Patients between the ages of 30 and 49, and 50 and 69, had higher rates of documentation compared with those between the ages of 15 and 29 (1.8 times and 2.4 times, respectively). Patients who regularly visit the practitioner’s office are 1.2 times more likely to have documentation of their alcohol use.

Conclusion Electronic medical records of alcohol use can enable primary care providers and primary health care stakeholders to consistently target and offer programs to patients with excessive alcohol use who could benefit from a more organized approach to alcohol use, ultimately reducing related mortality, morbidity, and injury.

Context Lynch syndrome (LS) is a hereditary cancer syndrome estimated to cause 1% to 4% of colorectal cancers (CRC). Those who carry the LS gene mutation have a markedly elevated lifetime risk of cancers including CRC (50% to 80%) and endometrial carcinoma (25% to 60%). Average age of CRC onset in LS carriers is 45 years; therefore, population-based screening guidelines will not affect disease burden. Appropriate screening reduces cancer mortality. Individuals with LS are often missed owing to incomplete family histories, provider lack of awareness, or family histories not meeting stringent genetic testing criteria. Identification of characteristic tumour LS markers enables genetic testing for those with high probability of LS. Lynch syndrome carriers can then have enhanced screening for LS-associated cancers and family members can be tested. Routine tumour testing (reflex testing), is cost-effective; however, it occurs in few jurisdictions.

Objective To explore experiences with existing reflex LS testing programs focusing on the role of primary care providers (PCPs), to inform future programs

Design Semistructured interviews were conducted. Thematic and content analyses were used to analyze program features, best practices, and the role of primary care. A stakeholder meeting was held to confirm and triangulate findings.

Participants Program leaders, pathologists, technical staff, and family physicians involved in existing reflex LS testing programs internationally.

Main findings Twenty-six participants across 7 programs completed interviews. Participants expressed some tension about involving PCPs in LS reflex testing programs. Ideally, they wanted PCPs involved, but were concerned about their lack of knowledge, awareness, and interest, as well as time pressures. Important PCP roles included supporting patient decision making about genetic testing, discussing genetic test results, enabling cascade genetic testing of family members, and ensuring appropriate screening of those with LS. The long-term patient-PCP relationship was described as important to the success of LS testing. Education, practice resources, and connection to genetics clinics were identified as essential.

Conclusion Lynch syndrome reflex testing programs are an opportunity to explore how precision medicine could be integrated into primary care in the future and the role PCPs could play; PCPs need to be involved in the planning and delivery of genomic medicine programs in order to address the practice and educational challenges unique to primary care.

Context Inputs to the physician work force are well characterized but attrition has been less well studied. A broad perspective on physician retirement—one that considers changing medical practice patterns—is necessary in order to better understand physician retirement behaviour.

Objective To characterize the process of attrition from the primary care work force.

Design Longitudinal study using linked demographic and practice-related data from the Institute for Clinical and Evaluative Sciences.

Setting Ontario.

Participants All physicians belonging to the Ontario primary care work force between 1992 and 2012. Once included in the sample, physicians are followed through time until they are no longer practising or until the end of the study period.

Main outcome measures Practice patterns are characterized in terms of workload and scope of practice. Changes in these variables over time, and the influence of various factors—sex, age, generation, location of training, location and model of practice—on these are examined.

Results A sample of 21 240 primary care physicians has been identified and data analysis is in progress. Workload indices and participation in comprehensive primary care are examined longitudinally. Key career milestones are identified, including the age range through which physicians demonstrate peak workload, the average age at which physicians begin to decrease workload, the length of the period of phased retirement, and the average ages at which physicians stop providing comprehensive care and stop practising. Antecedents to retirement and the influence of various factors on physician practice patterns are also examined.

Discussion Implications of the findings for work force planning at the level of individual physicians, groups of physicians, communities, and the primary care work force as a whole are discussed.

Conclusion This study generates a dynamic picture of how primary care physicians practise as they age. By characterizing the process of physician attrition from the work force, this study will facilitate prediction of physician work force trends and enhance physician work force planning, in turn helping to align the supply of primary care physicians with the needs of the population.

Context By 2036, likely 1 in 5 Albertans will be 65 years of age or older. Alberta’s Continuing Care Strategy focuses on the concept of seniors “aging in place” and recognizes that the medical system needs to focus on community-based chronic care rather than acute care. While this model aligns with the desires of Alberta seniors and makes fiscal sense, there are unique implications for the 23% of Alberta seniors who live in rural areas.

Objective This project’s aim was to identify barriers to successful “aging in place” for rural southern Alberta seniors, as well as solutions to these barriers.

Design A critical review of a 2011 paper by Keating et al, which summarized the social barriers to aging in rural Canada, was compared with reports of 11 key health care stakeholders in rural southern Alberta. An EMBASE, MEDLINE search was performed on September 17, 2014, followed by a gray literature review between October 30 and November 6, 2014, to identify solutions to these barriers.

Results Nine barriers were identified from interviews: transportation or geographic isolation, social isolation, compulsory volunteerism, lack of services (health care and non–health care), housing, caregiver burnout, community uniqueness, and communication. Nine papers met the inclusion criteria and proposed solutions, yet they addressed only 3 of the identified barriers. The gray literature search revealed multiple small solutions to all identified barriers.

Conclusion Many solutions exist to mitigate barriers to successful “aging in place” in rural southern Alberta; however, the services are often small, fragmented, and lack supporting evidence and funding, leaving them vulnerable to collapse. Without a platform to streamline services, critically examine strategies, and share successful pilot projects, it is unlikely these solutions will grow to meet the demands of the future.

Context Group educational visits have the potential to deliver person-focused care in an effective yet cost-efficient manner. Health TAPESTRY is an intervention that includes the generation of population-level reporting of aggregated data on health goals and needs of groups of patients.

Objective To describe the development, implementation, and initial evaluation of a healthy aging group education series in a primary care setting. The series was delivered by an interprofessional health care team and focused on common patient-reported health goals.

Design This was a mixed-methods concurrent triangulation study.

Setting McMaster Family Health Team (MFHT) in Hamilton, Ont.

Participants Health TAPESTRY clients, all of whom were 70 years old and older and rostered with the MFHT, participated in the study.

Intervention Based on aggregate health information and health goals collected in the Health TAPESTRY program, a 4-part series was developed and implemented. This series included a robust introductory session in addition to interactive sessions on nutrition, fitness, and advance care planning. Interprofessional health care team presenters used evidence-based material and fostered engagement by using interactive learning opportunities in the sessions.

Main outcome measures Evaluation was completed via a post-session and post-series survey including open-ended feedback and comments and rated items of content and delivery of the session. Feedback from presenters was also solicited. Expenses were recorded.

Results and findings Of 69 people invited, a range of 26 to 37 people attended individual sessions of the series. Ratings across all sessions were positive—most attendees rated the information as relevant and new, and the presenters were rated as effective and engaging across all sessions. The series overall was rated positively with respect to meeting attendees’ expectations, being well-organized, having a likable location and facility, and recommending the event to friends. Open-ended feedback supported these positive ratings in addition to suggesting it be run in different contexts (eg, retirement homes). Feedback from the presenters indicated the desire to run the program for rostered patients outside of Health TAPESTRY.

Conclusion The healthy aging series was a feasible and effective way to address health goals self-reported by a sample of older adult patients of the MFHT. It was developed in a sustainable manner such that topics could be refined or added depending on health goals.

Contexte Les médicaments potentiellement inappropriés (PIM) chez les personnes âgées de 65 ans et plus sont un sujet d’actualité. On retrouve dans la littérature une prévalence de PIM se situant entre 23 % et 74,7 %, témoignant de l’importance du problème.

Objectifs Mesurer la prévalence de prescription de PIM dans un échantillon de patients suivis en clinique de médecine familiale, en utilisant les critères de Beers. Également, tenter d’identifier certaines caractéristiques des patients qui reçoivent des PIM et des médecins qui les prescrivent.

Type d’étude Il s’agit d’une étude non-expérimentale de type transversale.

Participants 296 dossiers de personnes âgées de 65 ans et plus ont été étudiés. Les visites à l’étude avaient lieu dans deux cliniques de soins de première ligne soit une unité de médecine familiale (milieu académique) et une clinique communautaire rurale (milieu non académique).

Intervention Les dossiers de visite sur rendez-vous entre le 1^er juillet 2014 et le 30 juin 2015 étaient révisés. On notait la présence ou l’absence d’une prescription de PIM ainsi que différentes caractéristiques liées aux patients et aux prescripteurs.

Résultats 72 patients ont reçu au moins une prescription de PIM, soit 24,3 %. Les types de PIM les plus fréquents étaient les benzodiazépines (53,2 %) et le zopiclone (16,5 %). Il existait une corrélation entre l’âge des médecins et la prescription de PIM (0,53 p<0,0001). Pour chaque médicament additionnel sur la liste du patient, ce dernier avait plus de chance de se voir prescrire une PIM supplémentaire (RC 1,18; p 0,003). Les femmes avaient plus de risque que les hommes de recevoir une PIM (RC 0,53; p 0,02). La présence d’antécédent psychiatrique était également associée à un plus grand risque de PIM (RC 7,15; p<0,0001). L’absence de comorbidité était associée à un plus faible risque de PIM.

Conclusion Les médicaments potentiellement inappropriés (PIM) constituent un problème réel dans notre pratique courante et certaines caractéristiques chez les patients et les médecins semblent s’associer à une augmentation du risque de prescription de PIM. Cette étude contribue à sensibiliser les cliniciens en vue de changements positifs dans leur pratique.

Context Discussing advance care planning (ACP) with patients is often challenging, and it is common for there to be discordant perceptions of both the content and occurrence of these discussions.

Objective This study describes the utility of a Web-based application (the TAP-App) administered to a sample of frail homebound seniors receiving home-based multidisciplinary primary care in Vancouver, BC, for “getting on the same page” about ACP.

Design This was a mixed-methods study that used survey data and qualitative interviews to assess the potential effects of the TAP-App among a sample of frail elder–informal caregiver dyads and their primary care providers.

Participants Participants were invited to participate if they had a requirement for activities of daily living support, 1 or more chronic diseases, and an involved family member or friend willing to participate. Thirty-nine homebound frail elderly and 43 family members were included.

Intervention Participants were surveyed about patients’ health, social lives, goals, quality of life, and ACP. Reports were later uploaded to the patients’ electronic medical records, and the primary care providers were notified. If a patient or family member answered yes to wanting to have an ACP conversation with their primary care provider, the system navigator immediately informed the primary care provider. At the end of the project a total of 8 family physicians and nurse practitioners were interviewed about the process and asked about ACP in particular.

Main outcome measures Qualitative interviews and surveys were used to explore the effect of the intervention.

Results and findings There was a disconnect between patients’ and family members’ recollections of having had an ACP conversation and the family physicians and nurse practitioners’ understanding of having had those conversations. The end-of-life care conversations were not consistently recognized by the patient or family member as ACP.

Conclusion This pilot study indicates the importance of multiple end-of-life conversations, using the formal wording advance care plan with patients and families to increase awareness in settings such as emergency room visits, and adding the plan to patients’ electronic medical records.

Context Advance care planning (ACP) is a process of planning for future medical care in the event an individual becomes unable to communicate and consent to treatment. The positive outcomes of ACP have been consistently demonstrated, including improved patient and family satisfaction with end-of-life care, less aggressive treatments near the end of life, decreased hospital and intensive care unit admissions, and reduced costs to the health care system. However, most Canadians have not discussed their end-of-life preferences with their health care providers.

Objective The aim of the current initiative was to increase rates of ACP discussions between patients aged 65 or older and their primary care providers.

Design This was a quality improvement study that was carried out through multiple Plan-Do-Study-Act cycles. Multiple interventions were tested, including creating a custom form to help guide ACP discussions; involving other health care professions such as nurses and social workers; and implementing a variety of reminders including stickers, posters, and electronic alerts.

Results The baseline rate of ACP discussions was found to be 0.31%. After implementation of an ACP custom form, the rate increased almost 10-fold to 2.7%. Other interventions, including reminders and involving other health care professionals, did not further increase rates of discussions.

Conclusion By creating a systematic approach to ACP discussions through use of a custom form in an easily identifiable patient population, we believe that some of the barriers to ACP in the primary care setting can be overcome.

Context Physician-assisted death became legal in Canada on February 6, 2016, and physicians needed to respond to requests from their patients without having had training or experience.

Objective To explore the experience of family physicians whose patients asked for an assisted death after it became legal in Canada.

Design Qualitative design, using semistructured interviews and thematic analysis.

Participants Family doctors whose patients requested an assisted death, whether or not that patient had an assisted death and whether or not the doctor participated in any way.

Methods Two family practice residents conducted semistructured interviews exploring the discussions the physicians had with their patients, how the doctors felt about assisted death before and after the law changed, what their reactions to the patients’ requests were, and how the doctors supported the patients and their families through the process.

Main findings None of the family doctors interviewed participated directly in an assisted death, but most were willing to refer the patient and write letters in support of the patients’ wishes. The primary theme was that they each recognized the suffering their patients endured and appreciated the patients’ perspectives. Some doctors mentioned concerns about medicolegal repercussions. Some talked about the discomfort they felt about the actual procedure.

Discussion These doctors were not talking about the issue of assisted death in general but about particular patients they knew well.