Vancouver, BC
Do urine cultures in the emergency department change management of young women with symptoms of uncomplicated urinary tract infection?
- Shelley McLeod, MSc,
- Elizabeth Poon, MD CCFP(EM),
- Lauren Self, MD CCFP(EM),
- Sean Caine, MD CCFP(EM) and
- Bjug Borgundvaag, MD CCFP(EM) PhD
Abstract
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.
Ontario data support Starfield’s theory on practice quality and cost
- Carol Mulder, DVM,
- Rick Glazier, MD CCFP FCFP,
- Frank Sullivan, PhD and
- George Southey, MD CCFP FCFP
Abstract
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.
Home-based primary care for frail elders
Does it reduce acute health services use?
- Margaret McGregor, MD CCFP MHSc,
- Jay Slater, MD CCFP,
- John Sloan, MD CCFP FCFP MSc,
- Lisa Ronald, MSc PhD,
- Jeff Poss, PhD,
- Michelle Cox, MSc and
- Kim McGrail, PhD
Abstract
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.
Measuring the social determinants of health with linked administrative data
- Alan Katz, MB ChB MSc CCFP FCFP,
- Dan Chateau, PhD,
- Jeff Valdivia, MSc,
- Carole Taylor, MSc,
- Scott McCollough, MA and
- Randy Walld, MSc
Abstract
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.
Using big data to understand medication adherence in Manitoba
- Alexander Singer, MB BAO BCh CCFP,
- Alan Katz, MB ChB MSc CCFP FCFP and
- Lisa Lix, MSc PhD PStat
Abstract
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.
Understanding patient referral wait times in Ontario
Retrospective chart audit
- Clare Liddy, MD MSc CCFP FCFP,
- Lois Crowe,
- Shelagh McRae, MD FCFP,
- Ariana Mihan,
- Nikhat Nawar,
- Christopher Russell,
- Derek McLellan, MD and
- Erin Keely, MD FRCPC
Abstract
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.
Development of a pharmacist referral program in a primary care clinic (PREPARE)
- Arden Barry, PharmD ACPR
Abstract
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.
Who is providing what care?
Delivery of mental health services for the opioid-dependent patient population
- Joseph Eibl, PhD,
- Katie Anderson, MD,
- Victoria Nguyen, MD and
- David Marsh, MD
Abstract
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.
Results of a team-based lifestyle intervention in primary care to reduce metabolic syndrome
- Doug Klein, MD CCFP
Abstract
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.
Qualitative study examining the experiences of patients requesting physician-assisted dying in Canada
- Sheila Holmes, MD,
- Ellen Wiebe, MD CCFP FCFP,
- Amelia Nuhn, MD MSc,
- Judy Illes, PhD and
- Alanna Just
Abstract
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.
Results of benchmarking of more than 2 years in a family medicine residency program
- Gary Viner, MD MEd CCFP FCFP,
- Douglas Archibald, PhD,
- Eric Wooltorton, MD MSc CCFP FCFP and
- Alison Eyre, MD CM CCFP
Abstract
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.
Exploring the benefits of a mandatory mindfulness workshop for third-year medical students in family medicine
- Millaray Sanchez Campos, MD CCFP FCFP,
- Doug Archibald, PhD,
- Joseph Burns, MSc,
- Diana Koszycki, PhD,
- Heather MacLean, MD FRCPC,
- Veronique Duchesne, MD and
- Carol Gonsalves, MD FRCPC
Abstract
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.
Practice simulated office orals as a predictor of Certification examination performance in family medicine
- Kendall Noel, MD CM CCFP FCFP MEd,
- Douglas Archibald, PhD and
- Carlos Brailovsky, MSc MD
Abstract
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.
Does quality of care differ in different models of primary care?
- Alan Katz, MB ChB MSc CCFP FCFP,
- Dan Chateau, PhD,
- Jeff Valdivia, MSc,
- Carole Taylor, MSc,
- Scott McCollough, MA and
- Randy Walld, MSc
Abstract
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.
Prospective validation of an iOS app to evaluate tremor in patients with alcohol withdrawal syndrome
- Bjug Borgundvaag, MD CCFP(EM) PhD,
- Shelley McLeod, MSc,
- Taylor Dear,
- Sally Carver,
- Narges Norouzi, PhD,
- Simon Bromberg,
- Meldon Kahan, MD CCFP FRCPC,
- Sara Gray, MD FRCPC MPH and
- Parham Aarabi, PhD
Abstract
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.
Improving team-based care for children
Collaborative well-child care involving family practice nurses
- Jolanda Turley, MD CM CCFP,
- Grace Warmels and
- Sharon Johnston, MD CCFP
Abstract
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.
Mental health plus
Qualitative study of family physician use of quetiapine
- Martina Kelly, MB BCh MICGP FRCGP CCFP and
- Tamara Pringsheim, MSc MD FRCPC
Abstract
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.
Evaluating behavioural health consultation in an integrated family practice setting
- Joachim Sehrbrock, PhD RPsych and
- Angela Nguan, MD CCFP
Abstract
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.
Patient-physician relationship in adults with severe and profound developmental disabilities
Phase 1
- Katherine Stringer, MB ChB CCFP,
- Bridget L. Ryan, PhD and
- Amanda L. Terry, PhD
Abstract
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.
Family medicine residents on call
Perceived learning value and the Canadian Triage and Acuity Scale
- Adam Jones-Delcorde, MD MSc CCFP and
- Ekaterina Slivko, MD CCFP
Abstract
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.
How does family medicine identity of residents develop in a longitudinal curriculum?
- Natasha Aziz, MD and
- Karen Schultz, MD CCFP FCFP
Abstract
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.
Examination of changes in assessment information before and after implementation of the Competency-Based Achievement System
- Shelley Ross, PhD,
- Shirley Schipper, MD CCFP,
- Pawandeep Kaur,
- Jamie Stobart,
- Paul Humphries, MD CCFP FCFP and
- Mike Donoff, MD CCFP FCFP
Abstract
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.
Seasonality of ankle swelling
Population symptom reporting using Google Trends
- Fangwei Liu, MD,
- G. Michael Allan, MD CCFP FCFP,
- Christina Korownyk, MD CCFP,
- Michael Kolber, MD CCFP MSc,
- Nigel Flook, MD CCFP FCFP,
- Harvey Sternberg, MD CCFP FCFP and
- Scott Garrison, MD PhD CCFP
Abstract
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.
An eGFR obtained by MDRD equation can potentially compromise anticoagulant dosing safety in elderly patients with atrial fibrillation
- Anwar Parbtani, MD CCFP PhD and
- Gaurav Dhindsa, MD CCFP
Abstract
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.
Is there a role for a formalized referral network for office procedures in family practice?
- Annabeth Loveys, MD MClSc CCFP
Abstract
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.
Qualitative evaluation of an academic family practice and psychiatry shared care program
- Eva Knifed, MD MHSc CCFP,
- Nicholas Howell, MSc,
- Purti Papneja, MD CCFP,
- Nathaniel Charach, MD,
- Amy Cheung, MD MSc FRCPC and
- Nikola Grujich, MD FRCPC
Abstract
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.
HealtheSteps improves physical activity and healthy eating in adults at risk of chronic disease
- Cassandra L. Bartol, MB BCh BAO MHK,
- Dawn P. Gill, PhD,
- Roseanne Pulford,
- Parinha K. Simmavong, MA,
- Wendy M. Blunt, MPH and
- Robert J. Petrella, MD PhD
Abstract
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.
Web communication learning
Does it make a difference?
- Emma Glaser, MD MSc,
- Claude Richard, PhD and
- Marie-Thérèse Lussier, MD MSc FCMF
Abstract
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.
Les relations juridiques entre le médecin-patron et le resident
Au-delà de l’enseignement!
- Gabrielle Trepanier, MD CCMF(MU)
Résumé
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.
Informing a new curriculum
Generalist lens
- Melissa Nutik, MD CCFP FCFP MEd,
- Azadeh Moaveni, MD CCFP,
- Ruby Alvi, MD CCFP MHSc,
- James Owen, MD CCFP and
- Risa Freeman, MD MEd CCFP FCFP
Abstract
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.
Detection of residents in difficulty is enhanced when assessors write more and better comments
- Shelley Ross, PhD,
- Orysya Svystun,
- Mike Donoff, MD CCFP FCFP,
- Shirley Schipper, MD CCFP and
- Paul Humphries, MD CCFP FCFP
Abstract
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 (F5,384 = 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.
Understanding antimicrobial prescribing in primary care
- Alexander Singer, MB BAO BCh CCFP,
- Sergio Fanella, MD FRCPC DTM&H,
- Kevin Hamilton, MSc,
- Ashley Walus and
- Leanne Kosowan, MSc
Abstract
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.
Influence of cognitive rest and graduated return to usual activities
Emergency department discharge instructions on symptoms of minor traumatic brain injury
- Catherine Varner, MD MSc CCFP(EM),
- Shelley McLeod, MSc,
- Negine Nahiddi, MD,
- Rosamond Lougheed, MD MSc and
- Bjug Borgundvaag, MD PhD CCFP(EM)
Abstract
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.
Mental health e-screening during pregnancy
Women’s perceptions of risks and benefits
- Anne Biringer, MD CCFP FCFP,
- Sheila McDonald, PhD,
- Marie-Paule Austin, MD FRCP,
- Paula Harvalik, RN,
- Sander Veldhuyzen van Zanten, MD FRCPC,
- Rebecca Giallo, PhD,
- Gerri Lasiuk, RN PhD,
- Glenda McQueen, PhD MD,
- Wendy Sword, RN PhD,
- Lydia Vermeyden, MSc and
- Dawn Kingston, RN PhD
Abstract
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.
What to say if your patients ask about tai chi
Evidence-based response
- Patricia Huston, MD CCFP MPH and
- Bruce McFarlane, MD CCFP FCFP
Abstract
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.
Utility of a mobile application using an algorithmic approach to clinical reasoning difficulties
- Elisabeth Boileau, MD CCMF,
- Christina St-Onge, PhD and
- Marie-Claude Audétat, PhD
Abstract
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.
Association between primary care attachment and poor glycemic control in diabetes
- Kerry McBrien, MD MPH CCFP,
- Marcello Tonelli, MD SM FRCPC,
- Robert Weaver, MSc,
- Brenda Hemmelgarn, MD PhD,
- Alun Edwards, MD FRCPC and
- Braden Manns, MD MSc FRCPC
Abstract
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 A1c 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 A1c 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.
Gaps in evidence
Novel generalist-driven approach to setting the research agenda
- Lee Green, MD MPH,
- Nicole Olivier, RAHT MLAT,
- Michael Kolber, MD CCFP MSc,
- Christina Korownyk, MD CCFP,
- G. Michael Allan, MD CCFP,
- Sandee Foss, RN,
- Michele Hannay,
- Mark A. Watt, RN,
- Laurie Deboer, RN,
- Kylie Kidd Wagner, MSc,
- Barbra McCaffrey and
- Eileen Patterson, MCE PMP
Abstract
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.
Toward understanding chaperone use during intimate clinical examinations
Scoping review of the literature
- Sonya Lee, MD CCFP MHSc FCFP,
- Salim Ahmed, MSc and
- Tanvir Chowdhury Turin, PhD
Abstract
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.
Women’s experience of trauma-informed care in the context of family medicine chronic disease management
- Eva Purkey, MD MPH CCFP,
- Tracey Beckett, MSW RSW,
- Francoise Mathieu, MEd CCC RP and
- Rupa Patel, MD FCFP
Abstract
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.
Family physicians’ roles in caring for patients with end-stage heart failure
- Kori LaDonna, PhD,
- Laura Nimmon, PhD,
- Joshua Shad, MD CCFP,
- Gil Kimel, MD RCPSC and
- Joanna Bates, MD CM CCFP
Abstract
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.
Rapid realist reviews for interventions to improve access to primary health care for vulnerable populations
- Kevin Pottie, MD MClSc CCFP FCFP,
- Vivian Welch, PhD,
- Caroline Gaudet, MSc,
- Micere Thuku,
- Simone Dahrouge, PhD,
- Danielle Rolfe, PhD,
- Mélanie Ann Smithman, MSc,
- Shannon Spenceley, RN MN PhD and
- Ryan Mallard, MA
Abstract
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.
Are erectile dysfunction medications a gateway drug for men?
Pharmacoepidemiologic study
- Sean Skeldon, MD MSc,
- Lucy Cheng, MSc,
- Steven Morgan, PhD,
- Allan Detsky, MD PhD,
- Larry Goldenberg, MD and
- Michael Law, PhD
Abstract
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.
Alcohol consumption data in Manitoba primary care practices
- Alexander Singer, MB BAO BCh CCFP,
- Leanne Kosowan, MSc,
- Rasheda Rabanni, PhD,
- Michelle Greiver, MD CCFP FCFP and
- Sheryl Spithoff, MD CCFP
Abstract
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.
Routine tumour testing for Lynch syndrome
Exploring the role for primary care in precision medicine
- June C. Carroll, MD CCFP,
- Natalie Baker, MSc,
- Corinne Daly, MSc,
- Erin D. Kennedy, MD PhD FRCSC,
- Steven Gallinger, MD FRCSC MSc,
- Linda Rabeneck, MD MPH FRCPC,
- Jill Tinmouth, PhD MD and
- Nancy N. Baxter, MD PhD FRCSC
Abstract
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.
End-of-career practice patterns of primary care physicians in Ontario
- Sarah Simkin, MD CCFP,
- Simone Dahrouge, PhD and
- Ivy Bourgeault, PhD
Abstract
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.
Aging in rural communities
Exploring barriers and solutions to healthy aging in rural southern Alberta
- Cassandra Hoggard, MD CCFP(COE)
Abstract
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.
Addressing population-based and individual health care goals through a healthy aging group educational series
- Larkin Lamarche, PhD,
- Doug Oliver, MD CCFP MSc,
- Laura Cleghorn, MA,
- Lisa Dolovich, PharmD MSc,
- Michele MacDonald Werstuck, RD,
- Glenda Pauw, RD,
- Martha Bauer, OT,
- Laura Doyle, PT,
- Colleen McPhee, PT,
- Colleen O’Neill, OT,
- Dale Guenter, MD CCFP,
- Samantha Winemaker, MD and
- Joy White, RN
Abstract
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.
Résumés d’affiches
Prévalence et facteurs de risque de médicaments potentiellement inappropriés chez les 65 ans et plus
- Anne-Sophie Grenon, MD,
- Marjorie Panneton, MD,
- Sabrina Leclair, MD CCMF and
- Mathieu Pelletier, MD CCMF
Résumé
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 1er 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.
Advance care planning with homebound frail elderly
How many conversations does it take?
- Melody Monro, MPA,
- Margaret McGregor, MD CCFP(COE) MSc,
- Jay Slater, MD CCFP(COE),
- John Sloan, MD CCFP FCFP MSc,
- Johanna Trimble and
- Alexis Kezirian
Abstract
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.
Improving advance care planning in a primary care unit
- Ginah Kim, MD CCFP MSc,
- Renata Leong, MD CCFP,
- Irene Ying, MD CCFP(PC) MHSc and
- William Watson, MD CCFP
Abstract
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.
Experience of family physicians with patients who request assisted death
- Ellen Wiebe, MD CCFP FCFP,
- Sheila Holmes, MD,
- Amelia Nuhn, MD MSc,
- Judy Illes, PhD and
- Alanna Just
Abstract
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.
Conclusion The study explored the experience of family physicians who were involved in the care of patients who requested assisted death.
Implementation of an organizational intervention to promote equity-oriented care in primary health care settings
- Carol P. Herbert, MD CCFP FCFP LM,
- Annette Browne, PhD,
- Colleen Varcoe, PhD,
- Marilyn Ford-Gilboe, PhD and
- Nadine Wathen, PhD
Abstract
Context Enhancing primary health care (PHC) for marginalized populations is a key pathway to reducing health inequities. However, little is known about how to implement strategies to enhance capacity for equity-oriented services in complex health care settings, or about the potential effects on staff, organizational processes, and patient care.
Objective In this study, we highlight the effects of a complex organization-level intervention designed to enhance the equity orientation of PHC services.
Design We draw on findings from Canadian Institutes of Health Research–funded research conducted at 4 PHC clinics in Canada. We delivered a complex, equity-oriented intervention at each clinic and examined effects on staff, patients, and organizations using mixed methods.
Setting Four PHC clinics in Canada.
Participants Staff members completed a structured survey at 3 time points over 2.5 years. The survey was completed by 88 staff members at baseline, 82 at 12 months, and 57 at 24 months. In-depth qualitative interviews were conducted with 35 staff members in clinical, administrative, and leadership positions.
Intervention The EQUIP intervention was grounded in previous research that identified 4 key dimensions of equity-oriented PHC: cultural safety; trauma- and violence-informed care; contextual tailoring; and harm reduction. These elements were embedded in an intervention using 2 phased approaches: staff education; and organizational integration and tailoring.
Main outcome measures Staff members were asked open-ended questions about their experiences with the intervention and any perceived effects on their own practices or their organization. The staff survey explored knowledge, awareness, and confidence related to providing equity-oriented PHC.
Results Analysis of qualitative data revealed commonalities across sites in terms of processes and mechanisms of change, as well as perceived effects. These included disruptions to the status quo, prompting and facilitating difficult conversations at the organizational level, surfacing and identifying practices and processes that were not working, and providing language and structure to address existing challenges. The staff survey results showed an increase in staff confidence over time related to various aspects of providing equity-oriented care.
Conclusion The EQUIP intervention shows promise in terms of effects on staff. Ongoing analyses will examine effects on patients.
Feasibility of targeted poverty screening in a large primary care team
- Kimberly Wintemute, MD CCFP FCFP,
- Michelle Greiver, MD CCFP FCFP and
- Gary Bloch, MD CCFP FCFP
Abstract
Context In Ontario, poverty affects up to 20% of families (Bloch et al, 2013) and is one of the strongest factors influencing the health of individuals (Brcic, 2011). An evidence-based tool for poverty screening and intervention in primary care has been developed (Bloch et al, 2013; Centre For Effective Practice, 2015). It is central to current screening recommendations in Ontario (from the Ontario College of Family Physicians). However, it can be difficult to implement routinely, as family physicians often have limited time. In some patient populations, it might be worthwhile to screen in a targeted way.
Objective We seek to understand whether targeted screening for poverty is feasible across a large, interprofessional primary care team
Design We have done a 3-month pilot to screen patients living in postal code regions associated with the lowest income index scores and the highest material deprivation scores (based on publicly available data indices from Statistics Canada). Charts containing these postal codes were flagged in our electronic medical record, creating targeted identification of patients who might be at higher risk.
Setting The pilot was done in 4 physician practices that cared for 4000 patients.
Results Results showed that 157 charts were flagged; 49 patients were screened at office visits; 12 patients were referred; and 8 patients saw the team case worker for help accessing income supports.
Conclusion In 2016 to 2017, our University of Toronto practice-based research network will assist us in expanding this across our 80-physician family health team, which serves 78 000 patients. Over time, we will evaluate the sensitivity and specificity of the guideline-based screening question when used in conjunction with the Statistics Canada indices. Ultimately, we aim to evaluate the effect of our interventions on patient household income.
Health status and epidemiology of newly arrived Syrian refugees in Toronto, Ont
- Shivani Felicia Chandrakumar, MD CCFP,
- Leila Makhani, MD CCFP MB ChB MSc,
- Aisha Lofters, MD PhD CCFP and
- Ashna Bowry, MB ChB MSc DTMH CCFP
Abstract
Context Newly arriving immigrants and refugees often have health needs that differ from those of Canadian-born individuals. There is a scarcity of existing studies examining the health status among Syrian refugees and immigrants. For more than 4 years, the Syrian population has been displaced with varying access to health care. Furthermore, the Syrian refugee population is unique in that it is largely composed of children and adolescents, and most incoming refugees are being resettled from other host nations.
Objective To develop a protocol to study the health status and epidemiology of newly arrived Syrian refugees in Toronto, Ont.
Design A descriptive, retrospective chart review to examine key demographic characteristics, migration patterns, and initial health status of newly arrived Syrian refugees assessed during the initial medical intake clinics at St Michael’s Hospital Academic Family Medicine Health Team, 7 affiliated academic family health teams, and 24 community health centres.
Setting Toronto.
Participants All newly arrived Syrian refugees presenting to the intake clinics between December 29, 2015, and June 1, 2016, will be included in the study. Non-Syrian refugees or those without a documented specified country of origin will be excluded.
Intervention Data will be extracted from a health history form developed specifically for the Syrian refugee initial intake clinics; this form reflects screening practices and key health indicators that have been guided by the 2011 Evidence-based Clinical Guidelines for Immigrants and Refugees from the Canadian Collaboration for Immigrant and Refugee Health.
Main outcome measures The prevalence rates of communicable and non-communicable disease within a population of newly arrived Syrian refugees in Toronto presenting to St Michael’s Hospital Family Health Team initial intake clinics as well as affiliated academic and community health care centres.
Evaluation of the Saskatoon, Sask, refugee health clinic pilot program
- Yvonne Blonde, MD CCFP,
- James Dixon,
- Sunny Lee,
- Mahli Brindamour, MD,
- Anne Leis, PhD and
- Lori Hanson, PhD
Abstract
Context The Canadian government accepted 25 000 Syrian refugees into the country in response to an international crisis, with approximately 400 Syrian refugees arriving in Saskatoon, Sask, since January 2016. As a result of this larger-than-usual refugee influx, the Saskatoon Refugee Collaborative (community stakeholders) established a temporary centralized primary health care clinic in Saskatoon.
Objective To determine whether a dedicated clinic for local Syrian refugees successfully improved access to primary health care services in an evidence-based, culturally sensitive, and timely manner, including screening measures as preventive health care.
Design Pilot program evaluation.
Setting Saskatoon.
Participants Inclusion criteria to identify participants to provide data for the evaluation included willing individuals who were involved in the collaborative planning committee of the clinic; who worked in the clinic at any point during its pilot period; and who accessed services at the clinic. Approximately 50 individuals agreed to provide information for the evaluation.
Methods Data were collected via specially designed clinical encounter intake forms, vaccination databases, and laboratory test tracking where all identifiers of patients were removed to maintain confidentiality. Satisfaction surveys were filled out by single refugee family members at the end of each visit. No names or identifying information were included in these surveys. Post-clinic surveys and interviews were conducted with members of the collaborative and staff who wished to participate. Quantitative and qualitative data were collected to capture the extent of access to primary health care services, consistency with evidence-based guidelines, cultural sensitivity and awareness, and timeliness of services at and after the clinic.
Main findings Analysis of data is currently ongoing. Preliminary benchmark findings show that 400 Syrian refugees, both government-sponsored and privately sponsored, attended the clinic. Refugees accessed multidisciplinary services at the clinic in a timely manner and had health care follow-up in the community. Effective communication and collaboration were suggested as the keys to success.
Conclusion The preliminary data analysis suggests the refugee health clinic succeeded in improving access to immediate and ongoing primary health services for Syrian refugees in Saskatoon. A permanent refugee health clinic is needed to improve health care access and possibly health outcomes for all refugees in Saskatoon.
Substance abuse among immigrant youth
Review of literature
- Syed Walid Ahmed, MB BS,
- Salim Ahmed, MSc,
- Nahid Rumana, MB BS PhD and
- Tanvir Chowdhury Turin, MB BS PhD
Abstract
Context Substance abuse has became one of the biggest societal issues affecting youth. Immigrant youth seem to be more vulnerable to these issues when they move to a totally new country in the process of emigration. A comprehensive understanding of factors associated with substance abuse and the extent of the effects of substance abuse on these youth is required for effective policy making and program planning.
Design We systematically searched databases (MEDLINE, PubMed, CINAHL, SocINDEX, and PsycINFO) for studies using a comprehensive list of key words around the theme of substance abuse, youth, and immigrant. We limited our search to English-language publications.
Results We identified 458 articles after duplicate removal. After screening based on titles and abstracts, 40 articles were identified to be read in full. Full-text evaluation resulted in 26 articles for the synthesis. Immigrant youth with psychosocial problems and those with immigration stress, low socioeconomic status, and exposure to substance use through friends and social circumstances were more likely to engage in substance abuse. Communication gaps between immigrant parents and youth appeared to be the most important theme on substance abuse. Substance abuse led to psychological disorders, altered behavioural patterns, and negative heath effects.
Conclusion This study illustrates the factors reported to be associated with substance abuse among immigrant youth. It also highlights the effects of abuse on the social and health outcomes of the life of the youth. Substance abuse among immigrant youth is an important issue that needs to be addressed at the level of primary care with greater emphasis.
Barriers to breast cancer screening among immigrant populations
Scoping review
- Tanvir Chowdhury Turin, MB BS PhD,
- Mahzabin Ferdous, MB BS,
- Salim Ahmed, MSc and
- Nahid Rumana, MB BS PhD
Abstract
Context Breast cancer is the most common cancer among Canadian women. Although secondary prevention through screening might enable early detection and treatment, and thus can reduce breast cancer mortality, the rate of breast cancer screening among Canadian immigrant women is still very low.
Objective To summarize the current knowledge about barriers to breast cancer screening among immigrant and ethnic women and to identify barriers reported for screening and future research opportunities.
Design We have done a scoping review of the literature following the 5-stage framework proposed by Arksey and O’Malley (2005), which includes identification of the research question, identification of relevant studies, study selection, data charting, and synthesis. We searched published articles in MEDLINE, EMBASE, CINAHL, and PsycINFO and the gray literature in Google, Google Scholar, ProQuest, OpenDOAR, HSO, TRIP, the Canadian Institute For Health Information, the Public Health Agency of Canada, and Health Canada. After duplication removal, 1115 articles were identified for review. We selected 192 articles based on the titles and abstracts to be read in full. After the full-text reading, 33 articles were selected on cancer screening barriers. Fifteen of these articles on breast cancer screening were selected for synthesis in this study.
Results We categorized the barriers into 7 themes, including sociodemographic barriers, economic barriers, cultural barriers, communication barriers, health care system–related barriers, knowledge-related barriers, and individual-level barriers. Lack of education, lack of physicians’ recommendations, preference for female physicians, inability to speak one of the official languages, and embarrassment were some of the common barriers identified.
Conclusion Based on existing literature, this study demonstrated the barriers to accessing cancer screening among immigrants and ethnic minority groups. It can be used as a source of information for policy makers, health care providers, and researchers for deciding the future direction of research in this field.
Exploring new immigrants’ need for mental health services in Regina, Sask, to improve service delivery
- Clara Rocha Michaels, MD CCFP,
- Rejina Kamrul, MD CCFP and
- Mamata Panday, PhD
Abstract
Context Migration might be undertaken to find better political, social, economic, and health opportunities. However, adjustments to a new culture, the stress of relocating, loss of social networks and supports, and changes in gender roles can have a detrimental effect on the mental health and health in general of immigrants.
Objective To explore new immigrants’ concepts of mental health and the need for mental health services in Regina, Sask, such that appropriate services can be developed to address those needs.
Design Thematic analysis. The participants attended 4, 1-hour focus group sessions. A psychology resident facilitated the focus groups for men and a team consisting of family physicians, medical students, and a researcher facilitated the focus groups for women.
Setting Regina.
Participants Thirty-seven participants (28 women and 9 men) from 15 different countries.
Main findings A thematic analysis of the focus group data revealed that all participants were able to define physical, mental, and spiritual health and mentioned the effects of mental health on physical health. Male participants, who often immigrated alone to gain increased financial support for families in their country of origin, identified the lack of familial support as a source of distress. A variety of strategies, such as positive thinking, support from close family members, exercise, and spiritual help, were adopted by immigrant women to deal with everyday stress. Most male participants listed conversations with peers or a person of senior status in their community as the main source of coping. Only 1 male participant indicated that he has accessed mental health care through his primary care physician. None of the other male or female participants indicated the need for mental health services or had knowledge about where such services could be accessed in Regina.
Conclusion Irrespective of the country of origin, all participants have a holistic approach to health and emphasized the importance of mental health in maintaining overall health. Language abilities and lack of knowledge about mental health services were identified as the main challenges to accessing counseling or other mental health services.
Addressing social determinants of health
Is there a role for a clinical decision aid in an aboriginal context?
- Emily Corbould, MSc,
- Andrew Bond, MD CCFP,
- Rami Shoucri, MD CCFP,
- Carole Laforest, MD,
- Leslie Malloyweir, PhD,
- Rosie Khurana, MD CCFP,
- Jill Torrie, MA and
- Anne Andermann, MD CCFP DPhil FRCPC
Abstract
Context The CLEAR Toolkit is a clinical decision aid aimed at encouraging front-line health care workers to ask their patients about the social determinants of health, to refer these patients to local support resources, and to advocate for wider social change to improve health. Our study’s objective was to assess the feasibility of implementing this tool kit in an aboriginal context and to explore how to best adapt the tool kit to be culturally sensitive and to meet local needs.
Design A mixed-methods study including an online survey, in-depth interviews, and focus groups was used to obtain the views of a purposive sample of health workers and community members on the common social causes of poor health in their community, current approaches for addressing these issues in clinical practice, interest in using the tool kit, and ways of adapting it to the local Cree context.
Results Thirty-five front-line health care workers and community members participated in 24 individual in-depth interviews and 5 focus groups, and an additional 13 health workers completed the online questionnaire. Respondents considered that the tool kit would be helpful for initiating discussions around social challenges and better supporting patients in clinical practice. The tool kit was considered particularly appropriate for a Cree setting, as it encouraged a holistic approach to health and might help overcome challenges related to the high turnover of health care staff and their consequent lack of knowledge of local resources and practices.
Conclusion Owing to the highly intertwined nature of health and social challenges, a clinical decision aid can help health workers ask about the social determinants of health and provide concrete suggestions for supporting patients and guiding community-level action. Knowing how to approach issues in a sensitive way and mapping out existing community resources and referral pathways are important prerequisites for implementation.
CLEAR Toolkit advanced pilot study
Helping health workers address the social causes of poor health
- Tal Cantor, MScPH and
- Anne Anderman, MD CCFP DPhil FRCPC
Abstract
Objective To assess whether training family medicine residents to use a clinical decision aid (CLEAR Toolkit) to help them ask about and address the social determinants of health in clinical practice improves health and social outcomes for their patients.
Design We used a mixed-methods study design involving a pilot randomized controlled trial with nested in-depth interviews. First, a workshop with health workers and community organizations was used to create a version of the CLEAR Toolkit adapted to the local context. Then, first-year family medicine residents at a large university training program were recruited to join the study following a core teaching session and, of those who agreed, half were randomly selected to receive further training on how to use the clinical decision aid (intervention group) and the other half had no further training (control group). A brief questionnaire was administered with their patients to measure differences in health and social outcomes, as well as any potential unintended harms, related to using the decision aid in practice. In-depth interviews were also conducted with patients, health workers, and community organizations to further explore how health workers helped patients in overcoming various health and social challenges.
Results Most first-year family medicine residents regularly came into contact with vulnerable patients in their clinical practice. While the family medicine residents understood the importance of asking about the social determinants of health for their patients, few obtained a detailed social history owing to time constraints and feeling uncomfortable asking about sensitive social issues. Patients were more transparent and forthcoming regarding their social vulnerabilities during interactions with local community organizations where they often felt more comfortable sharing personal information.
Conclusion Health workers might understand the relevance of the social determinants of health at a cognitive level, but patients are unlikely to spontaneously raise these issues during a doctor’s visit. Therefore, health workers need to help their patients to feel more at ease in discussing their social challenges, to better understand their rights, and to navigate with greater ease through the health and social systems.
Evaluating the efficacy of Varsity Docs
Innovative after-school, medical student–run sports program for children in vulnerable urban neighbourhoods
- Jennifer Cape and
- Joyce Nyhof-Young, MSc PhD
Abstract
Context More than 30% of Canada’s youth are classified as overweight or obese and less than 10% meet new physical activity guidelines. With no community centre, children in the priority neighbourhood of Weston in Toronto, Ont, have few opportunities to engage in recreational sport activities and are particularly vulnerable to obesity. Varsity Docs, an after-school sports program run by University of Toronto medical students and varsity athletes, aims to increase children’s sports access in low-income neighbourhoods and facilitate healthy childhood development.
Objective This study implemented and evaluated the Varsity Docs pilot project at H.J. Alexander Community School (kindergarten to grade 5) in Weston.
Design Program evaluation of a 9-week intervention with 5 medical student volunteer leads per session.
Participants Eighteen grade 5 students at H.J. Alexander and 26 medical students.
Intervention The inaugural program (6:00 to 7:30 PM, February to March 2015) ran on Tuesday evenings and offered instruction in a variety of recreational sports.
Main outcome measures Program feasibility, acceptability, and efficacy were evaluated via observation, volunteer and parent surveys, and a 10-minute student focus group.
Main findings Twenty-six out of 31 volunteers and 6 parents completed surveys. Fifteen of 18 grade 5 students participated in the focus group. The program ran successfully as intended and was well accepted by volunteers (7.6 out of 10), students, and parents (7.1 out of 10). All 15 grade 5 students thought they would sign up for the program again and many requested an increase in frequency and duration.
Conclusion The program was well received by volunteers, students, parents, and the school. Medical students appreciated having opportunities to participate in social advocacy and engage with the community. Volunteer feedback is shaping 2016 to 2017 programs. Volunteers requested session outlines and a program handbook. To accommodate medical student schedules, sessions now run on Wednesdays. Developing funding for volunteer transportation remains a priority. Volunteer recruitment began earlier in 2016 to avoid scheduling conflicts. Achievement of funded University of Toronto Medical Society student club status ensures program sustainability. Varsity Docs has expanded to include a Weston hotel temporarily housing many Syrian refugee families; more than 40 children participate weekly there, and ongoing volunteer recruitment (especially of Arabic speakers) aims to increase capacity.
Integrative review and analysis of psychometric properties of patient satisfaction tools aimed at primary care
- Frédéric Douville, RN PhD and
- Jean-Sébastien Renaud, PhD
Abstract
Context The quality of health care in clinical settings has a considerable effect on patients’ security, quality of life, and mortality. Quality of care is known to be positively correlated with patient satisfaction in clinical settings. Several assessment tools for patient satisfaction have been developed, often as patient self-administered questionnaires; however, no review of these tools aimed specifically at primary care could be found to help identify those with the best psychometric properties.
Objective To perform an integrative review of patient satisfaction assessment tools aimed at primary care and to document their psychometric properties.
Design CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and ABI/INFORM databases were searched for papers published in French or English from 1996 to 2016. Studies were considered if they met the following criteria: use of a patient satisfaction tool; evidence that this tool underwent psychometric assessment; and patient satisfaction tools used in primary care settings. The study data were extracted according to the Consensus-based Standards for the Selection of Health Measurement Instruments.
Results More than 8000 potentially relevant citations were identified, of which 36 met the inclusion criteria. From these studies, 26 different tools were identified. Most patient satisfaction tools were valid and reliable. Only 8 of them were developed explicitly for primary care, among which 2 were specifically aimed at general practice in the United Kingdom, but none was intended to assess family practice in Canada.
Conclusion This review identified 8 validated tools assessing patient satisfaction. Primary care researchers, hospital administrators, and accreditation bodies might wish to use these study results to choose the tool that is most applicable to their needs, based on content and psychometric properties. Further work should aim at modifying some of the tools to be more specific to family practice in Canada.
Patients’ perspectives of block fees
Qualitative analysis
- Eva Knifed, MD CCFP MHSc,
- Nicholas Howell, MSc and
- Danielle Martin, MD CCFP FCFP MPP
Abstract
Context Block fees are a way for physicians to charge for uninsured services. Proponents believe they are convenient, while opponents worry they might pose a barrier to equitable access to care. To date, no formal evaluation of patients’ views on block fees has appeared in the published literature.
Objective To estimate the prevalence of block fee–related complaints to the College of Physicians and Surgeons of Ontario (CPSO) and to determine patients’ perspectives on block fees.
Design A 2-part descriptive qualitative study: the Public and Physician Advisory Services database of the CPSO was searched for entries on block fees and uninsured services between October 2009 and October 2013 and Ontario residents who had experience with block fees were selected at random to be interviewed to assess their views of block fees. Descriptive thematic analysis was done with both phases.
Setting Ontario.
Participants Ontario residents aged 18 or older who spoke English and had been asked to pay a block fee by a physician.
Main findings A total of 835 were flagged by the CPSO as being related to block fees. Of these, 63 were related to complaints about block fees, with the majority (n = 23) expressing concern about not being able to opt out of paying. In the second phase, 24 interviews were conducted. Ontario residents were concerned about potential socioeconomic factors that might result in block fees being a barrier to accessing care for some. Many thought all services should be insured. Those who thought block fees were ethical believed that physicians should be compensated for services rendered. Most reported that the block fees were optional and their decision to pay or not pay did not affect their relationships with their doctors.
Conclusion While the absolute number of complaints is low, some Ontarians believed that block fees were mandatory. Patients’ ethical and socioeconomic concerns are important to consider in block fee policy and communication. Future work should estimate the prevalence and costs of block fees, and compliance with CPSO policy, to provide additional context.
My patients can’t afford their meds
Canadian primary care physicians’ perspectives on prescription drug affordability
- Eileen Ten Cate, MD,
- Emilie Boucher, MD,
- Babak Aliarzadeh, MD MPH,
- Eric Mang, MPA,
- Steven G. Morgan, PhD,
- Chris Simpson, MD FRCPC FACC FHRS,
- Emmanuelle Britton, MD CM CCFP and
- Danielle Martin, MD CCFP FCFP MPP
Abstract
Objective To better understand the human effects of medication unaffordability in Canada.
Design This is a mixed-methods study that incorporates both an online survey and semistructured interviews.
Setting Canada.
Participants Family physicians in active practice who were members of the College of Family Physicians of Canada in 2015.
Instrument A link to an online survey was distributed via the College of Family Physicians of Canada’s e-newsletter. Respondents were invited to participate in follow-up interviews.
Results and findings There were 139 physicians who completed the survey. Of those who responded to the survey, 10 participated in the interview. Sixty percent of family physicians are noticing the effects of cost-related nonadherence on patient health and on the health care system on at least a weekly basis. Family physicians are engaging in suboptimal “workarounds” to try to obtain access to medicine for their patients, such as giving out free samples (90.5%) and modifying medication choice, dosage, or regimen (82.8%). From the thematic analysis, 3 themes became evident: the current system of drug coverage in Canada is unfair; the current system causes harm to the health of patients and creates avoidable downstream use of more intensive resources; and physicians react to the unaffordability problem by creating suboptimal workarounds to try to get access to medicines for their patients.
Conclusion The absence of universal coverage for medically necessary prescription drugs is palpable in primary care in Canada. Physicians feel the current system is unfair and they observe health and system effects of that inequality. They try to mitigate harm to their patients by engaging in suboptimal activities. Stories along these themes emerge from every region of the country. Cost-related medication nonadherence in Canada has a human face.
Using clinical encounter information from an EMR as a source of needs assessment for CPD
- Pamela Snow, MD CCFP FCFP and
- Marshall Godwin, MD CCFP FCFP
Abstract
Context The Virginia Study, led by Dr Maurice Wood in the1970s, studied the content and composition of family practice. Apart from work in the Netherlands, little has since been published on the content of family practice. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) allows access to rich patient and provider data for approximately 1 million Canadians. These electronic medical record (EMR) data might be a useful resource for needs assessment in continuing professional development (CPD) planning.
Objective To assess the use of the CPCSSN database in terms of encounter diagnosis type and frequency; how best to categorize the scope of ICD-9 codes entered in the database; medical provider demographic characteristics by sex and age; and the applicability, benefits, and challenges of using the data for needs assessment and CPD planning.
Design Access to the CPCSSN database was applied for and granted. Ethics approval was obtained. Encounter data were extracted for the year 2014. A total of 463 393 patient encounters with 418 family physicians were assessed. All ICD-9 codes were assessed individually and by diagnostic groupings. The data were analyzed (using SPSS) for frequencies, percentages, and cumulative percentages of encounter diagnoses, and for patient and provider demographic characteristics.
Results The EMR data suggest that 25% of the reasons for patient encounters with family physicians involve either undifferentiated symptoms and signs, or reasons related to general health care, counseling, prevention, and screening. Another 25% are related to mental disorders (overwhelmingly depression and anxiety), cardiovascular disease (overwhelmingly hypertension), and musculoskeletal conditions. This profile of what is happening in the practices of Canadian family physicians should be considered when planning CPD. Further, EMR diagnostic coding might be an unperceived learning need for family physicians.
Importance of data cleaning when reporting aggregated statistics from electronic medical record systems data
- David Parker,
- Julia Langton, PhD,
- FeiFei Wang and
- Sabrina T. Wong, RN PhD
Abstract
Context The percentage of Canadian primary care clinicians using electronic medical records (EMRs) continues to rise (approximately 75%), yet differences in coding practices and the format of data entered by users are problematic and can reduce the utility of these data for secondary use, such as research and evaluation of primary care services. To improve the use of EMR data for research and evaluation, the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) extracts data from 11 different EMRs, then anonymizes and standardizes data elements. As such, CPCSSN is a pan-Canadian EMR data repository that is used to produce new knowledge about the quality and delivery of primary care.
Objective To demonstrate the value of standardization on extracted EMR data when reporting on aggregated statistics by comparing 2 variables (patient smoking status and laboratory results of hemoglobin [Hb] A1c tests) before and after the application of standardization protocols.
Design Descriptive study comparing patient variables in EMR data before and after standardization protocols are applied. An aggregated report will be created for patient smoking status and total number of HbA1c laboratory results by physician. The data will then be standardized using the CPCSSN algorithms and the reports recreated on the now-standardized data. The data before and after standardization will then be compared for accuracy, consistency, content, and face validity.
Participants British Columbia CPCSSN receives data on approximately 50 000 patients from 37 family physicians.
Main outcome measures Smoking status and HbA1c results before and after standardization.
Results Before the standardization protocols, both smoking status and the HbA1c naming convention are inconsistent, ranging from 30% to 50% of the time. Using EMR data that have not been processed using standardization algorithms might not produce reliable or valid information. Once developed, these algorithms can be applied across CPCSSN to enable cross-provincial comparisons of important measures related to primary care. Moreover, these data can then be used in more complex algorithms such as medical complexity and frailty, which could be of great interest to primary care physicians.
Responding to the health needs of the population
Striking a balance between generalists and specialists
- Nick Busing, MD CCFP FCFP FCAHS and
- Justin Joschko, MA
Abstract
Context The ratio of FPs and GPs to other specialists varies dramatically worldwide. This ratio has important effects on the health of a population.
Objective To understand the factors that influence the ratio of FPs and GPs to other specialists in Canada.
Design A mixed-methods approach with semistructured interviews.
Participants Thirteen individuals with expertise in health human resources and medical education were identified through snowball sampling until data saturation was reached.
Intervention Quantitative data were collected to outline current and past trends regarding the numbers of FPs and GPs and other specialists in Canada. Additionally, data outlining the numbers of medical students and residents completing postgraduate training were gathered. Interviews were conducted by a research assistant using a standardized set of questions. Information was gathered on current and past trends contributing to the ratio of FPs and GPs to other specialists, including information looking at medical education and other factors that might influence the ratio. A thematic analysis of the interviews was done using a constant comparison approach. All interviews were coded, themes were identified, and a report was synthesized.
Main findings Factors that have influenced the ratio of FPs and GPs to other specialists in Canada include government policy, medical education (including the role of family medicine in teaching and the development of distributed campuses), the role of the College of Family Physicians of Canada, and a historical perspective that a 50:50 ratio has served us well.
Conclusion Canada has a healthy balance between FPs and GPs and other specialists but has to be attentive to the factors that can help maintain this ratio.
Project facilitation in primary care
- Frank Sullivan, MD FRSE FRCP FRCGP CCFP,
- Ivanka Pribramska, PhD,
- Rabiya Siddiqui and
- Saddaf Syed, OCT PGCE
Abstract
Context Recruitment to research projects in family medicine often fails. The University of Toronto Practice-Based Research Network (UTOPIAN) offers tools and support for primary care research, including practice facilitators. Practice facilitators enable researchers, primary care clinicians, and practices to answer important health care questions and translate findings into practice.
Objective To determine whether providing direct support for research through engaging project facilitators increases the number of research projects and number of primary care professionals involved in projects within UTOPIAN.
Design Qualitative analysis of documentation and feedback from network members and researchers.
Participants Since 2012, UTOPIAN has been involved in more than 25 primary care research projects spread over 14 family medicine teaching sites and included approximately 1400 faculty members; UTOPIAN has 2 practice facilitators available to engage in research projects.
Intervention Many primary care practices do not have adequate resources, skills, or knowledge to undertake essential research activity in their practices. Practice facilitators provide a range of supportive services in order to improve the quality of care delivered, patients’ experiences with care, and patient outcomes. This support focuses on building organizational research capacity for continuous improvement within the practice and typically includes assisting with research ethics board applications, recruiting for studies on both family practice and patient levels, and conducting electronic medical record searches for or on behalf of the project team.
Main outcome measures Factors that enable practice participation in research.
Main findings Providing research support to family practices, by a process of facilitation, increases the number of research projects within the network, research project success, and willingness of practices to take part in primary care research. Support is particularly suitable for pilot and feasibility studies, as these provide robust evidence for grant applications.
Conclusion Practice facilitation has allowed busy clinicians and researchers to execute research projects, recruit specific sites and clinics, recruit patient populations, and establish realistic, workable processes to ensure the success of their studies. One main benefit to involving UTOPIAN practice facilitators is leveraging existing relationships between practices, hospitals, research ethics boards, and UTOPIAN to inform and generate participation among all parties involved, and to improve patient care.
Scope of practice of family medicine graduates who completed rural versus urban residency programs, by practice location
- Doug Myhre, MD CCFP,
- Olga Szafran, MHSA,
- Shirley Schipper, MD CCFP,
- James Dickinson, MB BS CCFP PhD and
- Fred Janke, MD CCFP
Abstract
Context Do site of residency training (rural vs urban program) and practice location influence scope of family practice?
Objective To compare the practice patterns of Alberta family medicine graduates who completed the urban versus rural residency program, by practice location.
Design Cross-sectional, mailed questionnaire.
Participants A total of 651 graduates who completed family medicine residency training at the University of Calgary or University of Alberta during 2006 to 2011.
Main outcome measures Nineteen domains of care in 4 categories (types of care, clinical procedures, practice settings, and specific populations) were rated on a 5-point scale ranging from 1 (not part of practice) to 5 (element of core practice). Mean rating scores were compared between rural and urban program graduates by practice location.
Results Responses were received from 307 graduates (47%), of whom 173 obtained a residency position via the urban and 59 via the rural program. Mean scores for rural program graduates were higher (P < .05) than for urban program graduates for postnatal care, intrapartum care and deliveries, palliative care, office-based procedures, in-hospital procedures, emergency department care, in-hospital care, home care, work in long-term care facilities, and caring for rural or aboriginal populations. Mean scores for rural program graduates in rural practice were significantly higher than for urban program graduates in rural locations for 5 domains of care. Rural program graduates in urban practice had higher mean scores for intrapartum care and deliveries than urban program graduates in urban practice locations did.
Conclusion Alberta family medicine graduates who completed a rural residency program tended to have a broader scope of practice than urban program graduates did, regardless of practice location.
Encouraging careers in family medicine
Regionally distributed medical education in British Columbia
- David Snadden, MB ChB MClSc MD CCFP FRCGP,
- Chris Lovato, PhD,
- Helen Hsu, MSc,
- Angela Towle, PhD,
- Oscar Casiro, MD FRCPC and
- Joanna Bates, MD CM CCFP FCFP
Abstract
Context In 2004 the University of British Columbia implemented a provincial model of regionally distributed undergraduate medical education.
Objective To determine the effect of the University of British Columbia’s distributed model on career choice and location of practice.
Design and participants We studied a cohort of students admitted between 2000 and 2007. Logistic regression was used to compare the results of the predistribution (2000 to 2003) and postdistribution (2004 to 2007) approaches using 2 outcomes: likelihoods of selecting family and rural practice. The relationship between program sites after distribution was also examined for the same outcomes. We adjusted for sex and age in the models. Students still in training were excluded.
Intervention Students spent their first semester in Vancouver; 32 students then relocated to Prince George or Victoria regional sites. Prince George has a mandate to encourage students to consider rural medicine and includes a supplementary admissions process that evaluates rural suitability.
Main outcome measures Data on practice specialty (family medicine, other specialties) and practice location (rural, urban) were extracted from the Canadian Medical Directory and other administrative data sources.
Results Of students entering medical school between 2000 and 2007, 70% (n = 985) were practising when data were retrieved. Half (50%) were family physicians and 77 (8%) were in rural practice. Students from the postdistribution period were more likely to practise family medicine (odds ratio [OR] = 2.21, 95% CI 1.70 to 2.87), compared with those from the predistribution period (59% vs 39%). After distribution, students who attended Prince George were more likely to practise family medicine (OR = 2.08, 95% CI 1.14 to 3.80) compared with Vancouver students (77% vs 55%), and female students (OR = 1.96, 95% CI 1.50 to 2.54) had higher odds of practising family medicine. For rural practice, there was no difference before and after distribution. However, Victoria students were more likely to be in rural practice (OR = 3.24, 95% CI, 1.33 to 7.89) than Vancouver students were (13% vs 4%), as were Prince George students (OR = 8.90, 95% CI 3.95 to 17.41; 30% vs 4%).
Conclusion Implementation of a distributed regional model is associated with more trainees choosing family medicine. Students in the Prince George site were more likely to choose family practice. Students from both sites outside Vancouver were more likely to choose rural practice. These early findings suggest that the context of training can influence both career choice and rural interest.
Perceptions and experiences of family medicine residents regarding prenatal screening and related ethical issues
- Adeela Arooj, MB BS MHSc and
- Saadia Hameed, MB BS CCFP
Abstract
Objective To explore the experiences and perceptions of family medicine residents around ethical challenges related to prenatal screening among different Canadian religious and cultural groups.
Design Qualitative study using in-depth interviews.
Setting Western University in London, Ont.
Participants Nine family medicine residents from postgraduate years 1, 2, and 3 at St Joseph Family Medicine Centre London; 7 of the participants were female and 2 were male.
Methods Using a qualitative approach, in-depth interviews were conducted. Perceptions and experiences with respect to several aspects of prenatal screening were examined. Study data were audiorecorded and transcribed verbatim. Independent and team analyses were performed in an iterative and interpretive manner.
Main findings The study findings revealed 2 prominent themes that had an effect on the knowledge and perceptions of family medicine residents at the university: physician factors and patients factors. Physician factors included general understanding around prenatal screening tests, confidence in counseling patients, moral distress, communication challenges, sex of physicians, patient-physician relationships, and need for more training. Patient factors included age, invasiveness of tests, socioeconomic status and educational level of the patient, cultural background, religious background, and nonjudgmental approach of counseling. Moreover, participants showed a keen interest in further learning different aspects of prenatal screening.
Conclusion Despite describing poor confidence, gaps in knowledge, and having challenges during counseling, the participants identified positive experiences around prenatal screening counseling and were well aware of having a strong patient-physician relationship by offering open discussion. Supporting these new learners and educating them on this sensitive topic will encourage family medicine residents to improve their confidence by increasing their competency in counseling patients and appropriately following patients with positive prenatal screening results in their practices.
Improving family medicine residents’ knowledge of deprescribing in the elderly
- Lesley Leung, MD,
- Jennifer Jayakar, MD,
- Deanna Telner, MD CCFP and
- Christopher Frank, MD CCFP
Abstract
Context Caring for elderly patients is often complicated by polypharmacy. Deprescribing is the process of titration or weaning and discontinuation of potentially inappropriate medications. However, barriers to deprescribing such as a lack of education prevent this process from occurring in daily practice.
Objective To determine whether an electronic module is an effective tool to increase knowledge and confidence in deprescribing and decrease perceived barriers to deprescribing.
Design Survey before and after completing an electronic module.
Setting Michael Garron Hospital in Toronto, Ont.
Participants All family medicine residents at the Michael Garron Hospital were invited to participate; 26 of 37 residents agreed to participate.
Intervention Subjects participated in an anonymous survey and electronic module that presented principles of deprescribing. Multiple-choice questions based on the content were presented before and after the module to assess a change in score. Subjects were also asked to qualify their experiences using Likert scales.
Main outcome measures The primary outcome of this study was to determine whether there was an increase in test scores after subjects worked through the electronic module. Secondary outcomes assessed subjects’ confidence in deprescribing, their perceived barriers before and after the module, and their likelihood of using the Beers criteria in the future. Statistical analysis was performed using SPSS.
Results The mean increase in scores after the module was 12% (5.2% to 18.9%, P = 0.001). Of those who did not have confidence in deprescribing, 93% versus 7% endorsed an increase in confidence after the module (P = .012). Fewer residents cited “fear of harming the patient” (22 vs 14, P = .021) and “medication started by a specialist” (25 vs 14, P = .003) as barriers to deprescribing after the module, and 100% of subjects stated they would use the Beers criteria in the future (P < .001).
Conclusion The module might be an effective tool to teach deprescribing in residency and to decrease barriers to practising this in a clinical setting. The effects on deprescribing practices after the module were not studied in this project but merit further study.
Environmental health attitudes, knowledge, and learning needs of family medicine residents
Multiprogram survey
- Mehvish Mehrani, MD CCFP,
- Margaret Sanborn, MD CCFP,
- Lawrence Grierson, PhD,
- Ross Upshur, MD CCFP FRCPC,
- Cathy Vakil, MD CCFP,
- Lynn Marshall, MD FAAEM,
- Fran Scott, MD CCFP FRCPC,
- Lauren Griffith, PhD and
- Donald Cole, MD FRCPC
Abstract
Context Research has shown that family physicians feel unprepared to diagnose and manage illness resulting from environmental exposures. No previous studies have similarly examined residents.
Objective To assess environmental health attitudes, knowledge, and learning needs among family medicine residents.
Design A questionnaire was developed using the Delphi method with 19 consultants: physician and nonphysician experts in environmental health and family medicine program directors. Questions derived from the literature or suggested by these experts were rated in 2 iterations, with more than 74% rater approval of the final questionnaire.
Participants After obtaining ethics approvals, the Web-based survey was administered from November 2015 to January 2016 to 887 family medicine residents at 4 Ontario medical schools; 203 family medicine residents responded, resulting in 181 usable data sets.
Main outcome measures Ninety-three items measured attitudes, knowledge, learning needs, and clinical practices regarding environmental health.
Results No significant (P < .05) differences were observed between programs in any environmental health components of the survey, and no differences in knowledge and skill levels were found between residents in first year versus those in senior years. Overall, 58% of residents were negative or neutral in their satisfaction ratings of current training in environmental health. Most family medicine residents (92%) were highly concerned about the health effects of environmental exposures but only 32% had specific training to take environmental exposure histories, and 48% believed these took too much time in office practice. Mold exposure from flooding was recognized as a climate change health effect by 55% and asthma from ground-level ozone by 34%. Residents felt most unprepared for the advocate and expert roles. Only 11% of residents believed their supervisors had a good understanding of environmental exposures.
Conclusion Family medicine residents reported the importance of assessing environmental exposures but identified a lack of knowledge, specific skill training, and mentorship to learn these skills. Our results should be useful to family medicine residency programs wanting to address perceived training gaps in environmental health.
Assessing exposure to and education on abortion during training and future intention to provide abortion among Canadian family medicine residents
- Daniel Myran, MD,
- Jillian Bardsley, MD and
- Kristine Whitehead, MD CCFP
Abstract
Context The number of abortion providers in North America is in decline. Evidence shows that the decline in providers is particularly pronounced in rural settings. The amount of education that medical trainees receive on abortion, in addition to their intention to provide abortion, are the 2 strongest predictors of future provision. Anecdotal data suggest that family medicine residents receive little or no education on abortion provision during their training in residency.
Objective To determine the quantity and type of education, in addition to the exposure that family medicine residents receive, on abortion during their training and whether this exposure and education are elective. Secondary objectives were to determine the intentions of family medicine residents to provide abortion during their future practice and the relationship between intention and attitudes, social norms, and logistical barriers. A tertiary objective was to determine the knowledge of family medicine residents on abortion provision.
Design A 21-item survey based on a well-validated social psychology theory for the prediction of future behaviour, the Theory of Reasoned Action and Planned Behavior, was created in conjunction with content experts in the field of medical education and women’s health. The survey was piloted with 5 family medicine residents, and areas of uncertainty were clarified. The survey will be administered online over a 1-month period.
Participants First- and second-year family medicine residents at English-speaking universities in Canada. A convenience sample of schools with inter-university research ethics board agreements with the University of Ottawa in Ontario will be used. Approximately 2060 participants will be eligible.
Main outcome measures Number of hours of medical education receiving during residency on abortion; nature of educational exposure (opt-in vs opt-out); attitudes, perceived social norms, perceived difficulty of training in and providing abortion, and intention to provide abortion; and percentage of knowledge-testing multiple-choice questions answered correctly.
Results The survey is currently being administered. Linear regression will be used to determine the effects of attitudes, perceived social norms, and perceived behavioural control on intentions; t tests will be used to determine the effects of educational exposure on intention to provide abortion.
Exercise medicine in residency
Are we preparing future family physicians to prescribe exercise as medicine?
- Kara Solmundson, MD CCFP(SEM) CASEM SportMedDip,
- Michael Koehle, MD PhD and
- Don McKenzie, MD PhD
Abstract
Context Physical activity is an important intervention in the prevention and treatment of chronic disease, yet few physicians prescribe exercise. Exercise medicine has traditionally been marginally represented in medical school and residency training programs. With the growing epidemic of chronic disease, the integral role primary care physicians can play by discussing physical activity and providing exercise prescription to patients has been widely recognized and acknowledged as critical.
Objective To assess residents’ knowledge, skills, and competence in exercise prescription and their perspectives on training received in exercise medicine.
Design Cross-sectional survey.
Setting University of British Columbia in Vancouver.
Participants All 396 family medicine residents registered at the University of British Columbia (graduating classes 2013 to 2015) were eligible to complete the 49-item survey.
Main outcome measures All variables were evaluated on a 7-point Likert scale. Data were analyzed using continuous and bivariate analysis, with statistical significance set conservatively at P = .01.
Results The response rate was 80.6% (319 of 396). Fifty-two percent of residents correctly identified the physical activity guideline for adults, 21.8% for children, and 29% for older adults. Residents recorded a low overall knowledge score of 44.3% (95% CI 41.3% to 47.3%) and there was no difference between the knowledge scores of residents at different stages of training. Residents reported greater competence prescribing exercise to healthy patients compared with patients with chronic disease: 57.5% (95% CI 55.0% to 60.0%) versus 45.9% (95% CI 43.3% to 48.4%); P < .001. There was a small but significant (P = .001) increase in residents’ perceived exercise prescription competence between residents at the beginning, midway through, and at completion of training of 46.8% (95% CI 42.8 to 50.8%), 51.9% (95% CI 48.3% to 55.4%), and 57.5% (95% CI 53.6% to 61.4%), respectively, with an overall resident competence of 51.6% (95% CI 49.3% to 53.9%). There was, however, no difference in competence in any of the 6 individual exercise prescription skills assessed between residents at different stages of training. Overall, only 18.6% of residents felt they received adequate training in exercise medicine and 91% desired additional training in exercise prescription.
Conclusion Current medical training is not providing physicians with the adequate knowledge, skills, and competence to provide patient-centred exercise counseling and exercise prescription. In the context of the chronic disease epidemic, this underscores the need for enhanced curriculum development in exercise medicine.
Novel approach to documenting assessed maternal and newborn care competence
- Gary Viner, MD MEd CCFP FCFP,
- Kristine Whitehead, MD CCFP,
- Douglas Archibald, PhD,
- Eric Wooltorton, MD CCFP MSc and
- Alison Eyre, MD CM CCFP
Abstract
Context Our department developed a series of 11 expected antenatal plus postpartum competencies (APPCs) and 10 intrapartum competencies (IPCs) in family medicine obstetrics (FMOB). These were included on specialized field notes (FMOBFNs) to be completed by supervisors for our trainees and performance categorized based on the standard of a graduating resident: not applicable, does not do this, is starting to do this, or does this. They were implemented in widespread fashion on our electronic field note system (eFNS) in June 2014. In November 2014, we set explicit expectations regarding the number of FMOBFNs required and guidelines as to when competencies should be attained over the residency.
Objective To review reported competency for all 21 FMOB items using the data in the eFNS database.
Design We retrospectively analyzed the FMOB data contained in the eFNS over the academic years 2013 to 2014 and 2014 to 2015.
Setting University of Ottawa in Ontario.
Participants At total of 53 second-year residents and 31 new graduates in the 2014 to 2015 year.
Main outcome measures Department of Family Medicine expectations stipulated that all residents would have a minimum of 12 FMOBFNs and would have 73% of APPCs and 80% of IPCs rated as “does this” by the end of the second year of residency.
Results For the 53 second-year residents, the average number of FMOBFNs was 9.1 (0 to 26), the greatest proportion being intrapartum. The average number of FMOBFNs per resident was unpredictable based on site of training. Twenty-seven residents attained the expectation of 73% of APPCs (average attainment was 53%). Thirty-four attained the IPC expectation of 80% (average attainment was 65%). To compare, the 31 new graduates had an average of 4 FMOBFNs (0 to 11), and only 1 attained the 80% IPC expectation (average attainment was 20%).
Discussion It was the first year of explicit, formalized expectations and the improvement in documentation of FMOB competencies is gratifying. As it appeared to be independent of teaching environment, the improvement is attributed to resident initiative. The “does this” performance assessment does not guarantee competence, as it is still a subjective contextual assessment, perhaps by a single supervisor.
Conclusion Having introduced a clear policy and electronic process to gather information on performance, our department has driven residents to focus attention on acquiring FMOB skills and demonstrate competence.
Canadian national survey on point-of-care ultrasound training in family medicine residency programs
- Shuo Peng, MD CM,
- David Braganza, MD CM,
- Taft Micks, MD,
- Pamela Doran, MSc,
- Patti McCarthy, MSc,
- Kyle Sue, MD CCFP MHM,
- Jeffrey Hall, MD,
- Harland Holman, MD,
- Danielle O’Keefe, MD CCFP,
- Peter Steinmetz, MD CCFP and
- Peter Rogers, MD CCFP(EM)
Abstract
Context Point-of-care ultrasound (POCUS) has undergone rapid expansion of its application in the past decade. Although many advocate for its increased use in primary care, current perceptions and prevalence of ultrasound training in family medicine residency programs have not been established.
Objective In our study we aimed to assess the current status of POCUS training in Canadian family medicine residency programs.
Design We carried out a cross-sectional survey evaluation of ultrasound education in accredited Canadian family medicine residency programs. The Web-based anonymous survey consisted of 27 multiple-choice questions and was scheduled to be completed over a period of 4 months in 2016. Our data were collected using Fluid Surveys and entered into an electronic database using Microsoft Excel.
Participants The 17 accredited Canadian family medicine residency programs represented by their program director or their proxy. Only 1 completed survey was to be accepted per residency program.
Main outcome measures Using aggregated data, gap analysis and descriptive statistics were reported.
Results At the time of writing, 70% of program directors had completed the study. Only 16.7% of respondents reported an established ultrasound curriculum and 41.6% are in the process of establishing core ultrasound training. In contrast, 90% believed that POCUS teaching should be integrated into family medicine residency. Barriers to establishing training included lack of adequate equipment (58.3%), lack of instructors (58.3%), lack of available time in the curriculum (50%), and lack of funding available to support training (58.3%). Most (66.7%) respondents believe that POCUS can be used in family medicine to alter clinical decision making. Leading potential benefits associated with POCUS use in primary care included rapid diagnosis (83.3%), useful adjunct to physical examination (91.6%), and potential to reduce health care costs (66.7%).
Conclusion Although few Canadian family medicine residency programs reported an established ultrasound curriculum, most program directors believe that POCUS training should be offered to trainees and that ultrasound use can positively affect primary care practice. A growing number of residency programs are considering incorporating ultrasound training, but resource availability remains a main barrier to implementation.
Revisiting the Impact of Cultural Differences on Residency Experiences (ICDRE) survey
- Douglas Archibald, PhD,
- Dorota Szczepanik, MD CCFP,
- Alison Eyre, MD CM CCFP and
- Kirsten Desjardins-Lorimer
Abstract
Context The growing number of international medical graduates (IMGs) arriving from medical schools abroad to undergo residency and begin clinical practice in Canada has increased the diversity of cultural influences, beliefs, and opinions about medical practice. With this comes the perceived risk by educators of cultural discordance with regard to communication, collaboration, and professionalism in IMGs, for whom these spheres might differ from the culture of Canadian medicine.
Objective The goal of the Impact of Cultural Differences on Residency Experiences (ICDRE) survey is to identify significant differences in underlying assumptions regarding communication, collaboration, and professionalism among both IMGs and Canadian medical graduates (CMGs) and to determine whether significant differences occur between the 2 groups.
Design Survey research program evaluation.
Setting University of Ottawa in Ontario.
Participants Faculty and residents across the Faculty of Medicine.
Main outcome measures The ICDRE survey comprises 48 items assessed on a Likert-type scale that measures self-reported perceptions of a residency experience with regard to the concepts of sense of hierarchy, individualism and teamwork, and risk tolerance.
Results In 2015, the ICDRE was completed by 86 residents and 14 faculty in 30 different specialties at the University of Ottawa. Seven items on the survey yielded significant differences between CMGs and IMGs (α = .05).
Conclusion The ICDRE survey identifies differences in underlying influences between CMGs and IMGs that might lead to perceived problems with professionalism, collaboration, and communication among IMGs.
Feedback on feedback
Innovative addition to electronic workplace-based daily assessment forms
- Jane Griffiths, MD CCFP FCFP,
- Nancy Dalgarno, MEd PhD and
- Karen Schultz, MD CCFP FCFP
Abstract
Context Assessment in competency-based medical education is designed to support resident learning and competency decisions. Direct observation and formative feedback are foundational in competency-based medical education and are used in daily, low-stakes, workplace-based assessment. Preceptors often lack opportunities to receive specific feedback about the feedback they provide to residents.
Objective The purpose of this qualitative pilot study was to design an addition to electronic daily assessments that provides feedback to the preceptors about the feedback they provide to residents.
Design Phenomenologic design was used, based on the residents’ perspectives about the feedback they deemed most useful. Participants were first-year residents in a Canadian family medicine training program.
Methods Participants were invited to nominate documented feedback they identified as particularly useful in their learning and describe why. Eighteen entries from 5 competitions were included.
Main findings Five themes emerged from this pilot that indicate feedback was most useful to residents when it changed and improved their practice; taught them something new; motivated them to learn more; confirmed they were doing the right thing; and promoted reflection. Based on the findings, the electronic assessment forms were changed such that residents can now identify feedback that was of particular value to them, giving it a “thumbs up” and including why from a choice of the 5 themes. Enabling residents to identify feedback that drives their learning and to identify why offers preceptors feedback on their feedback. The full study will validate the 5 themes and investigate the effects this information might have on preceptors.
Conclusion Daily, workplace-based formative assessment supports residents to better understand their own learning needs. By indicating “thumbs-up,” residents can give feedback to preceptors on what drives their learning best and should provide opportunities to inform preceptors about the effects of the feedback they provide learners, thereby increasing its effectiveness and usefulness for learners.
Enhanced skills in health equity and global health
Guidelines for curriculum development
- Russell Dawe, MD CCFP MDiv,
- Andrea Pike, MSc,
- Jill Allison, MA PhD and
- Monica Kidd, MD CCFP MSc
Abstract
Context Global health (GH) is the practice, education, and research of health equity in international and domestic populations. Because the field is highly contextualized from one scenario to the next, some have questioned the relevance of competencies, and postgraduate programs have taken a wide spectrum of approaches to GH training in primary care.
Objective To determine consensus on best practices (regarding content, learning format, and assessment) for an enhanced skills program (ESP) in GH for family medicine residents.
Design The Delphi technique was used with 3 iterations of an online survey and opportunities for participant feedback. The online survey included items assessing the core topics for training in GH, as well as preferable modalities for teaching and assessment.
Participants Fifty-seven Canadian family physicians with expertise in GH and medical education including faculty and recent graduates from all 5 Canadian ESPs in GH, with a balance of experience in domestic and international GH, were invited to participate. Fifty-two agreed to participate, and 42 completed surveys in the first round.
Main outcome measures Survey items assessing opinions, perspectives, and preferences regarding the core topics and methods of teaching and assessment.
Results We anticipated reaching convergence of opinion (defined as a minimum of 75% agreement) on aspects of the overarching objective of a GH ESP, core content of the program, and preferred methods of teaching and learner assessment.
Conclusion Postgraduate medical education today places a strong emphasis on achievable competencies, yet there are currently no nationally recognized standards for postgraduate training in GH. This represents both a challenge to curriculum planning and an opportunity to make a national contribution to curriculum building in GH and health equity. This research will be used to build an innovative new medical training program at Memorial University of Newfoundland in St John’s (a third-year ESP for family medicine residents in the area of GH and health equity). We will also create a “best practices” document for GH training in Canada.
Competency-based assessment in sport and exercise medicine enhanced skills resident programs
Pilot project
- Constance Lebrun, MD CCFP(SEM) DipSportMed,
- Lisa Fischer, MD CCFP DipSportMed,
- Terra Manca, MA,
- Susan Ferbey, MEd,
- Sandra Shaw,
- Michel Donoff, MD CCFP FCFP,
- Robin Wiley, MA,
- Preston Wiley, MD CCFP(SEM) DipSportMed,
- Victor Lun, MD CCFP(SEM) DipSportMed and
- Shelley Ross, PhD
Abstract
Context Competency-based assessment is required for category 1 enhanced skills raining programs, where a certificate of added competence is to be awarded.
Objective To evaluate uptake and implementation of the Competency-Based Achievement System (CBAS) in sport and exercise medicine enhanced skills programs at 3 Canadian university-based clinics over 3 academic years.
Design Mixed-methods prospective cohort study using semistructured interviews and field notes (observations).
Participants Preceptors (n = 26), residents (n = 15), support staff (n = 1), and program directors (n = 4). Purposive sampling included all involved in the core enhanced skills sport and exercise medicine programs.
Main outcome measures Identification of barriers and enablers to CBAS implementation and use of the CBAS (numbers and range of field notes collected).
Results and findings Initially, low uptake of the CBAS suggested that resident and preceptor resistance was high. While the case for competency-based assessment was clearly accepted, the need for frequent, documented, formative feedback (ie, field notes) was not. Residents resisted scrutiny and repeated verification of their competency, and pursuing preceptors for field notes. In a fee-for-service environment, preceptors resisted the time burden of producing field notes to evaluate residents. Program directors valued field notes for early identification of at-risk residents, evidence to support summative assessments, and for tracking development of professional and clinical competencies. Over time, quantitative data analysis showed that entry of field notes increased significantly per resident, per preceptor, and per study site. Resident and preceptor acceptance rose as minimum expectations were established and technical issues were resolved. Permitting residents to initiate and enter field notes for preceptor sign-off reduced preceptor burden and increased resident ownership. Subtle changes in attitude included residents acknowledging feedback as beneficial rather than threatening, and viewing accumulated field notes as transparent proof of competency. Similarly, preceptors saw opportunities for “teachable moments” as opposed to judgment. Uptake and transition also improved when former residents trained in CBAS were integrated as new preceptors.
Discussion Initial resistance to CBAS gave way to acceptance as a result of changes in program implementation that increased ownership, reduced burdens, and reframed observations of competency as opportunities for feedback rather than judgment.
Conclusion Successful implementation of CBAS required ongoing adaptations to address participant concerns and ease the transition to competency-based assessment based on formative feedback.
Physician education on decision-making capacity assessment
Current state and future directions
- Lesley Charles, MB ChB CCFP(COE),
- Jasneet Parmar, MB BS,
- Suzette Bremault-Phillips, PhD,
- Bonnie Dobbs, PhD,
- Lori Sacrey, PhD and
- Bryan Slugett, MA
Abstract
Objective To examine FPs’ training needs for conducting decision-making capacity assessments (DMCAs) and to determine how training materials, based on a DMCA model, can be adapted for use by FPs.
Design A scoping review of the literature and qualitative research methodology (focus groups and structured interviews).
Setting Edmonton, Alta.
Participants Nine FPs, who practised in various settings, who chose to attend a focus group on DMCAs.
Methods A scoping review of the literature to examine the current status of physician education regarding assessment of decision-making capacity, and a focus group and interviews with FPs to ascertain the educational needs of FPs in this area.
Main findings Based on the scoping review of the literature, 4 main themes emerged: increasing saliency of DMCAs owing to an aging population, suboptimal DMCA training for physicians, inconsistent approaches to DMCA, and tension between autonomy and protection. The findings of the focus groups and interviews indicate that, while FPs working as independent practitioners or with interprofessional teams are motivated to engage in DMCAs and use the DMCA model for those assessments, several factors impede their conducting DMCAs. The most notable barriers were a lack of education, isolation from interprofessional teams, uneasiness around managing conflict with families, fear of liability, and concerns regarding remuneration.
Conclusion This pilot study has helped to inform ways to better train and support FPs in conducting DMCAs. Family physicians are well positioned, with proper training, to effectively conduct DMCAs. To engage FPs in the process, however, the barriers should be addressed.
Digging into why residents fail the CFPC examination
Examiners’ narratives
- Shirley Schipper, MD CCFP,
- Shelley Ross, PhD,
- Carlos Brailovsky, MD MA(Ed) MCFP(Hon) and
- Judith Belle Brown, PhD
Abstract
Context Near the end of training all family medicine residents in Canada, including international medical graduates (IMGs), write the national Certification examination. Candidates who fail the Certification examination are not able to practise in some regions in Canada. To rewrite the examination is both stressful and expensive. Providing insight into failures might help residents and training programs in multiple areas: improving examination preparation activities, guiding curriculum change, or tailoring training for those who require it.
Objective To review current research looking into the reasons why residents fail the oral portion of the College of Family Physicians of Canada’s Certification examination, specifically the simulated office oral (SOO) portion of the examination.
Design Scoring patterns were analyzed and examiners’ comments were captured from the score sheets. The comments were also analyzed; themes and quotes were identified.
Participants Approximately 100 candidates failed the 2013 and 2014 spring and fall sittings of the examination. Of them, 52 candidates who failed the SOOs were studied.
Results In both the written and oral parts of the examination, and across Canada, IMGs performed less well than Canadian-trained medical graduates did. Candidates who fail are given quantitative data on their SOO performance; however, examiners often write narrative comments on the backs of score sheets, which are not shared. Candidates who fail often have similar performance issues noted by examiners. Some candidates who fail often have the same difficulty on subsequent examination attempts. The behaviour and comments on the narratives provide specific performance information, which would be valuable to resident candidates and residency programs.
Conclusion Knowledge of why candidates fail examinations is essential feedback. Currently candidates receive global feedback, which indicates only how they scored. More specific feedback (such as missed cues, problems with communication) could be helpful.
Selected specialized activities in the family medicine residency curriculum at Laval University
Program evaluation
- Véronique Fournier, MD,
- Maude Deschênes, MD,
- Jean-Sébastien Renaud, PhD,
- Miriam Lacasse, MD MSc CCFP,
- Josée D’Amours, MD CCFP,
- Christian Rheault, MD CCFP and
- Annie St-Pierre, MD PhD CCFP
Abstract
Context To meet the College of Family Physicians of Canada’s accreditation standards, the family medicine residency program at Laval University in Quebec has developed selected specialized activities (SSAs) to help residents enhance their competencies in specific areas of expertise, such as women’s health, teen health, and musculoskeletal medicine.
Objective To assess the overall appreciation of the new SSAs; evaluate the effects of the new SSAs on family medicine residents’ learning and skills regarding women’s health, teen health, and musculoskeletal medicine; and to identify the strengths and weaknesses of the SSAs and ways to improve them.
Design This mixed-method descriptive study used the Kirkpatrick model for program evaluation (levels 1, 2, and 3).
Participants Family medicine residents were asked to answer a pre-SSA and a post-SSA self-assessment questionnaire.
Main outcome measures The questionnaire was designed to determine residents’ SSA appreciation, perceived learning, and sense of competence following SSA completion. Descriptive analyses were used to identify barriers and facilitators to the SSAs.
Results Twenty-six out of 53 residents answered the post-SSA questionnaire regarding women’s health, as well as 24 out of 46 for teen health, and 19 out of 38 for musculoskeletal medicine. Residents were satisfied with the SSAs, with an average appreciation of 8.3 out of 10 (level 1, reaction). Most residents (≥ 77%) indicated that they achieved their learning objectives. Most residents reported an overall improvement in their knowledge and sense of competence following the completion of the SSA regarding women’s health (≥ 92%), teen health (≥ 88%), and musculoskeletal medicine (≥ 63%), except for the following themes: permanent contraception; counseling about induced abortion care; bursitis, capsulitis, subluxation, tendinitis, and spine issues; physical examination of the spine and the hip; and infiltrations (levels 2 and 3, learning and behaviour). The main SSA aspects that need to be improved are clinical lack of exposure, need to transit between training sites, and some organizational issues. The main recommendations mentioned were to have a full day dedicated to the SSAs instead of a half-day to increase patient output and to have access to training reference materials.
Conclusion Intensive learning activities that provide residents with opportunities to delve into specific areas of expertise in family medicine are mostly appreciated by residents, seem to be associated with better self-assessed knowledge, and improve residents’ sense of competence for most SSA themes.
Strengths and weaknesses found in Canadian family medicine residency programs during accreditation visits
- Keith Wycliffe-Jones, MB ChB FRCGP CCFP,
- Shirley Schipper, MD CCFP,
- Ric Almond, MD FCFP and
- Judith Scott, MA
Abstract
Context The foundation for the College of Family Physicians of Canada’s process of accreditation of family medicine (FM) residency programs in Canada is the full, on-site external review at each school. A survey team spends almost an entire week meeting with program leaders, residents, and faculty to generate a report describing the program’s strengths and weaknesses. These reports are shared only with the accreditation committee and the schools. This leaves many programs uncertain about what the more common areas of challenge are for programs in meeting accreditation standards, and potentially misses an opportunity to highlight where programs have been exemplary and sometimes quite innovative in meeting or exceeding training standards.
Objective This study aims to identify common strengths and weaknesses found during Canadian FM accreditation visits over the past 40 years.
Design The strengths and weaknesses in each of the external review reports over the past 40 years will be analyzed for content and frequency. The strengths and weaknesses will then also be categorized according to current accreditation standards. The analysis will include the accreditation status and follow-up on programs that resulted from each external review. All data will be anonymized and collated so no individual program’s data can be identified. Data will be gathered using a manual data-gathering tool listing identified strengths and weaknesses found during each external review.
Setting All 17 Canadian FM 2-year residency programs.
Participants Accreditation reports and transmittal letters for all 17 FM 2-year residency programs over the past 40 years will be accessed.
Main outcome measures The common strengths and weaknesses found during accreditation visits will be presented, as well as the accreditation status of each program that resulted from the visit.
Results The results were not available at the time of presentation.
Conclusion This study will, for the first time, present and share information about the common strengths and weaknesses found during accreditation visits to Canadian FM residency programs. This will help programs consider their own ongoing quality-improvement processes and highlight the considerable areas of strength in postgraduate FM training in Canada.
Knowledge translation of pain-reduction strategies in childhood vaccinations among health care professionals
- Christina Fung, MD,
- Faizah Ilyas, MD,
- Krishin Singh, MD and
- Alexiel Zhang, MD
Abstract
Context The advent of vaccines has drastically changed health care in terms of the incidence and mortality of many diseases of childhood. While vaccines are routine, there is no routine pain prevention plan associated with these needle injections, which is the main barrier to adherence.
Objective To influence intent to change health care professionals’ use of pain-reduction strategies during routine childhood vaccines. Stage 1: To understand barriers to uptake of pain-reduction strategies among health care professionals. Stage 2: To develop a motivational and education intervention intended to change practice based on findings from stage 1.
Design This is a 2-stage knowledge-translation project.
Setting The Stonechurch Family Health Centre in Hamilton, Ont.
Participants Purposive sampling will be used to recruit representative stakeholder staff members (physicians, residents, receptionists, team assistants, and nurse practitioners) who are directly or indirectly involved in administering childhood vaccines and are influential in practice change within the clinic.
Intervention Stage 1: A focus group will be conducted using a structured interview guide based on the Theoretical Domains Framework that identifies barriers related to knowledge, skills, professional role and identity, beliefs about capabilities, beliefs about consequences, motivation and goals, and environmental context and resources. Stage 2: Findings gathered from the focus group will be used to develop a facilitated workshop addressing the main barriers to uptake of recent Canadian guidelines.
Main outcome measures Stage 1: Themes of facilitators and barriers to using pain-reduction strategies will be identified. Stage 2: Evaluation of intent to change practice will be determined using the Nursing Practice Questionnaire. This survey quantifies readiness to change practice and will be administered before-, immediately after, and 3 months after a workshop. Scores will be analyzed for significant change over time.
Main findings We anticipate possible barriers related to health professional awareness, belief in the intervention effectiveness, and scheduling limitations. We anticipate advancement in readiness to change as a result of our workshop intervention.
Conclusion Implications of this knowledge-translation project might lead to a reduction of the gap between evidence and uptake of reducing pain during childhood vaccines, which might improve adherence to the childhood vaccine schedule.
Methodologic quality and reporting in pediatric preventive care recommendations
Review of guidelines from English-speaking countries
- Gabriel Cartman, MD,
- Hyejee Ohm,
- Leslie Rourke, MD FCFP FAAFP MClSc,
- Denis Leduc, MD CCFP FAAP FRCPC and
- Patricia Li, MD MSc FRCPC FAAP
Abstract
Context Early childhood has a profound influence on physical, mental, and emotional health throughout life. Comprehensive guidelines have been developed internationally for child health promotion based on the best available evidence.
Objective To assess the methodologic quality and reporting of guidelines for pediatric preventive care.
Design A structured review and quality assessment of nationally endorsed guidelines for preventive care well-child visits in children 0 to 5 years old from English-speaking countries.
Methods Five guidelines and programs from English-speaking countries were retrieved: Tamariki Ora (New Zealand), Healthy Child Programme (United Kingdom), Guidelines for Preventive Activities in General Practice (Australia), Bright Futures (United States), and the Rourke Baby Record (Canada). We assessed the rigour and transparency of guideline development using the AGREE II international tool. Three independent reviewers allocated scores according to 6 domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence. We gave specific attention to examining the process for synthesizing the evidence, as well as formulating and updating recommendations. Guidelines were further compared descriptively to identify any content differences.
Results There was a wide variation in scores across all domains, with each guideline exhibiting different strengths and weaknesses. Overall scores for rigour of development, for example, ranged from 33.3% (New Zealand) to 71% (United States). The 1 item that scored poorly across guidelines (score less ≤ 3) was the description of how recommendations were formulated and updated.
Conclusion Methodologic rigour in the development of pediatric primary preventive care guidelines varied substantially across countries. All guidelines would be improved with explicit reporting of the recommendation development process.
Patient characteristics and beliefs influencing influenza vaccination uptake at SETFHT
- Alexis Pizale, MD,
- Kara Wollach, MD and
- Sam Tirkos, MD CCFP
Abstract
Context The seasonal influenza vaccine is the most effective way to prevent influenza, yet only one-third of Ontarians receive the flu vaccine each year.
Objective To identify patient characteristics and beliefs influencing influenza vaccine uptake with the goal of generating useful information that can be used to inform physicians and guide future influenza vaccine campaigns.
Design A paper survey regarding the influenza vaccine.
Setting South East Toronto Family Health Team (SETFHT) in Toronto, Ont.
Participants The SETFHT front staff recruited patients older than 18 years of age to participate.
Main outcome measures The information collected was used to generate descriptive statistics, and Fisher exact tests were employed to determine the statistical significance of the data.
Results Of the 67 respondents to the survey, 59.7% had received the influenza vaccine for the 2015 to 2016 season. Individuals with postsecondary education were significantly more likely to receive the influenza vaccine (P = .014). Similarly, individuals who had received the influenza vaccine in the past were significantly more likely to receive the vaccine (P < .001). The most commonly identified reasons for influenza vaccine refusal were lack of efficacy, belief about being unlikely to suffer complications from the flu, and “other.”
Conclusion Based on the data from the SETFHT, future influenza vaccine campaigns should target individuals with less education and those who have never received the influenza vaccine. To address the most commonly cited reasons for influenza vaccine refusal, campaigns should focus on potential complications from influenza as well as the efficacy of the vaccine. Since the most commonly identified reason for receiving the influenza vaccine was recommendation from a health care provider, physicians should counsel patients regarding the influenza vaccine and spend additional time counseling those who are unlikely to receive the vaccine.
Scoping review of the benefits and risks of domperidone as a galactagogue
- Danielle Carpentier, MD,
- Andrew Andrawes, MD and
- Martina Kelly, MB BCh MICGP FRCGP CCFP
Abstract
Context Breastfeeding is best for baby, yet many women experience difficulties due to inadequate breast milk production. Domperidone is commonly used off-label as a galactagogue to promote breast milk production. Safety warnings regarding domperidone use have been issued by the US Food and Drug Administration and Health Canada.
Objective To review evidence on the benefits and risks of domperidone as a galactagogue.
Methods Scoping study (Arksey and O’Malley, 2005). A search protocol for databases (MEDLINE, CINAHL, EMBASE, OVID HealthSTAR) and gray literature (guidelines, point-of-care tools, breastfeeding websites and blogs) was developed with librarian input with no language or year restrictions. Two reviewers independently reviewed full texts and performed data extraction. The PRISMA guidelines informed review reporting and the Oxford critical appraisal tool was used to examine randomized controlled trial (RCTs) quality. Data were charted, collated, and summarized. A consultation exercise included 3 interviews with breastfeeding experts and 3 workshops with family physicians and residents.
Results From an initial list of 552 citations, 35 articles were included: 12 RCTs, 1 systematic review, 1 meta-analysis, case reports, and commentaries. Health Canada provided information on 291 adverse case reports between 1965 and 2015; 14 were life-threatening, 52 required hospitalization, and there was 1 reported case of death. Of the RCTs, 10 of the 12 were conducted in preterm infants. Domperidone doses in studies varied between 10 and 20 mg 3 times daily with only 1 study using 20 mg 4 times daily. Two studies compared the effect of different doses and showed clinical but not statistically significant increases in milk production with higher doses. Treatment duration was 2 days to 6 weeks. Withdrawal symptoms with longer durations of domperidone were reported. Side effects of domperidone use were poorly recorded, and 1 study suggested more side effects at a higher dose. The consultation exercise with the lactation experts and practitioners confirmed that current clinical practice is to prescribe domperidone for long periods of time, at up to 40 mg 4 times a day. Screening for cardiac disease varied greatly from no screening to screening with electrocardiogram.
Conclusion Use of domperidone for mothers of term babies for longer than 6 weeks or in high doses is not in accordance with existing evidence. There is a gap between research evidence and clinical practice.
Effect of family physicians’ prenatal breastfeeding counseling on maternal breastfeeding practices in Calgary, Alta
- Ibiye Briggs, MD,
- Grace Perez, MSc and
- Monica Kidd, MD CCFP
Abstract
Context Exclusive breastfeeding for 6 months is considered to be optimal infant nutrition, yet many populations around the world fail to meet this ideal. Prenatal visits are an opportunity to influence women’s knowledge, attitudes, and practices relating to breastfeeding, which might help improve breastfeeding rates. There are currently no studies in Canada examining solely patient-physician interaction in support of breastfeeding during prenatal visits.
Objective We obtained mother and physician perspectives on the scope and relevance of breastfeeding counseling offered in the prenatal period and the extent to which it influenced postpartum breastfeeding practices.
Design This was a retrospective cohort study of postpartum women and a cross-sectional study of family physicians providing prenatal care using convenience sampling. Self-administered questionnaires were used.
Setting Calgary, Alta.
Participants Ninety-five English-speaking postpartum mothers of infants 6 months and younger and 32 family physicians were recruited through posters in low-risk obstetric prenatal clinics and academic family medicine teaching clinics.
Main outcome measures To determine whether physicians’ contact with mothers during the prenatal period had an effect on breastfeeding decisions and outcomes.
Results Most mothers (80%) made the decision to breastfeed before becoming pregnant, and the strongest influences on mothers’ decisions to breastfeed were friends and family. However, only about half (51%) of mother participants were exclusively breastfeeding when they were surveyed. Most mothers (60%) indicated that their physicians usually or always provided breastfeeding counseling and support at prenatal visits, and most (88%) found this to be useful; 78% of physicians indicated they always recommended exclusive breastfeeding, with most (69%) providing breastfeeding counseling at all or most prenatal encounters. Mothers and physicians differed in how often they believed breastfeeding was discussed. Mothers recalled fewer discussions of breastfeeding during prenatal visits than reported by physicians.
Conclusion Family physicians should be reassured that women find frequent breastfeeding counseling helpful. Physicians should be supported with continuing medical education to increase their level of confidence with breastfeeding advice.
Identifying risk factors of concussion injury among NHL players
- Laurence Biro, MD CCFP,
- Carmen Baker, MSc,
- Anthony Wan,
- Paul Klas,
- Laura Bolt, PhD and
- Peter Tanner
Abstract
Context Concussion injuries among professional hockey players in the National Hockey League (NHL) result in enormous economic and functional burdens to professional teams. These preventable injuries often also result in serious and long-term neurological deficits. In the 2011 to 2012 regular season 1700 man-games were lost owing to concussions, despite improvements in safety equipment and rule changes. Current research on concussion injury among professional hockey players is scarce and there are no studies that have quantitatively evaluated the modifiable (eg, fighting, player position, goal scoring) and nonmodifiable (eg, height, age) risk factors for concussion among NHL players. Identifying risk factors for concussion injury will highlight high-risk individuals and inform evidenced-based changes of modifiable behaviour to prevent future injury.
Objective To identify risk factors of concussion injury in NHL athletes through analysis of modifiable and nonmodifiable player characteristics.
Design and participants We extracted publicly accessible game-level data for 1488 NHL players from 4 NHL seasons (2009 to 2013). Anthropometric and game data for each player (including concussion injury, penalty minutes, points, and time on ice) were collected for every game. A Cox proportional hazards model was used to determine associations between concussion injury, anthropometric characteristics, and performance-related behaviour.
Main outcome measures Concussions sustained during NHL regular season games from October 2009 to April 2013.
Conclusion Our study is the first to empirically evaluate risk factors of concussion injury among NHL hockey players using Cox proportional hazard models. Identifying anthropometric risk factors will allow physicians to identify athletes who might be at high risk of sustaining a concussion and prevent subsequent and exacerbating injury. Results from our study will also be beneficial for the prevention of concussion by identifying specific on-ice behaviour associated with the occurrence of these debilitating and preventable injuries.
Concussions and the need to standardize care
Concussion awareness training tool kit for medical professionals
- Shelina Babul, PhD and
- Kate Turcotte, MSc
Abstract
Context Concussion recognition, treatment, and management are crucial in supporting recovery and decreasing the risk of long-term brain damage. Long-term effects are often not recognized early enough to prevent postconcussion syndrome, resulting in effects on social and professional lives.
Objective To determine whether concussion knowledge, attitudes, and practices (KAP) are significantly improved among physicians following completion of the Concussion Awareness Training Toolkit (CATT) for medical professionals.
Design A preintervention and postintervention questionnaire designed to measure changes in physician KAP.
Participants Physicians working in emergency departments and trauma care facilities.
Intervention Based on established international principles, CATT is an online tool kit (www.cattonline.com) providing learner-directed concussion awareness training for medical professionals, as well as assessment resources (SCAT3, Child-SCAT3), links to clinical resources, patient handouts, journal articles (including the Zurich Consensus Statement), related websites, concussion videos, and study cases.
Main outcome measures Changes in physician KAP regarding concussion recognition, treatment, and management.
Results Forty-four physicians were recruited, with postintervention questionnaires completed by 34 (77.3%) participants. Participants demonstrated a statistically significant positive change in concussion practices (P = .001). Change in knowledge was not significant, while attitudes had a negative change (P = .041). Positive change in knowledge was detected for those who typically see more than 10 concussions per year (P = .039).
Discussion The CATT is effective in improving concussion practices among physicians, which will potentially minimize adverse concussion outcomes and lower health care costs among concussion patients. The CATT also includes an evaluated tool kit for parents, players, and coaches, and evaluation of the CATT for school professionals is currently in progress.
Conclusion The need to standardize care is vital in preventing adverse concussion outcomes.
Systematic review of therapy for concussion and mild brain injury
- Roger E. Thomas, MD CCFP PhD MRCGP,
- Jorge Alves, PhD,
- Rosana Magalhaes, PhD and
- Marcus M. Vaska, MLIS
Abstract
Context Concussed patients can have long waits for specialist therapy. Are there effective therapies that family physicians can recommend to their patients? And can simple forms of any of these therapies be recommended for partners or family members to initiate while waiting for specialist therapy?
Objective To assess the effectiveness of interventions used in randomized controlled trials (RCTs) for concussion. Risk of bias was assessed with the Cochrane Risk of Bias Tool.
Participants Individuals with concussion or mild brain injury.
Intervention Forty RCTs were identified that addressed the areas of therapy identified by the INCOG review group as effective interventions for concussion.
Main outcome measures Improvements in attention and information processing speed; executive function and self-awareness; cognitive communication; and memory.
Results Effective interventions include the following. Attention and information processing speed: training to perform everyday functional activities with metacognitive strategies (eg, asking for repetition, replaying interactions, applying skills in situations of increasing complexity, and performing a cognitive exercise with a physical activity, such as walking). Executive function and self-awareness: training to perform metacognitive strategies for everyday functional planning, problem-solving, and reasoning skills. Direct cognitive feedback to improve self-awareness of skills, errors, and contexts in which strategies should be used ought to be incorporated into every intervention. Participants should be taught to improve self-monitoring and incorporate feedback into future performance. Group-based interventions to remediate problem-solving and executive deficits are helpful. Cognitive communication: Help patients identify goals to improve everyday social communication and rehearse communication skills. Memory: Metacognitive strategies (visualization, repeated practice, practice in retrieval, self-cueing, self-talk, smartphones, and notebooks) are helpful. Most RCTs are in the areas of improving executive function and self-awareness.
Conclusion The essential intervention in beginning simple interventions at home while awaiting specialist help is to identify a “communication partner” who can work with the concussed individual on everyday communications at home and the simpler skills essential for work. There is a need to develop knowledge translation to provide information with clear examples so a partner or family member can choose and implement some of the simpler strategies promptly after a concussion to help the patient make progress while waiting for specialist help.
Tobacco control research trends from the past decade
Findings from a scoping review of reviews
- Gayle Halas, RDH MA PhD,
- Annette Schultz, RN PhD,
- Janet Rothney, MLIS,
- Pam Wener, MEd,
- Jennifer Enns, MSc PhD,
- Maxine Holmqvist, PhD CPysch and
- Alan Katz, MB ChB CCFP FCFP
Abstract
Context Over the past several decades the volume of tobacco control (TC) research has grown. Diminishing tobacco use and exposure to tobacco smoke remain primary health care priorities globally. In 2005, the World Health Organization’s Framework Convention on Tobacco Control (FCTC) entered into force, strategically outlining strategies for reduction of demand and supply for tobacco.
Objective To provide an overview of the breadth of research foci within TC research, obtain evidence regarding the FCTC action areas within the context of primary prevention, and identify research gaps.
Design We conducted a scoping review of TC literature (2003 to 2014), drawing on Arksey and O’Malley’s approach (2005). Five databases were searched using key word strings relevant to tobacco, FCTC strategies, interventions, efficacy, and review types.
Study selection Reviews that address primary prevention within developed countries.
Methods Our multidisciplinary team iteratively produced a data extraction tool that was applied to eligible references. Two reviewers screened the initial pool of references (N = 5022) and extracted data from eligible abstracts (n = 376); disagreements were resolved with a third reviewer.
Main findings Reviews often covered more than one strategy or population. The FCTC strategic areas were operationalized by 7 actions; most abstracts (78%) focused on tobacco dependence and cessation, with fewer initiatives (18%) on increasing awareness and education. Marketing and sponsorship, exposure to tobacco smoke, packaging and tobacco products, pricing and taxation, and illicit sales and selling to minors are, together, addressed in less than 25% of the literature. Target populations for these strategies are described by 8 categories. Most reviews involved individuals (68%). Reviews with strategies directed toward children, youth, schools, and families comprised 21% of the abstracts; society, health care, community, and workplaces were represented in 41.5%.
Conclusion This scoping review of TC reviews was a productive approach for mapping TC research trends within the context of primary prevention. It reveals a considerable base of evidence concerning tobacco dependence and cessation, which overshadows other important aspects of TC strategies. Exploring the breadth of this literature reveals translational challenges and ideas for future research.
Critical review of effectiveness and tobacco-dependence treatment interventions
Scoping review study
- Annette Schultz, RN PhD,
- Gayle Halas, RDH MA PhD,
- Kylee Hurl, MA,
- Janet Rothney, MLIS,
- Pam Wener, MEd,
- Jennifer Enns, MSc PhD,
- Maxine Holmqvist, PhD CPysch and
- Alan Katz, MB ChB CCFP FCFP
Abstract
Context Tobacco use has important effects on health. The World Health Organization’s 2005 Framework Convention on Tobacco Control (FCTC) states that primary care providers must support patients’ cessation efforts. A vast body of research and practice guidelines inform the delivery of tobacco-dependence treatments.
Objective To review tobacco-dependence treatment initiatives in published reviews (2003 to 2014), map effectiveness measures, and critically reflect on translation into practice.
Design Addressing effectiveness within the tobacco-dependence treatment literature is part of a larger scoping review of published tobacco-control reviews, informed by Arksey and O’Malley’s methodology (2005). A data extraction table was iteratively developed by the team and used to extract data from full articles.
Study selection We performed a systematic search of 5 databases using key word strings informed by the FCTC strategies. The effectiveness review focused on a subset of reviews addressing tobacco-dependence treatment. Selection of articles went through a 2-step process of eligibility selection (n = 188).
Methods Researchers tracked measures of effectiveness across reviews and interventions.
Main findings Interventions were grouped as psychological or educational, pharmacologic, alternative (eg, hypnosis or acupuncture), other (eg, peer support, financial assistance), or a combined therapeutic regimen. The effectiveness of interventions focused on smoking cessation measured by self-report or biological verification (point-prevalence or sustained abstinence) most commonly at 6 to 24 months after intervention. Authors’ suggestions for future research include longer-term follow-up studies, clearer reporting, and more rigorous measurement of smoking cessation.
Conclusion Canadian data show fewer than 45% of current smokers receive advice to quit from health professionals. The volume of cessation intervention reviews suggests this is an ongoing research priority. Our review and critical reflection on effectiveness were driven by questions of translation challenges. Critical review of effectiveness measures noted in this literature shed light on a gap between research aims and practice realities for addressing the complexity of tobacco dependence.
Barriers and facilitators to diabetes care
Qualitative study
- Michelle Zeng, MD,
- David Nicholas, PhD RSW,
- Jazmin Marlinga, MD CCFP DTM&H,
- Linda Au, MSW RSW,
- Braden Manns, MD FRCPC,
- Alan Edwards, MD FRCPC,
- Christopher Naugler, MD FRCPC and
- Kerry McBrien, MD CCFP
Abstract
Context Safe, efficacious, and cost-effective interventions for optimizing diabetes management in Canada are available but are currently underutilized owing to a combination of patient-, provider-, and system-level barriers. A better understanding of barriers and facilitators to diabetes care is needed to increase resource utilization and develop new programs to assist diabetes patients, especially those with poor control (hemoglobin [Hb] A1c ≥ 10%).
Objective To explore patient-perceived facilitators and barriers to good diabetes disease management in a qualitative study using open-ended questions.
Design Qualitative descriptive study using a telephone survey that included 2 open-ended questions exploring patient-perceived barriers and facilitators to care. Patient responses were recorded.
Setting Calgary, Alta.
Participants A total of 1217 patients with diabetes identified from the Calgary Laboratory Services database: 811 with HbA1c of 10% or greater, and 406 with HbA1c between 7% and 8%.
Methods We used thematic analysis of participant responses to summarize key information into themes and subthemes.
Main findings We identified 5 major thematic categories that influence diabetes care: self-efficacy with disease management, general health and disease burden, accessibility and perceived quality of health care, social support, and financial factors. Within each, we identified factors that had both positive and negative influences on diabetes care. Examples of subthemes included competing priorities, social stigma, self-motivation, patient knowledge, attitudes, self-discipline, general health and comorbidities, medication burden, access to care and programs, perceived provider competency, financial burden of disease, and insurance coverage.
Conclusion Participants reported a number of factors that they perceived as either helpful or not helpful in their diabetes care. The range of reported barriers and facilitators indicate the importance of an individualized approach in helping patients overcome barriers to improving their diabetes control. Our findings have important implications for family medicine since family physicians are the front-line doctors for diabetes management. These findings will facilitate the development of programs and initiatives to improve diabetes care in Canada and beyond.
Psychosocial diagnoses occurring after patients present with fatigue
- Peter Reagh MacKean, MD FCFP MClSc,
- Moira Stewart, PhD and
- Heather L. Maddocks, PhD
Abstract
Context There is an association between psychosocial problems and fatigue. For Canadian patients who present to their FP with a complaint of fatigue, it is not known how often a psychosocial diagnosis is made. Additionally, it is not known how often any diagnosis can be made.
Objective To discover the frequency of psychosocial and other diagnoses occurring at the end of a visit when patients present to their FPs with concerns about fatigue.
Design Cross-sectional study of patient-FP encounters for fatigue.
Setting Ten FP practices in southwestern Ontario.
Participants A total of 259 encounters involving 167 patients presenting to their FPs between March 1, 2006, and June 30, 2010, with concerns about fatigue.
Main outcome measures The frequency of psychological and social diagnoses made at the end of visits, and whether diagnoses were made by FPs at the end of the visits versus whether the code for fatigue remained. The associations between patient age, sex, fatigue presenting with other symptoms, or the presence of previous chronic conditions and the outcomes was tested.
Results Psychosocial diagnoses were made 23.9% of the time. Among psychosocial diagnoses made, depressive disorder and anxiety disorder or anxiety state were diagnosed more often in women (P = .048). Slightly less than 30% of the time, the cause of patients’ fatigue remained undiagnosed at the end of the encounter. A diagnosis was made more often in men.
Conclusion Causes of fatigue frequently remain undiagnosed; however, when there is a diagnosis, psychosocial diagnoses are common. Therefore, it would be appropriate for FPs to screen for psychosocial issues when their patients present with fatigue, unless some other diagnosis is evident. Depression and anxiety could be considered particularly among female patients with fatigue.
What’s new in infectious disease?
Top hits in 2016 in the Canada Communicable Disease Report
- Patricia Huston, MD CCFP MPH
Abstract
Context The Canada Communicable Disease Report (CCDR) is a peer-reviewed journal that publishes articles on infectious diseases for front-line clinicians and public health professionals including research, reviews, the most recent statistics on infectious diseases in Canada, and advisory committee statements with recommendations for clinical care.
Objective To give family physicians a quick update on trending infectious disease issues in Canada by identifying and reviewing the 5 most high-profile articles published in 2016.
Design Observational study that analyzes the number of hits to the CCDR website for all articles published in CCDR from January 7 to October 6, 2016. The top 5 will be identified for more detailed review.
Results Articles could include such things as the health status of Syrian refugees in Canada, Committee to Advise on Tropical Medicine and Travel recommendations for Zika virus, new advances in Lyme disease, or the effect of climate change on infectious diseases in Canada. The focus will be on summarizing the clinically relevant findings.
Conclusion The CCDR is a source of interesting, timely, and reliable information on trending infectious disease issues for family physicians and contains pearls for clinical practice.
Stool softeners for constipation
What does the evidence say?
- Janice Mann, MD,
- Wendy Prichett-Pejic,
- Aleksandra Grobelna, MIS and
- Eftyhia Helis, MSc
Abstract
Context As many as one-quarter of all adults, an estimated 3 out of every 4 seniors living in long-term care, and almost everyone who takes opioids regularly for chronic pain experience constipation. Symptoms of constipation can be a minor annoyance for some but might be severely debilitating for others, having a huge effect on a person’s quality of life. Stool softeners are often the treatment of choice for our patients with constipation. In fact, “bowel protocols” that include the routine use of stool softeners are in place in many hospitals and long-term care facilities across Canada. Stool softeners are safe, are well-tolerated by patients, do not tend to interact with other medications, and are low cost. But do they actually work?
Objective To review the evidence on the effectiveness of stool softeners (ie, docusate sodium or docusate calcium) and other constipation treatments.
Design Findings from a Rapid Response review of the evidence performed by the Canadian Agency for Drugs and Technologies in Health will be presented. The review assessed relevant evidence based on 2 systematic reviews, 1 randomized controlled trial, and 2 non-randomized studies.
Target population Medical practitioners who prescribe treatments for patients with constipation.
Results The review indicates that docusate does not improve the symptoms of constipation for patients taking opioids or who are long-term care residents. There is no evidence on the effectiveness of stool softeners for other patient groups.
Conclusion The findings of the evidence review suggest discussion is needed about decisions on the treatment of patients with constipation.
Genetic testing of patients with first unprovoked venous thromboembolic events
No-brainer or no point?
- Janice Mann, MD,
- Karen Cimon,
- Anthony Budden, PGCert(Pharmacoeconomics) and
- Eftyhia Helis, MSc
Abstract
Context Factor V Leiden (FVL) and prothrombin gene mutations can lead to an increased risk of developing blood clots—a condition called thrombophilia. When patients experience a first blood clot, such as deep vein thrombosis or pulmonary embolism in the absence of other risk factors, can testing help determine the risk of future recurrence and the appropriate clinical management?
Objective To review the evidence on the effectiveness and safety of FVL and prothrombin gene mutation testing for patients with a first unprovoked venous thromboembolic event (VTE).
Design The Canadian Agency for Drugs and Technologies in Health—an independent agency that finds and assesses evidence on drugs and other health technologies—conducted a systematic review of the clinical evidence and performed a health economic analysis comparing testing with no testing. An expert panel, which included family physicians, made recommendations on the use of these tests in patients who have experienced a first unprovoked VTE.
Target population Medical practitioners who need to provide care for patients with unprovoked thromboembolism.
Results The review of the evidence indicates that routine testing for FVL and prothrombin gene mutations in patients with a first unprovoked VTE might have limited clinical effectiveness.
Conclusion The research findings and the recommendations allow family physicians to readily use this knowledge in their practices.
Prevalence of coronary artery disease in a Saskatchewan family medicine clinic
- Natasha Desjardins, MD,
- Kristine Pederson, MD,
- Kevin Wasko, MD CCFP MA and
- Kelechi Eguzo, MD MPH
Abstract
Context There is limited information on the prevalence of coronary artery disease (CAD) and its risk factors in southwest Saskatchewan. The unique population characteristic of the Cypress Health Region (CHR) (two-thirds older than 45 years, 14% aboriginal, 6% Hutterite, and largely rural) makes it necessary to understand the context of CAD in this region.
Objective To determine the prevalence of CAD and risk factors in the largest family medicine clinic in CHR.
Design A cross-sectional retrospective chart audit was performed using electronic medical records.
Setting Associate Family Physicians Clinic (AFPC) in southwest Saskatchewan.
Participants All adults aged 40 years or older who received ongoing care at AFPC between January 1, 2013, and December 31, 2014 (N = 2373).
Main outcome measures Diagnosis of CAD (ICD-9 diagnostic code 414) and its risk factors, including hypertension, hyperlipidemia, age, sex, diabetes mellitus, family history, active smoking status, body mass index, and residence (rural or urban). Data were analyzed using descriptive statistics.
Results A total of 357 charts met the inclusion criteria, with the prevalence of CAD at 15% (357 of 2373). Mean (SD) age of patients with CAD was 71 (11) years, and mean (SD) body mass index was 29.8 (5.8) kg/m2. Up to 257 patients (71.9%; 257 of 357) had at least 3 risk factors. Hypertension was the most common individual risk factor (n = 310), followed by hyperlipidemia (n = 307), while smoking was the least common (n = 43). Each patient attended a mean (SD) of 11 (6) clinic visits during the study period. Individuals who resided in the urban centre (Swift Current, Sask) had a significantly higher clinic attendance compared with people in rural areas (P = .02), but this did not significantly affect their outcomes (dead or alive; P > .999).
Conclusion There is a high prevalence of CAD risk factors in CHR, especially hyperlipidemia and hypertension. Given the unique population structure of CHR, it is important that clinicians should be diligent in screening at-risk individuals to reduce the prevalence of CAD. Interestingly, despite a significant Hutterite population, there were no CAD cases among Hutterites who attended AFPC. Further research is required to study the distribution of CAD and its risk factors among specific population groups, such as Hutterites.
Preliminary evaluation of an intervention to improve supportive care for caregivers of patients with cancer
- Michèle Aubin, MD CCFP FCFP PhD,
- Lucie Vézina, MA,
- René Verreault, MD PhD CCFP FCFP,
- Sébastien Simard, PhD,
- Lise Tremblay, MD FRCPC,
- Jean-François Desbiens, RN PhD,
- Serge Dumont, PhD,
- Maman Joyce Dogba, PhD and
- Pierre Gagnon, MD FRCPC
Abstract
Context Family caregivers (FCs) of cancer patients often report higher distress than patients do. Many cancer centres have implemented distress screening programs, but they target only patients.
Objective To assess the effectiveness of an intervention to support FCs of patients with lung cancer.
Design Randomized controlled trial.
Setting An oncology clinic in Quebec.
Participants A total of 120 FCs and their relative with lung cancer, randomly assigned to the experimental (exposed to intervention) or control group (usual care).
Intervention Systematic distress screening and problem assessment; privileged contact of FCs with an oncology nurse; and liaison with the FC FP for those reporting high distress (thermometer score ≥ 5; range 0 to 10) or problems relying on FP expertise.
Main outcome measures Family caregiver distress (measured with the Indice de détresse psychologique Enquête Santé Québec [IDPESQ]).
Preliminary results At the time of writing, 49 FCs had been recruited (24 intervention and 25 control); 73.5% are female and the average age is 62 years. Some of their relatives with cancer did not want to participate, so 42 patients have been recruited (20 intervention and 22 control); 47.6% are female, the average age is 67 years, and 78.5% have good functional status (ECOG of 0 to 1). Many (70%) have metastases and 80% have received chemotherapy or radiation therapy or both. At baseline, 8 out of 24 FCs in the experimental group reported high distress at the screening test and 4 needed to be referred to the psycho-oncologist. According to the IDPESQ, 45% of FCs from both groups had high distress (score ≥ 26.2) compared with only 14.3% of patients (P < .0001).
Conclusion The high proportion of FCs with distress reinforces the relevance of addressing FC distress as part of routine cancer care. It also represents a good opportunity for collaboration between primary care and oncology care providers.
Shared medical appointments
Effective way to promote weight reduction and improve lifestyle choices
- Erin Palmer, MD CCFP and
- Sara Davidson, MD
Abstract
Context Obesity is a considerable problem in New Brunswick, with 63% of adults being overweight or obese. One method physicians can use to support weight loss and lifestyle changes in their patients is shared medical appointments (SMAs). Shared medical appointments empower patients with education and self-management tools. The group setting and sharing provide time, inspiration, and peer support.
Objective To determine the effects of an SMA program for weight management, supporting healthy lifestyle choices, and encouraging readiness to change.
Design The study included both the intervention of an SMA along with prestudy, poststudy, and 6-month follow-up questionnaires.
Setting St Joseph’s Community Health Centre in Saint John, NB.
Participants Patients who were older than 18 years of age and had a body mass index (BMI) greater than 30 kg/m2 were invited to participate in this study.
Intervention Ten participants were enrolled in an SMA program, which consisted of 90-minute group sessions once weekly for 10 weeks. Lifestyle and readiness-to-change questionnaires and measurement of BMI and systolic and diastolic blood pressure were completed prior to commencing the program, at the end of the 10 weeks, and 6 months after completion of the program. Systolic and diastolic blood pressure and BMI were recorded at each weekly session.
Main outcome measures Participants’ BMI measurements, blood pressure, dietary habits, physical activity levels, and readiness-to-change levels were compared before and after the intervention, as well as at 6 months afterward.
Results At the end of the 10-week intervention, all patients had dropped an average of 4.4% from their baseline BMI, and all but 2 of the patients continued to lower their BMI an average of 1.7% during the 6-month follow-up period. Blood pressure levels were not statistically different from baseline to follow-up. Readiness to change physical activity changed over time, increasing at the end of the 10-week program but decreasing at the 6-month follow-up mark.
Conclusion Shared medical appointments are an effective approach to supporting people in losing weight. Readiness to change, which is an integral part of making positive behavioural changes, might need to be supported in an ongoing way to achieve long-term weight loss.
Beliefs and experiences of palliative care patients and their physicians when using cannabinoids for care
- Amrish Joshi, MD MB BS CCFP DipPalMed and
- Pippa Hawley, MD FRCPC
Abstract
Context There has been much media coverage of the use of cannabis and synthetic cannabinoids for numerous ailments, as well as debate on legislation and prescribing. Some physicians prescribe cannabis or synthetic cannabinoids at their patients’ request; others might recommend their use as part of symptom management.
Objective To explore the beliefs and experiences of palliative care patients and palliative care physicians when using cannabinoids in medical care.
Design A qualitative approach recorded the experiences of patients and doctors.
Setting The End of Life Care Program for Fraser Health Authority in British Columbia.
Participants Patients receiving specialist palliative care and their treating physicians. Both patients and physicians were part of the End of Life Care Program for Fraser Health Authority. A total of 8 patients and 9 physicians were interviewed.
Methods A semistructured interview was administered, and a thematic analysis of the data was conducted. Theoretical constructs were then conceived from the recurring themes.
Results Twelve patient subthemes and 14 physician subthemes were identified. The themes identified from interviews with the patients included patient level of perception, recasting the viewpoint, perception of others, drawbacks to treatment, symptom control, and perceived benefits. The themes identified from interviews with the physicians included level of cognizance, recasting the viewpoint, perception of others, drawbacks to treatment, symptom control, and perceived benefits.
Conclusion Medicinal and recreational uses of cannabis need to be disentangled when considering evidence-based prescribing. Poor knowledge and misinformation have resulted in conflict between societal concerns and best medical treatment. Further studies are required on the use of medicinal cannabis in palliative care.
Mannitol cream in the treatment of postherpetic neuralgia
Randomized, placebo-controlled, crossover pilot study
- Helene Bertrand, MD CM CCFP LM,
- Marylene Kyriazis, PharmD,
- Dean Reeves, MD,
- An Lin Cheng, PhD and
- Tess Debelle
Abstract
Context Current treatments for postherpetic neuralgia are not very effective and, in the most-often-affected elderly population, have multiple side effects and addiction potential.
Objective To determine whether a cream containing mannitol can relieve the pain of postherpetic neuralgia.
Design Double-blind, randomized, placebo-controlled, crossover pilot project.
Participants Eleven men and 9 women who suffered from postherpetic neuralgia for a median of 54 months (5 to 252 months). Median daily worst pain was 7 out of 10; median daily average pain was 5 out of 10.
Intervention Participants were observed for 1 week, then they received either the cream with mannitol or the same cream without mannitol, randomly allocated in the second week. After a 3-day washout period, they received the other cream for 1 week.
Main outcome measures Numeric rating scale for pain on a scale of 0 to 10.
Results On day 7, patients’ pain scores improved a mean of 0.5 when using the cream without the mannitol, while the pain scores of those using the cream with the mannitol improved a mean of 1.15 (P = .074). One patient dropped out because she developed a rash when using the mannitol cream, and 2 patients dropped out because they stated the mannitol cream increased their pain.
Discussion Although the average improvement in pain levels was better with the cream containing mannitol, the difference was not significant. This is consistent with other studies on topical treatments for postherpetic neuralgia, where the dropout rate is in the range of 40% and fewer than half of the participants find relief of their pain. It might be that the trial period was too short, as most randomized controlled studies last more than 2 weeks for each treatment; because of this, a 3-month open-label study follows the current study. The mannitol-containing cream is slightly granular, and rubbing it on participants’ sensitized skin might have produced irritation that worsened symptoms and might have produced a rash. Menthol increases the skin absorption of mannitol by a factor of 100. One of the dropouts’ pain was almost completely relieved by the same mannitol cream with menthol (1.25%) added. All further studies will be done on creams containing mannitol and menthol with a menthol placebo.
Conclusion One week of mannitol cream alone did not relieve postherpetic neuralgia.
Developing an intervention to improve opioid guideline adherence using a behaviour change framework and theory
- Caitlyn Timmings, MPH,
- Pamela Leece, MD CCFP FRCPC MSc,
- Julia Moore, PhD,
- Yalnee Shantharam and
- Andrea Furlan, PhD MD
Abstract
Context Opioid prescribing varies widely and often deviates from current clinical guidelines. Implementation science can assist with the development of effective implementation strategies for opioid guidelines.
Objective To develop an evidence-informed, theory-informed intervention for improving family physician adherence to opioid prescribing guidelines for chronic pain.
Design This phase of our larger research program focused on mapping potential facilitators and barriers to physician adherence to opioid prescribing guidelines to a behaviour change framework, the Theoretical Domains Framework (TDF), and theory, the Capability, Opportunity, Motivation, and Behaviour model, to guide the development of an evidence-informed, theory-driven multifaceted intervention. First, we conducted a literature search to identify relevant barriers and facilitators to opioid guideline use. Then, 3 independent raters mapped the identified barriers and facilitators to behaviour change domains using the TDF. Next, we analyzed the components of a pilot intervention for opioid prescribers for coverage and gaps in addressing each behaviour change domain. Based on this analysis, we will modify the pilot intervention and will evaluate its effectiveness.
Main outcome measures Outcomes of the mapping process included identifying barriers and facilitators to opioid guideline adherence, coding these according to the TDF behaviour change domains, and selecting evidence-informed, theory-driven implementation strategies to address each of the behaviour change domains.
Main findings We found few articles that directly investigated the barriers and facilitators to opioid guideline adherence. Among the most pertinent articles, barriers identified at the provider level included lack of education, complicated dosing calculations, and time-consuming assessments. The pilot program includes educational and quality improvement components. Gaps in addressing TDF domains include developing educational materials to address the provider-level barrier of role confusion, as well as use of an opinion leader or champions strategy to tap into barriers related to social influence.
Conclusion Using a systematic, theoretical process grounded in implementation science methods might assist with developing effective interventions to improve adherence to opioid prescribing guidelines.
Measurement of medication discrepancies and use of medication wallet cards to increase patient self-efficacy
- Rimpy Cheema, MB BCh BAO,
- Stephanie Kwolek, MD,
- Justin Frias, MD,
- Dee Mangin, MB ChB DPH FRNZCGP,
- Ainsley Moore, MD CCFP MSc(HB) and
- Muhib Masrur
Abstract
Context In Canada, 70 000 preventable adverse drug events occur each year, and 24% of these are related to medication errors, which include discrepancies between personal, physician, hospital, and pharmacy medication records.
Objective To quantify and compare rates of medication discrepancies between family health team (FHT) electronic medication records (EMR) and community pharmacy medication lists, and to understand the effect of a medication wallet card (MWC) tool on patients’ self-efficacy regarding their medication and health management.
Design This is a 2-part study. Part 1: Quantitative analysis of the frequency of discrepancies between family physician EMRs and community pharmacy medication lists. Part 2: Pilot randomized controlled trial comparing patients’ self-efficacy scores in relation to the introduction of a MWC, compared with usual care.
Setting McMaster FHT in Hamilton, Ont.
Participants A total of 100 McMaster FHT patients older than 70 years of age taking 5 or more medications were identified from a larger study, TAPER (Team Approach to Polypharmacy Evaluation and Reduction).
Intervention Data collection based on requested medication lists from patients’ pharmacies compared with physicians’ EMRs. An MWC will be explained and provided to those randomized to the intervention group (n = 50). The comparator group will receive usual care (n = 50).
Main outcome measures Quantification of medication discrepancies, including dosages and frequency, unidentified discontinued medications, and those prescribed by others not included in the FHT EMR. We will use t test scores to detect significant differences between summarized patients’ enablement scores among intervention and comparator groups. Feedback from patients’ regarding uptake and usability of the MWC will be solicited.
Results We anticipate frequent discrepancies, most likely related to medications prescribed by other providers. We hypothesize a significant increase in patient enablement for those receiving the MWC versus usual care.
Conclusion This study addresses common and critical problems related to medication prescribing in family medicine. It reveals the extent of the problem for family clinician prescribers. It also evaluates feasibility and potential effectiveness of a simple patient enablement tool (the MWC) to empower patient medication management.
Footnotes
These abstracts have been peer reviewed
Ces résumés ont fait l’objet d’une révision par des pairs
- Copyright© the College of Family Physicians of Canada