Priorities among effective clinical preventive services in British Columbia, Canada.

BACKGROUND: Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing. METHODS: We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained. RESULTS: Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services. CONCLUSIONS: These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Survey of perceptions and educational needs of primary care providers regarding management of patients with class II and III obesity in Ontario, Canada.

BACKGROUND: Primary care providers (PCPs) are typically the primary contact for patients with obesity seeking medical and surgical weight loss interventions; however, previous studies suggest that fewer than 7% of eligible adult patients are referred to publically funded medical and surgical weight loss interventions (MSWLI). METHODS: We performed an anonymous survey study between October 2017 and June 2018 to explore the knowledge, experiences, perceptions, and educational needs of PCPs in Southeastern Ontario in managing patients with class II and III obesity. RESULTS: Surveys were distributed to 591 PCPs (n = 538 family physicians; n = 53 nurse practitioners) identified as practicing in the Southeastern Ontario and 92 (15.6%) participated. PCPs serving a rural population estimated that 14.2 ± 10.9% of patients would qualify for MSWLI compared to 9.9 ± 8.5% of patients of PCPs serving an urban population (p = .049). Overall, 57.5% of respondents did not feel competent prescribing MSWLI to patients with class II/III obesity, while 69.8% stated they had 'good' knowledge of the referral criteria for MSWLI. 22.2% of respondents were hesitant to refer patients for bariatric surgery (BS) due to concerns about postoperative surgical complications and risks associated with surgery. Only 25% of respondents were comfortable providing long-term follow up after BS, and only 39.1% had participated in continuing education on management of patients with class II/III obesity in the past 5 years. CONCLUSION: The majority of PCPs believe there is a need for additional education about MSWLI for patients with class II/III obesity. Future studies are needed to develop and compare the effectiveness of additional education and professional development around risks of contemporary BS, indications to consider referral for MSWLI, management and long-term follow-up of patients after BS.

Colonoscopy resource availability and its association with the colorectal cancer diagnostic interval: A population-based cross-sectional study.

BACKGROUND: Colonoscopy is a key resource used to diagnose colorectal cancer (CRC). This study evaluated the relationship between colonoscopy availability and the length of the CRC diagnostic interval. METHODS: This is a cross-sectional study of CRC patients diagnosed in Ontario, Canada, in 2008-2012. We used administrative health data to characterise colonoscopist density, private colonoscopy clinic access, distance to the closest colonoscopist and the diagnostic interval, defined as the time from patients' first cancer-related healthcare encounter to their cancer diagnosis date. We used multivariable quantile regression to evaluate the association between colonoscopy availability and the diagnostic interval, modelling the median and 90th percentile. RESULTS: The median diagnostic interval was 84 days (90th percentile 323 days). The diagnostic interval was longer in patients residing in areas with lower colonoscopists density or private clinic access (adjusted median difference = 9 and 19 days, respectively), with evidence of effect modification by symptom status. Increased distance to a colonoscopist was associated with a longer diagnostic interval in asymptomatic patients, but a shorter diagnostic interval in symptomatic patients (adjusted median difference = 29 and -25 days, respectively). CONCLUSIONS: This study demonstrated that reduced colonoscopy resource availability is associated with longer diagnostic intervals for CRC patients.

Correction to: Twenty-five years on: revisiting Bosnia and Herzegovina after implementation of a family medicine development program.

Following publication of the original article [1], the authors opted to correct the name of co-author Amra Zalihic from Zahilic to Zalihic. The original article has been corrected.

Twenty-five years on: revisiting Bosnia and Herzegovina after implementation of a family medicine development program.

BACKGROUND: The wars that ravaged the former Socialist Federal Republic of Yugoslavia in the 1990's resulted in the near destruction of the healthcare system, including education of medical students and the training of specialist physicians. In the latter stages of the war, inspired by Family Medicine programs in countries such as Canada, plans to rebuild a new system founded on a strong primary care model emerged. Over the next fifteen years, the Queen's University Family Medicine Development Program in Bosnia and Herzegovina played an instrumental role in rebuilding the primary care system through educational initiatives at the undergraduate, residency, Masters, PhD, and continuing professional development levels. Changes were supported by new laws and regulations to insure sustainability. This study revisited Bosnia and Herzegovina (B-H) 8-years after the end of the program to explore the impact of initiatives through understanding the perspectives and experiences of individuals at all levels of the primary care system from students, deans of medical schools, Family Medicine residents, practicing physicians, Health Center Directors and Association Leaders. METHODS: Qualitative exploratory design using purposeful sampling. Semi-structured interviews and focus groups with key informants were conducted in English or with an interpreter as needed and audiotaped. Transcripts and field notes were analyzed using an interpretative phenomenological approach to identify major themes and subthemes. RESULTS: Overall, 118 participants were interviewed. Three major themes and 9 subthemes were identified including (1) The Development of Family Medicine Education, (subthemes: establishment of departments of family medicine, undergraduate medical curriculum change), (2) Family Medicine as a Discipline (Family Medicine specialization, academic development, and Family Medicine Associations), and (3) Health Care System Issues (continuity of care, comprehensiveness of care, practice organization and health human resources). CONCLUSIONS: Despite the impact of years of war and the challenges of a complex and unstable postwar environment, initiatives introduced by the Queen's Program succeeded in establishing sustainable changes, allowing Family Medicine in B-H to continue to adapt without abandoning its strong foundations. Despite the success of the program, the undervaluing of Primary Care from a human resource and health finance perspective presents ongoing threats to the system.

Validation of an EMR algorithm to measure the prevalence of ADHD in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN).

BACKGROUND: Building and validating electronic algorithms to identify patients with specific disease profiles using health data is becoming increasingly important to disease surveillance and population health management. The aim of this study was to develop and validate an algorithm to find patients with ADHD diagnoses within primary care electronic medical records (EMR); and then use the algorithm to describe the epidemiology of ADHD from 2008 to 2015 in a Canadian Primary care sample. METHODS: This was a cross sectional time series that used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a repository of primary care EMR data. A sample of electronic patient charts from one local clinic were manually reviewed to determine the positive predictive value (PPV) and negative predictive value (NPV) of an ADHD case-finding algorithm. In each study year a practice population was determined, and the algorithm was used to measure an observed prevalence of ADHD. The observed prevalence was adjusted for misclassification, as measured by the validity indices, to obtain an estimate of the true prevalence. Estimates were calculated by age group (4-17 year olds, 18 to 34 year olds, and 35 to 64 year olds) and gender, and compared over time. RESULTS: The EMR algorithm had a PPV of 98.0% (95% CI [92.5, 99.5]) and an NPV of 95.0% (95% CI [92.9, 98.6]). After adjusting for misclassification, it was determined that the prevalence of patients with a clinical diagnosis of ADHD has risen in all age groups between 2008 and 2015, most notably in children and young adults (6.92, 95% CI [5.62, 8.39] to 8.57, 95% CI [7.32, 10.00]; 5.73, 95% CI [4.40, 7.23] to 7.33, 95% CI [6.04, 8.78], respectively). The well-established gender gap persisted in all age groups across time but was considerably smaller in older adults compared to children and young adults. CONCLUSION: Overall, the ADHD case-finding algorithm was found to be a valid tool to assess the epidemiology of ADHD in Canadian primary care practice. The increased prevalence of ADHD between 2008 and 2015 may reflect an improvement in the recognition and treatment of this disorder within primary care.

Bridging the gap in genetics: a progressive model for primary to specialist care.

BACKGROUND: The rapid expansion of genetic knowledge, and the implications for healthcare has resulted in an increased role for Primary Care Providers (PCPs) to incorporate genetics into their daily practice. The objective of this study was to explore the self-identified needs, including educational needs, of both urban and rural Primary Care Providers (PCPs) in order to provide genetic care to their patients. METHODS: Using a qualitative grounded theory approach, ten key informant interviews, and one urban and two rural PCP focus groups (FGs) (n = 19) were conducted. All PCPs practiced in Southeastern Ontario. Data was analyzed using a constant comparative method and thematic design. The data reported here represent a subset of a larger study. RESULTS: Participants reported that PCPs have a responsibility to ensure patients receive genetic care. However, specific roles and responsibilities for that care were poorly defined. PCPs identified a need for further education and resources to enable them to provide care for individuals with genetic conditions. Based on the findings, a progressive stepped model that bridges primary and specialty genetic care was developed; the model ranged from PCPs identifying patients with genetic conditions that they could manage alone, to patients who they could manage with informal or electronic consultation to those who clearly required specialist referral. CONCLUSIONS: PCPs identified a need to integrate genetics into primary care practice but they perceived barriers including a lack of knowledge and confidence, access to timely formal and informal consultation and clearly defined roles for themselves and specialists. To address gaps in PCP confidence in providing genetic care, interventions that are directed at accessible just-in-time support and consultation have the potential to empower PCPs to manage patients' genetic conditions. Specific attention to content, timing, and accessibility of educational interventions is critical to address the needs of both urban and rural PCPs. A progressive framework for bridging primary to specialty care through a 'stepped' model for providing continuing medical education, and genetic care can was developed and can be used to guide future design and delivery of educational interventions and resources.

The role of the practice facilitators in Ontario primary healthcare quality improvement.

BACKGROUND: Practice facilitation is a key component of quality improvement in primary healthcare. Studies have reported the effectiveness of practice facilitation in improving quality management and care delivery. However, little has been published about practice facilitators' training, facilitation activities, and their perceived role in quality improvement in primary healthcare. This study examined practice facilitators' training and the perceptions of the practice facilitator role in a provincial primary healthcare learning collaborative quality improvement initiative in Ontario, Canada. METHOD: Descriptive and qualitative methods were used to outline the practice facilitator training as well as to look into the experiences and perceptions of practice facilitators and primary healthcare teams regarding the practice facilitation role in quality improvement. Data collection included training artifacts, activity logs, self-reflection reports, and semi-structured interviews with practice facilitators and primary healthcare participants. Reflections and interviews were analyzed to identify the role of the practice facilitators from their own experience, and from the perspective of the participants. Descriptive statistics were used to learn about categories of facilitation activities undertaken and frequency of these activities. RESULTS: Sixteen practice facilitators and seven family healthcare teams participated in the study. Practice facilitators received a two-day intensive training workshop and continued training. Their time was spent mostly working directly with participating teams, continued learning and training, communications and administration. They served as coaches, resource providers, enablers and motivators. Participating teams expressed satisfaction with the practice facilitator role, although they had hoped this position would provide onsite and hands-on support in conducting activities of quality improvement at the practice level. CONCLUSIONS: Practice facilitators played a crucial role in the implementation of quality improvement in Ontario's learning collaborative program. The practice facilitator role is perceived to be that of a coach, enabler and motivator. This study suggests that the practice facilitator successfully supported participating teams to undertake quality improvement activities in primary healthcare settings.

Actionable nuggets: knowledge translation tool for the needs of patients with spinal cord injury.

OBJECTIVE: To present the results of a pilot study of an innovative methodology for translating best evidence about spinal cord injury (SCI) for family practice. DESIGN: Review of Canadian and international peer-reviewed literature to develop SCI Actionable Nuggets, and a mixed qualitative-quantitative evaluation to determine Nuggets' effect on physician knowledge of and attitudes toward patients with SCI, as well as practice accessibility. SETTING: Ontario, Newfoundland, and Australia. PARTICIPANTS: Forty-nine primary care physicians. METHODS: Twenty Actionable Nuggets (pertaining to key health issues associated with long-term SCI) were developed. Nugget postcards were mailed weekly for 20 weeks to participating physicians. Prior knowledge of SCI was self-rated by participants; they also completed an online posttest to assess the information they gained from the Nugget postcards. Participants' opinions about practice accessibility and accommodations for patients with SCI, as well as the acceptability and usefulness of Nuggets, were assessed in interviews. MAIN FINDINGS: With Actionable Nuggets, participants' knowledge of the health needs of patients with SCI improved, as knowledge increased from a self-rating of fair (58%) to very good (75%) based on posttest quiz results. The mean overall score for accessibility and accommodations in physicians' practices was 72%. Participants' awareness of the need for screening and disease prevention among this population also increased. The usefulness and acceptability of SCI Nugget postcards were rated as excellent. CONCLUSION: Actionable Nuggets are a knowledge translation tool designed to provide family physicians with concise, practical information about the most prevalent and pressing primary care needs of patients with SCI. This evidence-based resource has been shown to be an excellent fit with information consumption processes in primary care. They were updated and adapted for distribution by the Canadian Medical Association to approximately 50,000 primary care physicians in Canada, in both English and French.

Validating the 8 CPCSSN case definitions for chronic disease surveillance in a primary care database of electronic health records.

PURPOSE: The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first national chronic disease surveillance system based on electronic health record (EHR) data. The purpose of this study was to develop and validate case definitions and case-finding algorithms used to identify 8 common chronic conditions in primary care: chronic obstructive pulmonary disease (COPD), dementia, depression, diabetes, hypertension, osteoarthritis, parkinsonism, and epilepsy. METHODS: Using a cross-sectional data validation study design, regional and local CPCSSN networks from British Columbia, Alberta (2), Ontario, Nova Scotia, and Newfoundland participated in validating EHR case-finding algorithms. A random sample of EHR charts were reviewed, oversampling for patients older than 60 years and for those with epilepsy or parkinsonism. Charts were reviewed by trained research assistants and residents who were blinded to the algorithmic diagnosis. Sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) were calculated. RESULTS: We obtained data from 1,920 charts from 4 different EHR systems (Wolf, Med Access, Nightingale, and PS Suite). For the total sample, sensitivity ranged from 78% (osteoarthritis) to more than 95% (diabetes, epilepsy, and parkinsonism); specificity was greater than 94% for all diseases; PPV ranged from 72% (dementia) to 93% (hypertension); NPV ranged from 86% (hypertension) to greater than 99% (diabetes, dementia, epilepsy, and parkinsonism). CONCLUSIONS: The CPCSSN diagnostic algorithms showed excellent sensitivity and specificity for hypertension, diabetes, epilepsy, and parkinsonism and acceptable values for the other conditions. CPCSSN data are appropriate for use in public health surveillance, primary care, and health services research, as well as to inform policy for these diseases.

Social isolation in older adults who are frequent users of primary care services.

OBJECTIVE: To describe older adults who are frequent users of primary care services and to explore associations between the number of primary care visits per year and multiple dimensions that define social isolation. DESIGN: Mailed, cross-sectional survey. SETTING: An urban academic primary care practice in Kingston, Ont. PARTICIPANTS: Forty patients aged 70 years and older who attended 12 or more appointments in the previous year with residents, physicians, nurses, nurse practitioners, or registered practical nurses. MAIN OUTCOME MEASURES: Social isolation (size of close social network, loneliness, satisfaction with social participation, frequency of social participation), past and future need for health services related to social issues, and health and functional variables. RESULTS: The participants reported relatively low levels of loneliness, with a mean (SD) score of 4.1 (1.3) out of 9. Overall, 18.9% of participants reported having a small close social network, 45.9% of participants wanted to do more social activities, and 57.5% of participants were isolated according to at least 1 indicator. Some participants (23.1%) had received primary care services related to social issues, and most participants (54.5%) wanted these services in the future, including receiving information about other health services or community resources, or having discussions about loneliness, relationships, or social activities. Number of primary care visits was not associated with any of the 4 indicators of social isolation. CONCLUSION: Social isolation in older, frequent users of primary care services might be more common than previously thought, particularly the aspect of dissatisfaction with social participation. Expanded primary care services and referrals to other services might help to address this population's desires for services related to social issues. Future research could examine the social needs of older primary care attenders and the feasibility of providing related interventions in primary care settings.

Developing a method to estimate practice denominators for a national Canadian electronic medical record database.

BACKGROUND: Calculating disease prevalence requires both a numerator (number of persons with a disease) and a matching denominator (the 'population at risk' being studied). Determining primary care practice denominators is challenging. OBJECTIVE: To develop and test a method to calculate primary care practice denominators. METHODS: We compared a 'corrected yearly contact group', or practice population, with the number of patients enrolled with practices. The yearly contact group was the set of patients with a visit noted in the electronic medical records during the past year. The correction factor was the proportion of patients that reported contacting their physician in the past year. Eighty-one physicians from Toronto and Kingston, Ontario, provided data. The main outcome measure was the ratio of practice population to the number of enrolled patients. Other measures included the change in ratio over 2 years, differences between locations, and differences by provider, practice and patient characteristics. RESULTS: The ratio of practice population to enrolled patients was 1.03 in 2010 (95% confidence interval 1.00 to 1.05) and 1.03 in 2011 (95% confidence interval 1.00 to 1.05). There was no change in the ratio over time. Ratios by location, provider or practice characteristics differed by less than 10%. There was a slight under-estimation of practice population for younger male patients and over-estimation for female patients. CONCLUSION: This method provided a denominator that was reasonably similar to the enrolled population and was stable over time and by location, provider and practice characteristics. In regions without patient enrollment, this may provide an estimate of practice denominators.

pH1N1 - a comparative analysis of public health responses in Ontario to the influenza outbreak, public health and primary care: lessons learned and policy suggestions.

BACKGROUND: Ontario's 36 Public Health Units (PHUs) were responsible for implementing the H1N1 Pandemic Influenza Plans (PIPs) to address the first pandemic influenza virus in over 40 years. It was the first under conditions which permitted mass immunization. This is therefore the first opportunity to learn and document what worked well, and did not work well, in Ontario's response to pH1N1, and to make recommendations based on experience. METHODS: Our objectives were to: describe the PIP models, obtain perceptions on outcomes, lessons learned and to solicit policy suggestions for improvement. We conducted a 3-phase comparative analysis study comprised of semi-structured key informant interviews with local Medical Officers of Health (n=29 of 36), and Primary Care Physicians (n=20) and in Phase 3 with provincial Chief-Medical Officers of Health (n=6) and a provincial Medical Organization. Phase 2 data came from a Pan-Ontario symposium (n=44) comprised leaders representing: Public Health, Primary Care, Provincial and Federal Government. RESULTS: PIPs varied resulting in diverse experiences and lessons learned. This was in part due to different PHU characteristics that included: degree of planning, PHU and Primary Care capacity, population, geographic and relationships with Primary Care. Main lessons learned were: 1) Planning should be more comprehensive and operationalized at all levels. 2) Improve national and provincial communication strategies and eliminate contradictory messages from different sources. 3) An integrated community-wide response may be the best approach to decrease the impact of a pandemic. 4) The best Mass Immunization models can be quickly implemented and have high immunization rates. They should be flexible and allow for incremental responses that are based upon: i) pandemic severity, ii) local health system, population and geographic characteristics, iii) immunization objectives, and iv) vaccine supply. CONCLUSION: "We were very lucky that pH1N1 was not more severe." Consensus existed for more detailed planning and the inclusion of multiple health system and community stakeholders. PIPs should be flexible, allow for incremental responses and have important decisions (E.g., under which conditions Public Health, Primary Care, Pharmacists or others act as vaccine delivery agents.) made prior to a crisis.

Recommendations on screening for high blood pressure in Canadian adults.

OBJECTIVE: To provide recommendations on screening for hypertension in adults aged 18 years and older without previously diagnosed hypertension. QUALITY OF EVIDENCE: Evidence was found through a systematic search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews (EBM Reviews), from January 1985 to September 2011. Study types were limited to randomized controlled trials, systematic reviews, and observational studies with control groups. MAIN MESSAGE: Three strong recommendations were made based on moderate-quality evidence. It is recommended that blood pressure measurement occur at all appropriate primary care visits, according to the current techniques described in the Canadian Hypertension Education Program recommendations for office and ambulatory blood pressure measurement. The Canadian Hypertension Education Program criteria for assessment and diagnosis of hypertension should be applied for people found to have elevated blood pressure. CONCLUSION: After review of the most recent evidence, the Canadian Task Force on Preventive Health Care continues to recommend blood pressure measurement during regular physician visits.

Assessing methods for measurement of clinical outcomes and quality of care in primary care practices.

PURPOSE: To evaluate the appropriateness of potential data sources for the population of performance indicators for primary care (PC) practices. METHODS: This project was a cross sectional study of 7 multidisciplinary primary care teams in Ontario, Canada. Practices were recruited and 5-7 physicians per practice agreed to participate in the study. Patients of participating physicians (20-30) were recruited sequentially as they presented to attend a visit. Data collection included patient, provider and practice surveys, chart abstraction and linkage to administrative data sets. Matched pairs analysis was used to examine the differences in the observed results for each indicator obtained using multiple data sources. RESULTS: Seven teams, 41 physicians, 94 associated staff and 998 patients were recruited. The survey response rate was 81% for patients, 93% for physicians and 83% for associated staff. Chart audits were successfully completed on all but 1 patient and linkage to administrative data was successful for all subjects. There were significant differences noted between the data collection methods for many measures. No single method of data collection was best for all outcomes. For most measures of technical quality of care chart audit was the most accurate method of data collection. Patient surveys were more accurate for immunizations, chronic disease advice/information dispensed, some general health promotion items and possibly for medication use. Administrative data appears useful for indicators including chronic disease diagnosis and osteoporosis/ breast screening. CONCLUSIONS: Multiple data collection methods are required for a comprehensive assessment of performance in primary care practices. The choice of which methods are best for any one particular study or quality improvement initiative requires careful consideration of the biases that each method might introduce into the results. In this study, both patients and providers were willing to participate in and consent to, the collection and linkage of information from multiple sources that would be required for such assessments.