Building capacity for medical education research in family medicine: the Program for Innovation in Medical Education (PIME).

BACKGROUND: Despite the apparent benefits to teaching, many faculty members are reluctant to participate in medical education research (MER) for a variety of reasons. In addition to the further demand on their time, physicians often lack the confidence to initiate MER projects and require more support in the form of funding, structure and guidance. These obstacles have contributed to a decline in physician participation in MER as well as to a perceived decay in its quality. As a countermeasure to encourage physicians to undertake research, the Department of Family Medicine at the University of Ottawa implemented a programme in which physicians receive the funding, coaching and support staff necessary to complete a 2-year research project. The programme is intended primarily for first-time researchers and is meant to serve as a gateway to a research career funded by external grants. Since its inception in 2010, the Program for Innovation in Medical Education (PIME) has supported 16 new clinician investigators across 14 projects. METHODS: We performed a programme evaluation 3 years after the programme launched to assess its utility to participants. This evaluation employed semi-structured interviews with physicians who performed a research project within the programme. RESULTS: Programme participants stated that their confidence in conducting research had improved and that they felt well supported throughout their project. They appreciated the collaborative nature of the programme and remarked that it had improved their willingness to solicit the expertise of others. Finally, the programme allowed participants to develop in the scholarly role expected by family physicians in Canada. CONCLUSION: The PIME may serve as a helpful model for institutions seeking to engage faculty physicians in Medical Education Research and to thereby enhance the teaching received by their medical learners.

Effect of nurse practitioner and pharmacist counseling on inappropriate medication use in family practice.

OBJECTIVE: To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients. DESIGN: We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management. SETTING: Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont. PARTICIPANTS: A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes. INTERVENTION: A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later. MAIN OUTCOME MEASURES: We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial. RESULTS: At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50). CONCLUSION: We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses. TRIAL REGISTRATION NUMBER: NCT00238836 (ClinicalTrials.gov).

Striving for excellence: developing a framework for the Triple C curriculum in family medicine education.

PROBLEM ADDRESSED: Postgraduate medical education programs will need to be restructured in order to respond to curriculum initiatives promoted by the College of Family Physicians of Canada. OBJECTIVE OF PROGRAM: To develop a framework for the Triple C Competency-based Curriculum that will help provide residents with quality family medicine (FM) education programs. PROGRAM DESCRIPTION: The Family Medicine Curriculum Framework (FMCF) incorporates the 4 principles of FM, the CanMEDs-FM roles, the Triple C curriculum principles, the curriculum content domains, and the pedagogic strategies, all of which support the development of attitudes, knowledge, and skills in postgraduate FM training programs. CONCLUSION: The FMCF was an effective approach to the development of an FM curriculum because it incorporated not only core competencies of FM health education but also contextual educational values, principles, and dynamic learning approaches. In addition, the FMCF provided a foundation and quality standard to designing, delivering, and evaluating the FM curriculum to ensure it met the needs of FM education stakeholders, including preceptors, residents, and patients and their families.

Methods for a study of Anticipatory and Preventive multidisciplinary Team Care in a family practice.

UNLABELLED: BACKGROUND T o examine the methodology used to evaluate whether focusing the work of nurse practitioners and a pharmacist on frail and at-risk patients would improve the quality of care for such patients. DESIGN: Evaluation of methodology of a randomized controlled trial including analysis of quantitative and qualitative data over time and analysis of cost-effectiveness. SETTING: A single practice in a rural area near Ottawa, Ont. PARTICIPANTS: A total of 241 frail patients, aged 50 years and older, at risk of experiencing adverse health outcomes. INTERVENTION: At-risk patients were randomly assigned to receive Anticipatory and Preventive Team Care (from their family physicians, 1 of 3 nurse practitioners, and a pharmacist) or usual care. MAIN OUTCOME MEASURES: The principal outcome for the study was the quality of care for chronic disease management. Secondary outcomes included other quality of care measures and evaluation of the program process and its cost-effectiveness. This article examines the effectiveness of the methodology used. Quantitative data from surveys, administrative databases, and medical records were supplemented with qualitative information from interviews, focus groups, work logs, and study notes. CONCLUSION: Three factors limit our ability to fully demonstrate the potential effects of this team structure. For reasons outside our control, the intervention duration was shorter than intended; the practice's physical layout did not facilitate interactions between the care providers; and contamination of the intervention effect into the control arm cannot be excluded. The study used a randomized design, relied on a multifaceted approach to evaluating its effects, and used several sources of data. TRIAL REGISTRATION NUMBER NCT00238836 (CONSORT).

Randomized controlled trial of anticipatory and preventive multidisciplinary team care: for complex patients in a community-based primary care setting.

OBJECTIVE: T o examine whether quality of care (QOC) improves when nurse practitioners and pharmacists work with family physicians in community practice and focus their work on patients who are 50 years of age and older and considered to be at risk of experiencing adverse health outcomes. DESIGN: Randomized controlled trial. SETTING: A family health network with 8 family physicians, 5 nurses, and 11 administrative personnel serving 10 000 patients in a rural area near Ottawa, Ont. PARTICIPANTS: Patients 50 years of age and older at risk of experiencing adverse health outcomes (N = 241). INTERVENTIONS: At-risk patients were randomly assigned to receive usual care from their family physicians or Anticipatory and Preventive Team Care (APTCare) from a collaborative team composed of their physicians, 1 of 3 nurse practitioners, and a pharmacist. MAIN OUTCOME MEASURES: Quality of care for chronic disease management (CDM) for diabetes, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease. RESULTS: Controlling for baseline demographic characteristics, the APTCare approach improved CDM QOC by 9.2% (P < .001) compared with traditional care. The APTCare intervention also improved preventive care by 16.5% (P < .001). We did not observe significant differences in other secondary outcome measures (intermediate clinical outcomes, quality of life [Short-Form 36 and health-related quality of life scales], functional status [instrumental activities of daily living scale] and service usage). CONCLUSION: Additional resources in the form of collaborative multidisciplinary care teams with intensive interventions in primary care can improve QOC for CDM in a population of older at-risk patients. The appropriateness of this intervention will depend on its cost-effectiveness. TRIAL REGISTRATION NUMBER NCT00238836 (CONSORT).

Beyond fighting fires and chasing tails? Chronic illness care plans in Ontario, Canada.

PURPOSE: Recent work has conceptualized new models for the primary care management of patients with chronic illness. This study investigated the experience of family physicians and patients with a chronic illness management initiative that involved the joint formulation of comprehensive individual patient care plans. METHODS: A qualitative evaluation, framed by phenomenology, immediately followed a randomized controlled trial examining the effect of external facilitators in enhancing the delivery of chronic condition care planning in primary care. The study, set in Ontario family practices, used semistructured in-depth interviews with a purposive sample of 13 family physicians, 20 patients, and all 3 study facilitators. Analysis used independent transcript review and constant comparative methods. RESULTS: Despite the intervention being grounded in patient-centered principles, family physicians generally viewed chronic illness management from a predominantly biomedical perspective. Only a few enthusiasts viewed systematic care planning as a new approach to managing patients with chronic illness. Most family physicians found the strategy to be difficult to implement within existing organizational and financial constraints. For these participants, care planning conflicted with preexisting concepts of their role and of their patient's abilities to become partners in care. The few patients who noticed the process spoke favorably about their experience. CONCLUSIONS: Although the experiences of the enthusiastic family physicians were encouraging, we found important individual-level barriers to chronic illness management in primary care. These issues seemed to transcend existing organizational and resource constraints.

Improving prevention in primary care: Evaluating the sustainability of outreach facilitation.

OBJECTIVE: To assess the extent to which advances in preventive care delivery, achieved in primary care practices through outreach facilitation, could be sustained over time after purposefully redirecting the focus of practice physicians and staff away from prevention and toward a new content area in need of improvement-chronic illness management. DESIGN: Before-and-after study. SETTING: Primary care networks and family health networks in Ontario. PARTICIPANTS: A volunteer sample of 30 primary care practices recruited from 99 eligible sites. INTERVENTION: Outreach visits directed at modifying physician behaviour were delivered by trained nurse facilitators using practice-tailored systems strategies. For the first 12 months, the intervention focused on improving delivery of preventive care, after which facilitation of chronic illness management was introduced for another 3 to 9 months. MAIN OUTCOME MEASURES: Changes in practices' performance rates for selected preventive maneuvers (according to recommendations of the Canadian Task Force on Preventive Health Care) between baseline and follow-up, conducted 3 to 9 months after the end of the prevention intervention, measured from chart reviews for those maneuvers likely to be recorded and from telephoneinterviews with patients for lifestyle counseling. RESULTS: Four of the 30 practices dropped out of the study. In the remaining practices, at the postintervention follow-up, there was an increase in the delivery of the appropriate grade A (19.3%, 95% confidence interval [CI] 10.4% to 28.3%) and B (9.3%, 95% CI 5.4% to 13.2%) maneuvers, accompanied by a reduction in inappropriate grade D maneuvers (-15.9%, 95% CI -22.1% to -9.6%), for an absolute improvement of 12% (P < .0001) in the overall preventive care performance, as determined by a chart audit. We found no changes in the provision of lifestyle counseling maneuvers measured from telephone interviews with patients (1.3%, 95% CI 1.0% to 3.7%). CONCLUSION: The tailored, multifaceted intervention delivered by nurse facilitators was effective in producing significant improvements in preventive care performance that extended beyond the prevention intervention period.

Telehomecare for patients with multiple chronic illnesses: Pilot study.

OBJECTIVE: To examine the feasibility and efficacy of integrating home health monitoring into a primary care setting. DESIGN: A mixed method was used for this pilot study. It included in-depth interviews, focus groups, and surveys. SETTING: A semirural family health network in eastern Ontario comprising 8 physicians and 5 nurses caring for approximately 10 000 patients. PARTICIPANTS: Purposeful sample of 22 patients chosen from the experimental group of 120 patients 50 years old or older in a larger randomized controlled trial (N = 240). These patients had chronic illnesses and were identified as being at risk based on objective criteria and physician assessment. INTERVENTIONS: Between November 2004 and March 2006, 3 nurse practitioners and a pharmacist installed telehomecare units with 1 or more peripheral devices (eg, blood-pressure monitor, weight scale, glucometer) in patients' homes. The nurse practitioners incorporated individualized instructions for using the unit into each patient's care plan. Patients used the units every morning for collecting data, entering values into the system either manually or directly through supplied peripherals. The information was transferred to a secure server and was then uploaded to a secure Web-based application that allowed care providers to access and review it from any location with Internet access. The devices were monitored in the office on weekdays by the nurse practitioners. MAIN OUTCOME MEASURES: Acceptance and use of the units, patients' and care providers' satisfaction with the system, and patients' demographic and health characteristics. RESULTS: All 22 patients, 12 men and 10 women with an average age of 73 years (range 60 to 88 years), agreed to participate. Most were retired, and a few were receiving community services. Common diagnoses included hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease. All patients had blood pressure monitors installed, 11 had wired weight scales,5 had glucometers, and 5 had pulse oximeters. The units were in place for 9 to 339 days. Three patients asked to have the systems removed early because they did not use them or found them inconvenient. The other patients and their informal caregivers found the technology user-friendly and useful. Health care providers were satisfied with the technology and found the equipment useful. They thought it might reduce the number of office visits patients made and help track long-term trends. CONCLUSION: These pilot results demonstrate that telehomecare monitoring in a collaborative care community family practice is feasible and well used, and might improve access to and quality of care.

Home-based intermediate care program vs hospitalization: Cost comparison study.

OBJECTIVE: To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals. DESIGN: Single-arm study with historical controls. SETTING: Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario. PARTICIPANTS: Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity. INTERVENTIONS: Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone. MAIN OUTCOME MEASURES: Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and costs incurred by community home-care services for patients following discharge from hospital. RESULTS: The outcomes of 43 hospital admissions were matched with those of 363 controls. Patients enrolled in the program stayed longer in hospital (coefficient 3.3 days, P < .001), used more community care services following discharge (coefficient $729, P = .007), and were more likely to be readmitted to hospital within 3 months of discharge (coefficient 17%, P = .012) than patients treated in hospital. Total substituted costs of home-based care were not significantly different from the costs of hospitalization (coefficient -$501, P = .11). CONCLUSION: While estimated cost savings were not statistically significant, the limitations of our study suggest that we underestimated these savings. In particular, the economic inefficiencies of a small immature program and the inability to control for certain factors when selecting historical controls affected our results. Further research is needed to determine the economic effect of mature home-based programs.

Patient, informal caregiver and care provider acceptance of a hospital in the home program in Ontario, Canada.

BACKGROUND: Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting. METHODS: Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed. RESULTS: Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%-100%) and caregivers (92%-100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%-100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise. CONCLUSION: Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.

Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis.

BACKGROUND: Outreach facilitation has been proven successful in improving the adoption of clinical preventive care guidelines in primary care practice. The net costs and savings of delivering such an intensive intervention need to be understood. We wanted to estimate the proportion of a facilitation intervention cost that is offset and the potential for savings by reducing inappropriate screening tests and increasing appropriate screening tests in 22 intervention primary care practices affecting a population of 90,283 patients. METHODS: A cost-consequences analysis of one successful outreach facilitation intervention was done, taking into account the estimated cost savings to the health system of reducing five inappropriate tests and increasing seven appropriate tests. Multiple data sources were used to calculate costs and cost savings to the government. The cost of the intervention and costs of performing appropriate testing were calculated. Costs averted were calculated by multiplying the number of tests not performed as a result of the intervention. Further downstream cost savings were determined by calculating the direct costs associated with the number of false positive test follow-ups avoided. Treatment costs averted as a result of increasing appropriate testing were similarly calculated. RESULTS: The total cost of the intervention over 12 months was $238,388 and the cost of increasing the delivery of appropriate care was $192,912 for a total cost of $431,300. The savings from reduction in inappropriate testing were $148,568 and from avoiding treatment costs as a result of appropriate testing were $455,464 for a total savings of $604,032. On a yearly basis the net cost saving to the government is $191,733 per year (2003 Can dollars) equating to $3,687 per physician or $63,911 per facilitator, an estimated return on intervention investment and delivery of appropriate preventive care of 40%. CONCLUSION: Outreach facilitation is more expensive but more effective than other attempts to modify primary care practice and all of its costs can be offset through the reduction of inappropriate testing and increasing appropriate testing. Our calculations are based on conservative assumptions. The potential for savings is likely considerably higher.

Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program.

BACKGROUND: Serum creatinine concentration is an inadequate screening test for chronic kidney disease, especially in elderly patients. We hypothesized that laboratory reporting of estimated glomerular filtration rate (GFR) accompanied with an educational intervention would improve recognition of chronic kidney disease (CKD). METHODS: We conducted a before-and-after study at an outpatient family medicine practice. Patients 65 years or older for whom a Cockcroft-Gault GFR could be calculated from their medical record were included. The intervention consisted of automatic reporting of estimated GFR by the hospital laboratory along with an educational intervention directed toward the primary care physicians. The primary outcome was the recognition of CKD (defined as a Cockroft-Gault GFR <60 mL/min [<1.0 mL/s]) by the primary care physician. Factors associated with the recognition of CKD were also determined. RESULTS: The study population comprised 324 patients. Prior to the study intervention, 22.4% of patients with CKD were recognized, which increased to 85.1% after the intervention. Before the intervention, recognition was more likely in male subjects (odds ratio, 4.3; 95% confidence interval, 1.9-9.8) and patients with diabetes (odds ratio, 3.4; 95% confidence interval, 1.6-7.6). These associations were no longer statistically significant after the intervention. CONCLUSION: Laboratory reporting of estimated GFR coupled with an educational program markedly improves the recognition of CKD in the primary care setting.

Why do family physicians fail to detect renal impairment?

OBJECTIVE: To investigate why many patients with renal impairment (30.7%) were not recognized by their family physicians despite an earlier educational intervention on detecting renal impairment; and to determine whether certain factors related to physicians, patients, or the intervention itself were associated with whether renal impairment was detected. DESIGN: Qualitative approach using grounded theory. SETTING: A Health Service Organization in Ottawa, Ont. PARTICIPANTS: A purposeful sample of six family physicians. METHODS: In semistructured interviews, participants were asked to describe the workup ordered and their decision-making processes for patients in whom they had recently detected renal impairment. They were also asked to evaluate the six components of an educational intervention designed to help them to detect renal impairment. Finally, one patient's chart was reviewed (a chart containing a laboratory report noting an abnormal result for kidney function and having no indication that renal impairment had been recognized) to identify reasons for lack of detection. RESULTS: Most physicians did not investigate every patient with renal impairment (glomerular filtration rate of < 78 mL/min) in the same way because they took individual patient factors into consideration. Reasons for not detecting renal impairment were "managed differently" or "missed," with the former being the most common. The educational intervention physicians remembered most often was chart rounds, and these were viewed as helpful. "Missed" cases were more often deliberately managed differently than unintentionally not detected. CONCLUSION: Physicians used various approaches to detect and manage renal impairment despite interventions that recommended a consistent procedure.