Regional variations and associations between colonoscopy resource availability and colonoscopy utilisation: a population-based descriptive study in Ontario, Canada.

OBJECTIVE: There is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation. DESIGN: We conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18-99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex. RESULTS: There were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%-55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, p<0.001). Colonoscopy utilisation rates were 4% lower in individuals travelling 50 to <200 km and 11% lower in individuals travelling ≥200 km to colonoscopy, compared to <10 km. There was no association between private clinic access and colonoscopy utilisation. CONCLUSION: The substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decision-makers to address these potential inequalities in access in order to support the use of this medically necessary procedure.

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.

Barriers to accessing weight-loss interventions for patients with class II or III obesity in primary care: a qualitative study.

BACKGROUND: Over 1 million Canadians have class II or III obesity; however, access to weight-loss interventions for these patients remains limited. The purpose of our study was to identify the barriers to accessing medical and surgical weight-loss interventions from the perspectives of 3 groups: family physicians, patients who were referred for weight-loss intervention and patients who were not referred for weight-loss intervention. METHODS: Between November 2017 and May 2018, we conducted a qualitative exploratory research study using focus groups with family physicians and interviews with patients with class II or III obesity from 1 region in southern Ontario. We conducted a thematic analysis to identify emergent themes and used the barriers to change theory to classify the similarities and differences between the perspectives of family physicians, referred patients and nonreferred patients in first- and second-order barriers. RESULTS: Seventeen family physicians participated in 7 focus groups (1-4 participants/group), and we interviewed 8 referred patients and 7 nonreferred patients. We identified lack of resource supports, logistics and lack of knowledge about weight-loss interventions as first-order barriers to change, and lack of knowledge about root causes of obesity, lack of patient readiness for change and family physicians' perceptions about surgical weight loss as second-order barriers to change. Family physicians and patients had similar perceptions regarding lack of resource supports in the community, logistical issues, family physicians' lack of knowledge regarding weight-loss interventions, patients' lack of motivation and family physicians' perceptions of bariatric surgery as being high risk. They differed regarding the root cause of obesity, with family physicians attributing obesity to multiple extrinsic and intrinsic causes, whereas patients believed obesity was largely due to intrinsic causes alone. INTERPRETATION: It is important to address first- and second-order barriers to accessing weight-loss interventions through continuing professional development activities for family physicians to help ensure effective and timely treatment for patients with class II or III obesity and related comorbidities.

Is Screening for Atrial Fibrillation in Canadian Family Practices Cost-Effective in Patients 65 Years and Older?

We present an economic evaluation of a recently completed cohort study in which 2054 seniors were screened for atrial fibrillation (AF) in 22 Canadian family practices. Using a Markov model, trial and literature data were used to project long-term outcomes and costs associated with 4 AF screening strategies for individuals aged 65 years or older: no screening, screen with 30-second radial manual pulse check (pulse check), screen with a blood pressure machine with AF detection (BP-AF), and screen with a single-lead electrocardiogram (SL-ECG). Costs and outcomes were discounted at 1.5% and the model used a lifetime horizon from a public payer perspective. Compared with no screening, screening for AF in Canadian family practice offices using pulse check or screen with a blood pressure machine with AF detection is the dominant strategy whereas screening with SL-ECG is a highly cost-effective strategy with an incremental cost per quality-adjusted life-year (QALY) gained of CAD$4788. When different screening strategies were compared, screening with pulse check had the lowest expected costs ($202) and screening with SL-ECG had the highest expected costs ($222). The no-screening arm resulted in the lowest number of QALYs (8.74195) whereas pulse check and SL-ECG resulted in the highest expected QALYs (8.74362). Probabilistic analysis confirmed that pulse check had the highest probability of being cost-effective (63%) assuming a willingness to pay of $50,000 per QALY gained. Screening for AF in seniors during routine appointments with Canadian family physicians is a cost-effective strategy compared with no screening. Screening with a pulse check is likely to be the most cost-effective strategy.

The Prevalence and Risk for Herpes Zoster Infection in Adult Patients With Diabetes Mellitus in the Canadian Primary Care Sentinel Surveillance Network.

OBJECTIVES: Herpes zoster (HZ) is a common infection in Canada that can result in serious and long-term complications. People with diabetes may be at an increased risk for HZ. The objectives of this study were to develop and validate a case definition of HZ diagnosis based on electronic medical records; determine a prevalence estimate for HZ in adult patients in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and assess the association between HZ and diabetes. METHODS: This was a retrospective cross-sectional study. Patients 18 years of age or older who had made at least 1 visit to their primary health-care providers within the past 2 years in the CPCSSN were included. These data came from a 2015 extract of CPCSSN data, and a subsample of 289 patients was used to validate our case definition. Prevalences were estimated for the overall population and for people with diabetes, chronic obstructive pulmonary disease, cancer or HIV. Risk ratios were modelled for these conditions. RESULTS: The sensitivity, specificity, positive predictive value and negative predictive values for HZ were 100%, 73.8%, 83.9% and 100%, respectively. The 1-year prevalence of HZ in the CPCSSN data was 0.32%. The prevalence of HZ was higher in females (0.35%) than in males (0.28%). People with diabetes have an increased risk for HZ infection (RR 2.64, 95% CI 2.34, 2.99). CONCLUSIONS: People with diabetes have an increased risk for the diagnosis of HZ infection in the primary care setting in Canada. Women over the age of 65 years with diabetes and/or other chronic conditions are at greatest risk for developing HZ.

Impact of a primary healthcare quality improvement program on diabetes in Canada: evaluation of the Quality Improvement and Innovation Partnership (QIIP).

OBJECTIVE: Primary healthcare (PHC) quality improvement (QI) initiatives are designed to improve patient care and health outcomes. We evaluated the Quality Improvement and Innovation Partnership (QIIP), an Ontario-wide PHC QI program on access to care, diabetes management and colorectal cancer screening. This manuscript highlights the impact of QIIP on diabetes outcomes and associated vascular risk factors. RESEARCH DESIGN AND METHODS: A cluster matched-control, retrospective prechart and postchart audit was conducted. One physician per QIIP-PHC team (N=34) and control (N=34) were recruited for the audit. Eligible charts were reviewed for prespecified type 2 diabetes mellitus clinical process and outcome data at baseline, during (intervention range: 15-17.5 months) and post. Primary outcome measures were the A1c of patients above study target and proportion of patients with an annual foot exam. Secondary outcome measures included glycemic, hypertension and lipid outcomes and management, screening for diabetes-related complications, healthcare utilization, and diabetes counseling, education and self-management goal setting. RESULTS: More patients in the QIIP group achieved statistically improved lipid testing, eye examinations, peripheral neuropathy exams, and documented body mass index. No statistical differences in A1c, low-density lipoprotein or systolic/diastolic blood pressure values were noted, with no significant differences in medication prescription, specialist referrals, or chart-reported diabetes counseling, education or self-management goals. Patients of QIIP physicians had significantly more PHC visits. CONCLUSION: The QIIP-learning collaborative program evaluation using stratified random selection of participants and the inclusion of a control group makes this one of the most rigorous and promising efforts to date evaluating the impact of a QI program in PHC. The chart audit component of this evaluation highlighted that while QIIP improved some secondary diabetes measures, no improvements in clinical outcomes were noted. This study highlights the importance of formalized evaluation of QI initiatives to provide an evidence base to inform future program planning and scale-up.

Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study.

BACKGROUND: In Ontario, a province-wide quality-improvement program (Quality Improvement and Innovation Partnership [QIIP]) was implemented between 2008 and 2010 to support improved outcomes in Family Health Teams, a care model that includes many features of the patient-centred medical home. We assessed the impact of this program on diabetes management, colorectal and cervical cancer screening and access to health care. METHODS: We used comprehensive linked administrative data sets to conduct a population-based controlled before-and-after study. Outcome measures included diabetes process-of-care measures (test ordering, retinal examination, medication prescribing and completion of billing items specific to diabetes management), colorectal and cervical cancer screening measures and use of health care services (emergency department visits, hospital admission for ambulatory-care-sensitive conditions and rates of readmission to hospital). The control group consisted of Family Health Team physicians with at least 100 assigned patients during the study follow-up period (November 2009-February 2013). RESULTS: There were 53 physicians in the intervention group and 1178 physicians in the control group. Diabetes process-of-care measures improved more in the intervention group than in the control group: hemoglobin A1c testing 4.3% (95% confidence interval [CI] 1.2-7.5) more, retinal examination 2.5% (95% CI 0.8-4.4) more and preventive care visits 8.9% (95% CI 2.9-14.9) more. Medication prescribing also improved for use of statins (3.4% [95% CI 0.8-6.0] more) and angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers (4.1% [95% CI 1.8-6.4] more). Colorectal cancer screening improved 5.4% (95% CI 3.1-7.8) more in the intervention group than in the control group, and cervical cancer screening improved 2.7% (95% CI 0.9-4.6) more. There were no significant differences in any of the measures of use of health care services. INTERPRETATION: This large controlled evaluation of a broadly implemented quality-improvement initiative showed improvement for diabetes process of care and cancer screening outcomes, but not for proxy measures of access related to use of health care services.

Impact of a quality improvement program on primary healthcare in Canada: a mixed-method evaluation.

PURPOSE: Rigorous comprehensive evaluations of primary healthcare (PHC) quality improvement (QI) initiatives are lacking. This article describes the evaluation of the Quality Improvement and Innovation Partnership Learning Collaborative (QIIP-LC), an Ontario-wide PHC QI program targeting type 2 diabetes management, colorectal cancer (CRC) screening, access to care, and team functioning. METHODS: This article highlights the primary outcome results of an external retrospective, multi-measure, mixed-method evaluation of the QIIP-LC, including: (1) matched-control pre-post chart audit of diabetes management (A1c/foot exams) and rate of CRC screening; (2) post-only advanced access survey (third-next available appointment); and (3) post-only semi-structured interviews (team functioning). RESULTS: Chart audit data was collected from 34 consenting physicians per group (of which 88% provided access data). Between-group differences were not statistically significant (A1c [p=0.10]; foot exams [p=0.45]; CRC screening [p=0.77]; advanced access [p=0.22]). Qualitative interview (n=42) themes highlighted the success of the program in helping build interdisciplinary team functioning and capacity. CONCLUSION: The rigorous design and methodology of the QIIP-LC evaluation utilizing a control group is one of the most significant efforts thus far to demonstrate the impact of a QI program in PHC, with improvements over time in both QIIP and control groups offering a likely explanation for the lack of statistically significant primary outcomes. Team functioning was a key success, with team-based chronic care highlighted as pivotal for improved health outcomes. Policy makers should strive to endorse QI programs with proven success through rigorous evaluation to ensure evidence-based healthcare policy and funding.

The diagnosis of depression and its treatment in Canadian primary care practices: an epidemiological study.

BACKGROUND: A diagnosis of depression is common in primary care practices, but data are lacking on the prevalence in Canadian practices. We describe the prevalence of the diagnosis among men and women, patient characteristics and drug treatment in patients diagnosed with depression in the primary care setting in Canada. METHODS: Using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network, we examined whether the prevalence of a depression diagnosis varied by patient characteristics, the number of chronic conditions and the presence of the following chronic conditions: hypertension, diabetes, chronic obstructive pulmonary disease, osteoarthritis, dementia, epilepsy and parkinsonism. We used regression models to examine whether patient characteristics and type of comorbidity were associated with a depression diagnosis. RESULTS: Of the 304 412 patients who had at least 1 encounter with their primary care provider between Jan. 1, 2011, and Dec. 31, 2012, 14% had a diagnosis of depression. Current or past smokers and women with a high body mass index had higher rates of depression. One in 4 patients with a diagnosis of depression also had another chronic condition; those with depression had 1.5 times more primary care visits. About 85% of patients with depression were prescribed medication, most frequently selective serotonin reuptake inhibitors, followed by atypical antipsychotics. INTERPRETATION: Our data provide information on the prevalence of a depression diagnosis in primary care and associations with being female, having a chronic condition, smoking history and obesity in women. Our findings may inform research and assist primary care providers with early detection and interventions in at-risk patient populations.

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.

Improving collaboration between public health and family health teams in Ontario.

OBJECTIVES: To identify and explore areas where responsibilities may overlap between family health teams (FHTs) and public health units (PHUs); to identify facilitators or barriers to collaboration; and to identify priority areas for increased collaboration. DESIGN AND CONTEXT: Cross-sectional mixed-methods study of FHTs and PHUs in Ontario, Canada, consisting of a postal survey, key informant interviews and a roundtable meeting. RESULTS: The survey response rate was 46%. Direct client-based services such as giving immunizations, promoting prenatal health and nutrition, and counselling related to smoking cessation were identified as the top three areas of perceived overlap. The greatest interest in collaboration was expressed in the areas of emergency planning and preparedness, immunization, and prenatal health and nutrition. Good communication with a clear understanding of roles and functions was the most important facilitator, and lack of resources and absence of a clear provincial mandate and direction to collaborate were identified as significant barriers. CONCLUSIONS: Small, simple client-based projects of interest to both kinds of organization would be the best way to move forward in the short term. Improving communication between FHTs and PHUs, understanding of roles and functions, the use of shared or interoperable information systems and greater clarity from government on the ways in which these two key sectors of the healthcare system are intended to work together were identified as important for the success of increased collaboration.

Exploring patient perceptions of PSA screening for prostate cancer: risks, effectiveness, and importance.

OBJECTIVE: To study the beliefs of a group of Canadian men regarding the risks, effectiveness, and importance of routine prostate-specific antigen (PSA) testing when used as a screening tool for prostate cancer. DESIGN: A 1-page questionnaire designed to gauge patient beliefs about PSA screening. SETTING: Two primary care clinics in Kingston, Ont. PARTICIPANTS: Seventy-two men aged 41 to 80. MAIN OUTCOME MEASURES: Whether men believed that the PSA blood test was not risky when used as a screening test for prostate cancer, was effective at preventing death from prostate cancer, and was important for their health. RESULTS: Fifteen men reported having visited their physicians because of difficulty urinating in the past 2 years, or a personal history of prostate cancer, and were excluded; for these men, the use of the PSA blood test would not be for screening. Of the 57 men considered in the study, 54 (95%) believed that using the PSA blood test as a screening tool for prostate cancer was not risky, 39 (68%) believed that the PSA blood test was good or very good at preventing death from prostate cancer, and 45 (79%) believed that the routine use of the PSA blood test was important or very important for their health. Men in the suggested screening age group of 51 to 70 years (n = 32) had an equally positive impression of PSA screening. CONCLUSION: Despite a limited body of evidence showing its effectiveness, Canadian men continue to have a favourable impression of PSA screening and remain largely unaware of potential adverse events associated with PSA testing.

Update on pharmacologic and nonpharmacologic therapies for smoking cessation.

OBJECTIVE: To review the evidence on the efficacy and safety of pharmacologic and nonpharmacologic therapies for smoking cessation. QUALITY OF EVIDENCE: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for randomized controlled trials, meta-analyses, and systematic reviews (level I evidence) pertinent to pharmacologic and nonpharmacologic smoking cessation therapies. MAIN MESSAGE: Pharmacologic smoking cessation aids are recommended for all smokers trying to quit, unless contraindicated. A new pharmacologic smoking cessation aid, varenicline, is now available in Canada. Level I evidence at 1-year follow-up indicates that it is effective for smoking cessation. Adverse effects include nausea, insomnia, and abnormal dreaming. Nausea is mild or moderate and decreases over time. Varenicline is more effective than placebo or bupropion. Counseling also increases the likelihood of achieving cessation. CONCLUSION: Preliminary data indicate that varenicline is more effective than other available pharmacologic smoking cessation aids. Pharmacologic therapy should be combined with nonpharmacologic therapy.