Effect of a multimorbidity intervention on health care utilization and costs in Ontario: randomized controlled trial and propensity-matched analyses.

BACKGROUND: Patients with multimorbidity require coordinated and patient-centred care. Telemedicine IMPACT Plus provides such care for complex patients in Toronto, Ontario. We conducted a randomized controlled trial (RCT) comparing health care utilization and costs at 1-year postintervention for an intervention group and 2 control groups (RCT and propensity matched). METHODS: Data for 82 RCT intervention and 74 RCT control participants were linked with health administrative data. We created a second control group using health administrative data-derived propensity scores to match (1:5) intervention participants with comparators. We evaluated 5 outcomes: acute hospital admissions, emergency department visits, costs of all insured health care, 30-day hospital readmissions and 7-day family physician follow-up after hospital discharge using generalized linear models for RCT controls and generalized estimating equations for propensity-matched controls. RESULTS: There were no significant differences between intervention participants and either control group. For hospital admissions, emergency department visits, costs and readmissions, the relative differences ranged from 1.00 (95% confidence interval [CI] 0.39-2.60) to 1.67 (95% CI 0.82-3.38) with intervention costs at about Can$20 000, RCT controls costs at around Can$15 000 and propensity controls costs at around Can$17 000. There was a higher rate of follow-up with a family physician for the intervention participants compared with the RCT controls (53.13 v. 21.43 per 100 hospital discharges; relative difference 2.48 [95% CI 0.98-6.29]) and propensity-matched controls (49.94 v. 28.21 per 100 hospital discharges; relative difference 1.81 [95% CI 0.99-3.30]). INTERPRETATION: Despite a complex patient-centred intervention, there was no significant improvement in health care utilization or cost. Future research requires larger sample sizes and should include outcomes important to patients and the health care system, and longer follow-up periods. ONTARIO: ClinicalTrials.gov : 104191.

Responding to vulnerable patients with multimorbidity: an interprofessional team approach.

BACKGROUND: People with multimorbidity, who may be more vulnerable to certain social determinants of health, often require care by an interprofessional primary healthcare (PHC) team that can tailor their approach to address the multiple and complex needs of this population. This paper describes how the needs of vulnerable patients experiencing multimorbidity are identified and provided care by innovative interprofessional PHC teams during an innovative one-hour consultation, outside of usual care. METHODS: This was a descriptive qualitative study. Forty-eight interviews were conducted with 20 allied healthcare professionals: (e.g., social work, pharmacy); 19 physicians (e.g., psychiatry, internal medicine, family medicine); and 9 decision makers. The thematic analysis was iterative using an individual and team approach to identify the main themes and exemplar quotations for illustration. RESULTS: Participants described patients with multimorbidity who were vulnerable as those experiencing major challenges accessing and navigating the healthcare system. Mental health issues were a major contributor to being vulnerable and often linked to common social determinants of health. Cultural factors were identified as potentially causing patients to be vulnerable. Participants articulated how the collaborative nature of the team generated new ideas and facilitated creative recommendations designed to meet the specific needs of each patient. CONCLUSIONS: This one-time consultation went beyond the assessment of a patient's multimorbidity by including a psycho-social-contextual understanding of vulnerability within the healthcare system. Findings may have important clinical and policy implications in the adoption and implementation of this approach and further assist vulnerable patients with multimorbidity in having their complex needs addressed.

Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source.

BACKGROUND: Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures. OBJECTIVE: The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures. DESIGN: Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018. RESULTS: Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity. CONCLUSIONS: The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

Interventions for improving outcomes in patients with multimorbidity in primary care and community settings.

BACKGROUND: Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. OBJECTIVES: To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. SEARCH METHODS: We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. SELECTION CRITERIA: Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. MAIN RESULTS: We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. AUTHORS' CONCLUSIONS: This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.

Chronic disease prevention and management programs in primary care: Realist synthesis of 6 programs in Quebec.

OBJECTIVE: To identify the mechanisms associated with success and failure of chronic disease prevention and management (CDPM) programs, as well as their key contexts. DESIGN: Realist synthesis. SETTING: Six primary care CDPM programs funded between 2011 and 2013 in Quebec. PARTICIPANTS: Patients, health providers, program leaders, and other stakeholders involved in CDPM programs. METHODS: A collaborative research process was implemented, involving representatives from the executive and advisory committees: researchers, health care providers, decision makers, and patients and families. Leaders were asked to provide all documents related to their programs to the research team. The documents were selected depending on their relevance and rigour. The thematic analysis of each program consisted of identifying the outcomes and mechanisms, as well as the specific contexts associated with these outcomes. Results for each program were validated by its leader before synthesizing the results of all programs together. MAIN FINDINGS: A total of 108 documents (eg, grant applications, scientific reports) were collected from the programs. Positive and negative outcomes were observed at the patient, health care provider, and health care system levels. Four main mechanism categories were associated with outcomes: patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners. The main contextual factors that influenced the successes of these mechanisms were related to patients (multimorbidity, involvement of family caregivers), to health care providers (professional training, culture of interprofessional collaboration, mobilization of family physician), and to health care organizations (coordination between services, history of collaboration between partners, funding). CONCLUSION: This study confirms the essential role of patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners when caring for patients with chronic diseases. It constitutes a relevant contribution for stakeholders involved in primary care transformation and should be used to inform the sustainability and scaling up of CDPM programs.

A multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on results.

BACKGROUND: Limited studies exist on successful interventions for patients with multimorbidity. Even more limited is the knowledge on how socioeconomic factors have an impact on these interventions. The objective of this study was to analyze the effect of a multidisciplinary self-management intervention among patients with multimorbidity and the impact of socioeconomic factors on the results. METHODS: Secondary data analysis limited to multimorbid patients from of a pragmatic randomized trial evaluating an intervention that included patients (18 to 75 yrs.) from eight primary care practices in Quebec, Canada. The intervention included self-management support and patient-centred motivational approaches. Self-management was evaluated using the Health Education Impact Questionnaire (heiQ) which measures eight different domains. Changes in heiQ were analyzed following the three-month intervention with univariate and multivariate logistic regressions. RESULTS: Participants with three or more chronic conditions (n = 281), randomized to intervention or control groups, were included in this analysis. The effect of the intervention on the likelihood of an improvement in self-management was significant in six heiQ domains in the univariate analysis (Odd ratio; 95% CI): Health-directed behaviour (2.03; 1.16-3.55), Emotional well-being (1.97; 1.05-3.68), Self-monitoring and insight (2.35; 1.02-5.40), Constructive attitudes and approaches (2.91; 1.45-5.84), Skill and technique acquisition (1.96; 1.13-3.39), and Health services navigation (2.52; 1.21-5.21). After controlling for age and gender the results remained essentially the same. After additional adjustments for family income, education and self-perceived financial status, the likelihood of an improvement was no longer significant in the domains Emotional well-being and Self-monitoring and insight. CONCLUSIONS: The intervention produced significant improvements in multimorbid patients for most domains of self-management. Socioeconomic factors had a minor impact on the results. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01319656.

Integration of chronic disease prevention and management services into primary care (PR1MaC): findings from an embedded qualitative study.

BACKGROUND: The PR1MaC study was conducted to evaluate the integration of Chronic Disease Prevention and Management services into primary care practices and was reported effective. The aim of this study was to further explore the effects of the PR1MaC intervention on patients and their family. METHODS: We conducted a qualitative study embedded in a randomized controlled trial. The trial was implemented in eight primary health care practices in the Saguenay region, Quebec, Canada. The interdisciplinary patient-centred team-based intervention included self-management support and a motivational approach. We conducted focus groups and semi-directed individual interviews with patients, family members and healthcare professionals. RESULTS: Perceived positive effects can be grouped into six major themes: awareness, improved knowledge, improved motivation and empowerment, adoption of healthy behaviours, improvement of health status and improvement of quality of life. On the negative side, some participants reported lack of sustainability of newly acquired benefits in the months following the intervention. CONCLUSIONS: Integrating chronic disease prevention and management services into primary care settings had impacts on patients and their family members. These findings are consistent with findings that were reported in the quantitative study. Further studies should address longterm sustainabilility in terms of benefits for the patients. TRIAL REGISTRATION: ClinicalTrials.gov, no.: NCT01319656 .

Promoting cross-jurisdictional primary health care research: developing a set of common indicators across 12 community-based primary health care teams in Canada.

AimTo describe the process by which the 12 community-based primary health care (CBPHC) research teams worked together and fostered cross-jurisdictional collaboration, including collection of common indicators with the goal of using the same measures and data sources. BACKGROUND: A pan-Canadian mechanism for common measurement of the impact of primary care innovations across Canada is lacking. The Canadian Institutes for Health Research and its partners funded 12 teams to conduct research and collaborate on development of a set of commonly collected indicators. METHODS: A working group representing the 12 teams was established. They undertook an iterative process to consider existing primary care indicators identified from the literature and by stakeholders. Indicators were agreed upon with the intention of addressing three objectives across the 12 teams: (1) describing the impact of improving access to CBPHC; (2) examining the impact of alternative models of chronic disease prevention and management in CBPHC; and (3) describing the structures and context that influence the implementation, delivery, cost, and potential for scale-up of CBPHC innovations.FindingsNineteen common indicators within the core dimensions of primary care were identified: access, comprehensiveness, coordination, effectiveness, and equity. We also agreed to collect data on health care costs and utilization within each team. Data sources include surveys, health administrative data, interviews, focus groups, and case studies. Collaboration across these teams sets the foundation for a unique opportunity for new knowledge generation, over and above any knowledge developed by any one team. Keys to success are each team's willingness to engage and commitment to working across teams, funding to support this collaboration, and distributed leadership across the working group. Reaching consensus on collection of common indicators is challenging but achievable.

Assessment of scalability of evidence-based innovations in community-based primary health care: a cross-sectional study.

BACKGROUND: In 2013, the Canadian Institutes of Health Research funded 12 community-based primary health care research teams to develop evidence-based innovations. We aimed to explore the scalability of these innovations. METHODS: In this cross-sectional study, we invited the 12 teams to rate their evidence-based innovations for scalability. Based on a systematic review, we developed a self-administered questionnaire with 16 scalability assessment criteria grouped into 5 dimensions (theory, impact, coverage, setting and cost). Teams completed a questionnaire for each of their innovations. We analyzed the data using simple frequency counts and hierarchical cluster analysis. We calculated the mean number and standard deviation (SD) of innovations that met criteria within each dimension that included more than 1 criterion. The analysis unit was the innovation. RESULTS: The 11 responding teams evaluated 33 evidence-based innovations (median 3, range 1-8 per team). The innovations focused on access to care and chronic disease prevention and management, and varied from health interventions to methodological innovations. Most of the innovations were health interventions (n = 21), followed by analytical methods (n = 4), conceptual frameworks (n = 4), measures (n = 3) and strategies to build research capacity (n = 1). Most (29) met criteria in the theory dimension, followed by impact (mean 22.3 [SD 5.6] innovations per dimension), setting (mean 21.7 [SD 8.5]), cost (mean 17.5 [SD 2.1]) and coverage (mean 14.0 [SD 4.1]). On average, the innovations met 10 of the 16 criteria. Adoption was the least assessed criterion (n = 9). Most (20) of the innovations were highly ranked for scalability. INTERPRETATION: Scalability varied among innovations, which suggests that readiness for scale up was suboptimal for some innovations. Coverage remained largely unaddressed; further investigation of this critical dimension is necessary.

Snapshot of the primary care waiting room: Informing practice redesign to align with the Patient's Medical Home model.

OBJECTIVE: To describe the demographic characteristics, health, and health care experiences of adult patients in primary care waiting rooms in Quebec, and to determine which pillars of the Patient's Medical Home (PMH) are a priority to align primary care practices with the PMH model. DESIGN: Baseline survey of a prospective cohort study using self-administered on-site and mailed questionnaires. SETTING: Twelve primary care clinics within the geographic boundaries of 4 local health care networks in metropolitan, urban, rural, and remote settings in Quebec. PARTICIPANTS: A total of 1029 adult patients aged between 25 and 75 who were selected during a 1-week period in the 12 primary care clinics; 789 returned questionnaires. MAIN OUTCOME MEASURES: Patients' health profiles, health behaviour patterns, reasons for the visit, and health care experiences. RESULTS: In this 2010 snapshot, 66.8% of patients waited longer than 2 weeks for their appointment, 71.0% of visits were for routine or follow-up care, and longer wait times and patient multimorbidity correlated with more reasons for the visit. After the visit, most patients reported being able to express their most important needs and that the doctor listened well; however, only 28.1% reported that the doctor had explored whether the recommendations would be realistic for them, and only 18.0% indicated that the doctor had explored the personal or family dimensions that affected their health. Among all patients, 56.9% reported having at least 3 chronic conditions (multimorbidity), and 30.3% reported having high or moderate levels of psychological distress. When describing their financial status, 30.7% of patients indicated it was "poor to squeezed or tight." Slightly more than half of patients did not have complementary private health insurance to cover costs of psychological services. CONCLUSION: In this study, the 4 priority pillars for practices to align with the PMH were timely access, team-based care, comprehensive care, and a patient-centred approach. Widespread implementation of advanced access is an urgent priority in light of persisting difficulties in timely access. Team-based and comprehensive care are needed to address the high prevalence of multimorbidity and psychological distress and to support health behaviour change. Finally, the patient-centred approach needs to underpin every care encounter.

Health literacy - engaging the community in the co-creation of meaningful health navigation services: a study protocol.

BACKGROUND: A large proportion of patients encounter barriers to access and navigation in complex healthcare systems. They are unable to obtain information and services and to take appropriate action to improve their health. Low health literacy affects the ability of individuals to benefit from health services. Some social groups are disproportionately affected by low health literacy, including those with low educational attainment, Aboriginal people, and those on social assistance. These individuals face significant barriers in self-management of chronic diseases and in navigating the healthcare system. For these people, living in a context of deprivation contributes to maintaining disparities in access to healthcare and services. The objective of this study is to support knowledge co-construction and knowledge translation in primary care and services by involving underserved and Aboriginal people in research. METHODS: This study will integrate participatory health processes and action research to co-create, with patients, individuals, and community members impacted by health literacy, practical recommendations or solutions for facilitating navigation of the healthcare system by patients, individuals, and community members with less than optimal health literacy on how to best access health services. With this approach, academics and those for whom the research is intended will collaborate closely in all stages of the research to identify findings of immediate benefit to those impacted by health literacy and work together on knowledge translation. This study, carried out by researchers, community organizations and groups of people with low health literacy from three different regions of Quebec and Saskatchewan who can play an expert role in improving health services, will be conducted in three phases: 1) data collection; 2) data analysis and interpretation; and, 3) knowledge translation. DISCUSSION: Persons with low health literacy experience major obstacles in navigating the health system. This project will therefore contribute to addressing the gap between healthcare challenges and the needs of underserved patients with multi-morbidity and/or low health literacy who have complex health-related needs. It will pave the way for co-creating successful solutions for and with these communities that will increase their access to health services.

The relationship between health literacy and patient activation among frequent users of healthcare services: a cross-sectional study.

BACKGROUND: Frequent users of healthcare services are a vulnerable population that deserves attention due to high costs and negative outcomes such as lower quality of life and higher mortality. Healthcare systems should offer interventions tailored to their needs and to their level of health literacy, including strategies to promote activation. The relationship between health literacy and patient activation remains to be explored. The aim of this study was to examine the association between health literacy and patient activation in a population of frequent users of healthcare services with chronic diseases. METHODS: Cross-sectional data were collected (before randomization) through a clinical trial evaluating a case management intervention in primary care. Participants (n = 247) were recruited from the list of frequent users of 4 Family Medicine Groups (FMG) in the Saguenay-Lac-St-Jean region of Québec (Canada). They completed questionnaires by self-report during an encounter with a research assistant: (1) the Newest Vital Sign (NVS) to evaluate health literacy (independent variable); and (2) the Patient Activation Measure-13 (PAM-13) to evaluate patient activation (dependent variable). The relationship between health literacy and activation was examined using biserial correlations. RESULTS: No association was found between health literacy (independent variable) and patient activation (rb = 0.075, ρ = 0.07) for this population of frequent users of healthcare services. CONCLUSIONS: This study suggests that there is no relationship between health literacy and patient activation among frequent users of healthcare services. TRIAL REGISTRATION: NCT01719991 . Registered October 25, 2012.

Addressing the Evidence Gap in Stroke Rehabilitation for Complex Patients: A Preliminary Research Agenda.

Evidence suggests that a stroke occurs in isolation (no comorbid conditions) in less than 6% of patients. Multimorbidity, compounded by psychosocial issues, makes treatment and recovery for stroke increasingly complex. Recent research and health policy documents called for a better understanding of the needs of this patient population, and for the development and testing of models of care that meet their needs. A research agenda specific to complexity is required. The primary objective of the think tank was to identify and prioritize research questions that meet the information needs of stakeholders, and to develop a research agenda specific to stroke rehabilitation and patient complexity. A modified Delphi and World Café approach underpinned the think tank meeting, approaches well recognized to foster interaction, dialogue, and collaboration between stakeholders. Forty-three researchers, clinicians, and policymakers attended a 2-day meeting. Initial question-generating activities resulted in 120 potential research questions. Sixteen high-priority research questions were identified, focusing on predetermined complexity characteristics-multimorbidity, social determinants, patient characteristics, social supports, and system factors. The final questions are presented as a prioritized research framework. An emergent result of this activity is the development of a complexity and stroke rehabilitation research network. The research agenda reflects topics of importance to stakeholders working with stroke patients with increasingly complex care needs. This robust process resulted in a preliminary research agenda that could provide policymakers with the evidence needed to make improvements toward better-organized services, better coordination between settings, improved patient outcomes, and lower system costs.

Integration of chronic disease prevention and management services into primary care: a pragmatic randomized controlled trial (PR1MaC).

BACKGROUND: Chronic disease prevention and management programs are usually single-disease oriented. Our objective was to evaluate an intervention that targeted multiple chronic conditions and risk factors. METHODS: We conducted a pragmatic randomized controlled trial involving patients aged 18-75 years with at least 1 of the targeted chronic conditions or risk factors from 8 primary care practices in the Saguenay region of Quebec, Canada, to evaluate an intervention that included self-management support and patient-centred motivational approaches. Self-management (primary outcome) was evaluated using the Health Education Impact Questionnaire (heiQ). Secondary outcomes included self-efficacy, health-related quality of life, psychological distress and health behaviours. RESULTS: Three hundred thirty-two patients were recruited and randomly assigned (n = 166 for both intervention and control groups) and evaluated after 3 months. The intervention group showed improvement in 6 of the 8 heiQ domains: health-directed behaviour (relative risk [RR] 1.71, 95% confidence interval [CI] 1.13 to 2.59), emotional well-being (RR 1.73, 95% CI 1.07 to 2.79), self-monitoring and insight (RR 2.40, 95% CI 1.19 to 4.86), constructive attitudes and approaches (RR 2.40, 95% CI 1.37 to 4.21), skill and technique acquisition (RR 1.70, 95% CI 1.14 to 2.53), and health service navigation (RR 1.93, 95% CI 1.08 to 3.47). Improvement was also observed in the Physical Component Summary (p = 0.017) and the Single Index (p = 0.041) of the 12-Item Short Form Health Survey (version 2). The intervention group improved in fruit and vegetable consumption (odds ratio [OR] 2.36, 95% CI 1.41 to 3.95) and physical activity (OR 3.81, 95% CI 1.65 to 8.76). One-year improvement was maintained in the intervention group for several outcomes. INTERPRETATION: It is possible to implement an intervention integrating chronic disease prevention and management services into primary care settings. We obtained positive and promising results using this intervention. Trial registration: ClinicalTrials.gov, no.: NCT01319656.

Stepping Up to the Plate: An Agenda for Research and Policy Action on Electronic Medical Records in Canadian Primary Healthcare.

Building on a previous study, which identified gaps in primary healthcare electronic medical record (emr) research and knowledge, a one-day conference was held to facilitate a strategic discussion of these issues. This paper offers a multi-faceted research agenda and suggestions for policy actions as a way forward in bridging the gaps. one facet focuses on the need for research. The second facet focuses on harnessing the knowledge of primary healthcare emr stakeholders. finally, the third facet focuses on policy actions. this paper offers consensus-based suggestions with a view to improving the overall primary healthcare emr landscape in canada.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting.

BACKGROUND: Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation. METHODS: The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis. RESULTS AND DISCUSSION: Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event. CONCLUSION: The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Providing care to vulnerable populations: a qualitative study among GPs working in deprived areas in Montreal, Canada.

BACKGROUND: Communication barriers between persons living in poverty and healthcare professionals reduce care effectiveness. Little is known about the strategies general practitioners (GPs) use to enhance the effectiveness of care for their patients living in poverty. OBJECTIVE: The aim of this study was to identify strategies adopted by GPs to deliver appropriate care to patients living in poverty. METHODS: We conducted in-depth semi-structured interviews with 35 GPs practising in Montreal, Canada, who regularly provide care to underprivileged patients in primary care clinics located in deprived urban areas. Analysis consisted of interview debriefing, transcript coding, thematic analysis and data interpretation. RESULTS: GPs develop specific skills for caring for these patients that are responsive to their complex medical needs and challenging social context. Our respondents used three main strategies in working with their patients: building a personal connection to overcome social distance, aligning medical expectations with patients' social vulnerability and working collaboratively to empower patients. With these strategies, the physicians were able to enhance the patient-physician relationship and to take into account the impact of poverty on illness self-management. CONCLUSIONS: Our results may help GPs improve the health and care experience of their vulnerable patients by adopting these strategies. The strategies' impacts on patients' experience of care and health outcomes should be evaluated as a prelude to integrating them into primary care practice and the training of future physicians.

Comparisons of multi-morbidity in family practice--issues and biases.

BACKGROUND: As the population ages, practice and policy need to be guided by accurate estimates of chronic disease burden in primary care. OBJECTIVE: To produce a preliminary set of methodological considerations for cross-sectional and retrospective cohort studies of multi-morbidity in primary care using three studies as examples. Prevalence rate results from the three studies were re-estimated using identical age-sex groups. METHODS: We compared the methods and results of three separate studies in primary care: (i) patients in the Saguenay region of Quebec, Canada (2005); (ii) a substudy of the BEACH (Bettering the Evaluation and Care of Health) programme in Australia (2008); and (iii) the DELPHI (Deliver Primary Health Care Information) project in South-western Ontario, Canada (2009). Areas where the methods of multi-morbidity studies may differ were identified. The percentage of patients with two or more chronic conditions was compared by age-sex groups. RESULTS: Multi-morbidity prevalence varied by as much as 61%, where reported prevalence was 95% among females aged 45-64 in the Saguenay study, 46% in the BEACH substudy and 34% in the DELPHI study. Several aspects of the methods and study designs were identified as differing among the studies, including the sampling of frequent attenders, sampling period, source of data, and both the definition and count of chronic conditions. CONCLUSIONS: Understanding the differences among the methods used to produce prevalence data on multi-morbidity in primary care can help explain the varying results. Standardization of methods would allow for more valid inter-study comparisons.

Evaluating the integration of chronic disease prevention and management services into primary health care.

BACKGROUND: The increasing number of patients with chronic diseases represents a challenge for health care systems. The Chronic Care Model suggests a multi-component remodelling of chronic disease services to improve patient outcomes. To meet the complex and ongoing needs of patients, chronic disease prevention and management (CDPM) has been advocated as a key feature of primary care producing better outcomes, greater effectiveness and improved access to services compared to other sectors. The objective of this study is to evaluate the adaptation and implementation of an intervention involving the integration of chronic disease prevention and management (CDPM) services into primary health care. METHODS/DESIGN: The implementation of the intervention will be evaluated using descriptive qualitative methods to collect data from various stakeholders (decision-makers, primary care professionals, CDPM professionals and patients) before, during and after the implementation. The evaluation of the effects will be based on a combination of experimental designs: a randomized trial using a delayed intervention arm (n = 326), a before-and-after design with repeated measures (n = 163), and a quasi-experimental design using a comparative cohort (n = 326). This evaluation will utilize self-report questionnaires measuring self-efficacy, empowerment, comorbidity, health behaviour, functional health status, quality of life, psychological well-being, patient characteristics and co-interventions. The study will take place in eight primary care practices of the Saguenay region of Quebec (Canada). To be included, patients will have to be referred by their primary care provider and present at least one of the following conditions (or their risk factors): diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, asthma. Patients presenting serious cognitive problems will be excluded. DISCUSSION: In the short-term, improved patient self-efficacy and empowerment are expected. In the mid-term, we expect to observe an improvement in health behaviour, functional health status, quality of life and psychological well-being. At the organizational level, the project should lead to coordinated service delivery, improved patient follow-up mechanisms and enhanced interprofessional collaboration. Integration of CDPM services at the point of care in primary care practices is a promising innovation in care delivery that needs to be thoroughly evaluated. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01319656.

Mapping the concept of vulnerability related to health care disparities: a scoping review.

BACKGROUND: The aim of this paper is to share the results of a scoping review that examined the relationship between health care disparities and the multiplicity of vulnerability factors that are often clustered together. METHODS: The conceptual framework used was an innovative dynamic model that we developed to analyze the co-existence of multiple vulnerability factors (multi-vulnerability) related to the phenomenon of the 'Inverse Care Law'. A total of 759 candidate references were identified through a literature search, of which 23 publications were deemed relevant to our scoping review. RESULTS: The review confirmed our hypothesis of a direct correlation between co-existing vulnerability factors and health care disparities. Several gaps in the literature were identified, such as a lack of research on vulnerable populations' perception of their own vulnerability and on multimorbidity and immigrant status as aspects of vulnerability. CONCLUSIONS: Future research addressing the revealed gaps would help foster primary care interventions that are responsive to the needs of vulnerable people and, eventually, contribute to the reduction of health care disparities in society.