An institutional ethnography of chronic pain management in family medicine (COPE) study protocol.

BACKGROUND: Patients with chronic conditions and multiple comorbidities represent a growing challenge for health care globally. Improved coordination of care is considered essential for providing more effective and cost-efficient care for these patients with complex needs. Osteoarthritis is one of the most common and debilitating chronic conditions, is the most frequent cause of chronic pain yet osteoarthritis care is often poorly-coordinated. Primary care is usually the first contact for patients requiring relief from chronic pain. Our previous work suggests discordance between the policy goals of improving patient care and the experience of osteoarthritis patients. We plan to investigate the empirical context of the primary care setting by focusing on primary physicians' conceptualizations and performance of their work in treating complex patients with chronic pain. This will allow for an exploration of how primary health care is - or could be - integrated with other services that play an important role in health care delivery. METHODS: Our study is an Institutional Ethnography of pain management in family medicine, to be carried out in three phases over 3 years from 2014/15 to 2018. Over the first year we will undertake approximately 80 key informant interviews with primary care physicians, other health care providers, policymakers and clinical experts. In the second year we will focus on mobilizing our networks from year one to assist in the collection of key texts which shape the current context of care. These texts will be analyzed by the research team. In the final year of the study we will focus on synthesizing our findings in order to map the social relations informing care. As is standard and optimal in qualitative research, analysis will be concurrent with data collection. DISCUSSION: Our study will allow us to identify how the work of coordinating care across multiple settings is accomplished, in practice as well as discursively and textually. Ultimately, we will identify links between everyday experience of care for patients with chronic pain, and broader discourses related to health care system inefficiencies, integration and patient-centred care. An expected outcome of this study will be the development of new, or augmentation of existing, models of care, that are based in the local realities of primary care practice.

Nurse Practitioner Activities in Ontario Family Health Teams: Comparing Three Different Data Sources.

BACKGROUND: Despite the increase in nurse practitioners (NPs) working in primary healthcare, little standardized data are available to understand NP activities at the system level. The Nurse Practitioner Access Reporting system (NPAR), a pilot project underway at 40 family health teams in Ontario, involves NPs recording and submitting standardized codes. The codes are intended to reflect NPs' clinical activities, using an existing physician claim system. The study compared how well data collected through NPAR reflect NPs' activities. METHODS: The mixed-methods approach was used involving NPAR data, focus groups and time and motion data. RESULTS: All data sources indicated that NPs spent the majority of their time on direct patient care. Qualitative data and time and motion data revealed gaps in NPAR data, for example, codes that fail to capture activities unique to the NP role. CONCLUSION: Analysis of NPAR, time and motion and qualitative data provided a distinctive opportunity to examine NP-reported activities and patient characteristics; however, NPAR data did not adequately describe the scope or breadth of activities of NPs practising in primary healthcare.

Adverse effect of long work hours on incident diabetes in 7065 Ontario workers followed for 12 years.

OBJECTIVE: According to the International Diabetes Federation, the most important challenge for prevention is now to identify social and environmental modifiable risk factors of diabetes. In this regard, long work hours have recently been linked with diabetes, but more high-quality prospective studies are needed. We evaluated the relationship between long work hours and the incidence of diabetes among 7065 workers over a 12-year period in Ontario, Canada. RESEARCH DESIGN AND METHODS: Data from Ontario respondents (35-74 years of age) to the 2003 Canadian Community Health Survey were prospectively linked to the Ontario Health Insurance Plan database for physician services and the Canadian Institute for Health Information Discharge Abstract Database for hospital admissions. Our sample consisted of actively employed participants with no previous diagnoses of diabetes. Cox proportional hazard regression models were then performed to evaluate the relationship between long work hours (≥45 hours per week) and the incidence of diabetes. RESULTS: Long work hours did not increase the risk of developing diabetes among men. However, among women, those usually working 45 hours or more per week had a significantly higher risk of diabetes than women working between 35 and 40 hours per week (HR: 1.63 (95% CI 1.04 to 2.57)). The effect was slightly attenuated when adjusted for the potentially mediating factors which are smoking, leisure time physical activity, alcohol consumption and body mass index. CONCLUSION: Working 45 hours or more per week was associated with an increased incidence of diabetes among women, but not men. Identifying modifiable risk factors such as long work hours is of major importance to improve prevention strategies and orient policy making.

An examination of perceived health care availability and unmet health care need in the City of Toronto, Ontario, Canada.

OBJECTIVES: Although timely access to health care is a top priority, a burgeoning body of research highlights the important role of neighbourhood environments on unmet health care needs. This study aimed to examine an association between perceptions of neighbourhood availability of health care services and experience of unmet health care needs by gender in an urban city setting. METHODS: A total of 2338 participants from the Neighbourhood Effects on Health and Well-being (NEHW) study, between 25 and 64 years of age and dwelling in the City of Toronto, Ontario, Canada, were included in the analyses. Four different logistic regression models stratified by gender were used to examine the relationship between neighbourhood health care availability and unmet health care need as well as the impact of neighbourhood perception of health care availability on the three different types of unmet needs. RESULTS: Perceived health care availability was associated with higher likelihood of experiencing unmet health care needs in both women and men (women = OR: 1.58, 95% CI: 1.09-2.28; men = OR: 1.92, 95% CI: 1.23-2.99). In addition, perceived health care availability was associated with barrier- and wait times-related unmet health care need among women (OR: 1.83, 95% CI: 1.13-2.97; OR: 1.93, 95% CI: 1.10-3.40 respectively), and personal choice- and wait times-related unmet need among men (OR: 1.99, 95% CI: 1.10-3.58). CONCLUSION: Individuals' perception of health care availability plays a crucial role in the experience of unmet health care needs, suggesting the importance of community-based policy development for improving physical conditions and the social aspect of health care services.