"Family doctors are also people": a qualitative analysis of how family physicians managed competing personal and professional responsibilities during the COVID-19 pandemic.

BACKGROUND: Family physicians (FPs) fill an essential role in public health emergencies yet have frequently been neglected in pandemic response plans. This exclusion harms FPs in their clinical roles and has unintended consequences in the management of concurrent personal responsibilities, many of which were amplified by the pandemic. The objective of our study was to explore the experiences of FPs during the first year of the COVID-19 pandemic to better understand how they managed their competing professional and personal priorities. METHODS: We conducted semi-structured interviews with FPs from four Canadian regions between October 2020 and June 2021. Employing a maximum variation sampling approach, we recruited participants until we achieved saturation. Interviews explored FPs' personal and professional roles and responsibilities during the pandemic, the facilitators and barriers that they encountered, and any gender-related experiences. Transcribed interviews were thematically analysed. RESULTS: We interviewed 68 FPs during the pandemic and identified four overarching themes in participants' discussion of their personal experiences: personal caregiving responsibilities, COVID-19 risk navigation to protect family members, personal health concerns, and available and desired personal supports for FPs to manage their competing responsibilities. While FPs expressed a variety of ways in which their personal experiences made their professional responsibilities more complicated, rarely did that affect the extent to which they participated in the pandemic response. CONCLUSIONS: For FPs to contribute fully to a pandemic response, they must be factored into pandemic plans. Failure to appreciate their unique role and circumstances often leaves FPs feeling unsupported in both their professional and personal lives. Comprehensive planning in anticipation of future pandemics must consider FPs' varied responsibilities, health concerns, and necessary precautions. Having adequate personal and practice supports in place will facilitate the essential role of FPs in responding to a pandemic crisis while continuing to support their patients' primary care needs.

Finding Medical Photographs of Patients Online: Randomized, Cross-Sectional Study.

BACKGROUND: Photographs from medical case reports published in academic journals have previously been found in online image search results. This means that patient photographs circulate beyond the original journal website and can be freely accessed online. While this raises ethical and legal concerns, no systematic study has documented how often this occurs. OBJECTIVE: The aim of this cross-sectional study was to provide systematic evidence that patient photographs from case reports published in medical journals appear in Google Images search results. Research questions included the following: (1) what percentage of patient medical photographs published in case reports were found in Google Images search results? (2) what was the relationship between open access publication status and image availability? and (3) did the odds of finding patient photographs on third-party websites differ between searches conducted in 2020 and 2022? METHODS: The main outcome measure assessed whether at least 1 photograph from each case report was found on Google Images when using a structured search. Secondary outcome variables included the image source and the availability of images on third-party websites over time. The characteristics of medical images were described using summary statistics. The association between the source of full-text availability and image availability on Google Images was tested using logistic regressions. Finally, we examined the trend of finding patient photographs using generalized estimating equations. RESULTS: From a random sample of 585 case reports indexed in PubMed, 186 contained patient photographs, for a total of 598 distinct images. For 142 (76.3%) out of 186 case reports, at least 1 photograph was found in Google Images search results. A total of 18.3% (110/598) of photographs included eye, face, or full body, including 10.9% (65/598) that could potentially identify the patient. The odds of finding an image from the case report online were higher if the full-text paper was available on ResearchGate (odds ratio [OR] 9.16, 95% CI 2.71-31.02), PubMed Central (OR 7.90, 95% CI 2.33-26.77), or Google Scholar (OR 6.07, 95% CI 2.77-13.29) than if the full-text was available solely through an open access journal (OR 5.33, 95% CI 2.31-12.28). However, all factors contributed to an increased risk of locating patient images online. Compared with the search in 2020, patient photographs were less likely to be found on third-party websites based on the 2022 search results (OR 0.61, 95% Cl 0.43-0.87). CONCLUSIONS: A high proportion of medical photographs from case reports was found on Google Images, raising ethical concerns with policy and practice implications. Journal publishers and corporations such as Google are best positioned to develop an effective remedy. Until then, it is crucial that patients are adequately informed about the potential risks and benefits of providing consent for clinicians to publish their images in medical journals.

"There's nothing like a good crisis for innovation": a qualitative study of family physicians' experiences with virtual care during the COVID-19 pandemic.

BACKGROUND: Prior to the pandemic, Canada lagged behind other Organisation for Economic Cooperation and Development countries in the uptake of virtual care. The onset of COVID-19, however, resulted in a near-universal shift to virtual primary care to minimise exposure risks. As jurisdictions enter a pandemic recovery phase, the balance between virtual and in-person visits is reverting, though it is unlikely to return to pre-pandemic levels. Our objective was to explore Canadian family physicians' perspectives on the rapid move to virtual care during the COVID-19 pandemic, to inform both future pandemic planning for primary care and the optimal integration of virtual care into the broader primary care context beyond the pandemic. METHODS: We conducted semi-structured interviews with 68 family physicians from four regions in Canada between October 2020 and June 2021. We used a purposeful, maximum variation sampling approach, continuing recruitment in each region until we reached saturation. Interviews with family physicians explored their roles and experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support their patients through the pandemic. Interviews were audio-recorded, transcribed, and thematically analysed for recurrent themes. RESULTS: We identified three prominent themes throughout participants' reflections on implementing virtual care: implementation and evolution of virtual modalities during the pandemic; facilitators and barriers to implementing virtual care; and virtual care in the future. While some family physicians had prior experience conducting remote assessments, most had to implement and adapt to virtual care abruptly as provinces limited in-person visits to essential and urgent care. As the pandemic progressed, initial forays into video-based consultations were frequently replaced by phone-based visits, while physicians also rebalanced the ratio of virtual to in-person visits. Medical record systems with integrated capacity for virtual visits, billing codes, supportive clinic teams, and longitudinal relationships with patients were facilitators in this rapid transition for family physicians, while the absence of these factors often posed barriers. CONCLUSION: Despite varied experiences and preferences related to virtual primary care, physicians felt that virtual visits should continue to be available beyond the pandemic but require clearer regulation and guidelines for its appropriate future use.

The roles of family physicians during a pandemic.

Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by family physicians in five distinct stages of pandemic response: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting public health guidance to ensure continued access to primary care services, family physicians were often expected to operationalize public health roles (eg, staffing assessment centres), modulate access to secondary/tertiary services, help provide surge capacity in acute care facilities, and enhance supports and outreach to vulnerable populations. Future pandemic plans should include family physicians in planning, explicitly incorporate family physician roles, and ensure needed resources are available to allow for an effective primary care response.

Effectiveness of registered nurses on patient outcomes in primary care: a systematic review.

BACKGROUND: Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies. RESULTS: Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care. CONCLUSIONS: This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care. PROTOCOL REGISTRATION ID: PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 .

Effectiveness of registered nurses on system outcomes in primary care: a systematic review.

BACKGROUND: Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken. RESULTS: Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support). CONCLUSIONS: The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs. PROTOCOL REGISTRATION ID: PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767 .

Rural health research capacity building: an anchored solution.

Rural physicians face many challenges with providing rural health care, which often leads to innovative solutions. Despite their creativity with overcoming barriers, there is a lack of support for rural health research - an area of health care where research makes great impacts on small communities. Rural research capacity building (RRCB) is essential to support rural physicians so that they can conduct relevant research, but RRCB programs are sparse. Thus, our team at Memorial University of Newfoundland, Canada, has created an RRCB ecosystem through the 6for6 and Rural360 programs, which outline a pathway for rural physicians to make meaningful contributions to their communities through research. This article describes the RRCB ecosystem and explains how the 6for6 and Rural360 programs address the need for RRCB. Designed to train six rural physicians over six sessions per year, 6for6 fosters learning of research practices through a conceptual framework that envelops complexity science, systems thinking, and anchored instruction. The use of this framework allows the learning to be grounded in issues that are locally relevant for each participant and follows guiding principles that enable many types of learning. Rural360 continues the pathway by providing an in-house funding opportunity with an iterative review process that allows participants to continue developing their research skills and, ultimately, secure funding for their project. This anchored delivery model of RRCB programming is made possible through many support systems including staff, librarians, instructors, the university, and other stakeholders. It has successfully helped form communities of practice, promotes collaboration both between learners and with third parties, encourages self-organization with flexibility for learners outside of the in-house sessions, and ultimately drives social accountability in addressing local healthcare issues.

Sociodemographics and their impacts on risk factor awareness and beliefs about cancer and screening: results from a cross-sectional study in Newfoundland and Labrador.

BACKGROUND: Our objective was to examine cancer risk factor awareness and beliefs about cancer treatment, outcomes, and screening, and how these are mediated by sociodemographic variables, among Newfoundland and Labrador residents. METHODS: Participants aged 35 to 74 were recruited through Facebook advertising, and a self-administered online questionnaire was used to collect data. Descriptive statistics, Spearman rank correlations, and multivariate logistic regression analyses were performed. RESULTS: Of the 1048 participants who responded and met the inclusion criteria for this study, 1019 were selected for this analysis. Risk factor recognition was generally good, though several risk factors had poor awareness: being over 70 years old (53.4% respondents aware), having a low-fiber diet (65.0%), and drinking more than 1 unit of alcohol per day (62.8%). Our results showed that the participants' awareness of risk factors was significantly associated with higher income level (rs = 0.237, P <  0.001), higher education (rs = 0.231, P <  0.001), living in rural regions (rs = 0.163, P <  0.001), and having a regular healthcare provider (rs = 0.081, P = 0.010). Logistic regression showed that among NL residents in our sample, those with higher income, post-secondary education, those in very good or excellent health, and those with a history of cancer all had higher odds of having more positive beliefs about cancer treatment and outcomes. Those with a history of cancer, and those with very good or excellent health, also had higher odds of having more positive beliefs about cancer screening. Finally, compared to Caucasian/white participants, those who were non-Caucasian/white had lower odds of having more positive beliefs about cancer screening. CONCLUSION: Among adults in NL, there was poor awareness that low-fiber diets, alcohol, and age are risk factors for cancer. Lower income and education, rural residence, and not having a health care provider were associated with lower risk factor awareness. We also found a few associations between sociodemographic factors and beliefs about cancer treatment and outcomes or screening. We stress that while addressing awareness is necessary, so too is improving social circumstances of disadvantaged groups who lack the resources necessary to adopt healthy behaviours.

Expanding access to HIV testing through Canadian community pharmacies: findings from the APPROACH study.

BACKGROUND: There is a need for acceptable and feasible HIV testing options to ensure people living with HIV know their status so they can access care. Pharmacist-provided HIV point-of-care testing (POCT) may overcome testing barriers, including privacy concerns, testing wait times, and improve accessibility. In the APPROACH study, we aimed to develop and assess an HIV POCT program in community pharmacies for future scale up and evaluation. This paper describes the program uptake, participant and pharmacist experiences, and implementation factors. METHODS: A pharmacist-provided HIV POCT program was offered in 4 pharmacies in two Canadian provinces. A mixed methods design incorporated self-report questionnaire data, participant telephone interviews, pharmacist focus groups, workload analysis, and situational analysis to assess the uptake, acceptability and feasibility of the HIV POCT program. RESULTS: Over the 6-month pilot, 123 HIV tests were performed. One new case of HIV was identified; this participant was linked with confirmatory testing and HIV care. Participants were predominantly male (76%), with a mean age of 35 years. This was the first HIV test for 27% participants, and 75% were at moderate to very high risk of undiagnosed HIV infection, by Denver HIV Risk Score. Questionnaires and telephone interviews showed participants were very satisfied with the program; 99% agreed HIV POCT should be routinely offered in pharmacies and 78% were willing to pay for the service. Participants felt the pharmacy was convenient, discreet, and that the pharmacist was supportive and provided education about how to reduce their future risk. Pharmacists felt prepared, confident, and expressed professional satisfaction with offering HIV POCT. Community and public health supports, clear linkage to care plans to refer participants with positive HIV POCT results, and provision of counselling tools were important enabling factors for the program. Pharmacist remuneration, integration with existing healthcare systems, and support for ongoing promotion of HIV POCT availability in pharmacies were identified as needs for future scale-up and sustainability. CONCLUSIONS: A successful model of pharmacy-based POCT, including linkage to care, was developed. Further research is needed to determine the effectiveness and cost-effectiveness of this approach in finding new diagnoses and linking them with care. TRIAL REGISTRATION: Retrospectively registered with clinicaltrials.gov (NCT03210701) on July 6, 2017.

Using Facebook Advertising to Recruit Representative Samples: Feasibility Assessment of a Cross-Sectional Survey.

BACKGROUND: Facebook has shown promise as an economical means of recruiting participants for health research. However, few studies have evaluated this recruitment method in Canada, fewer still targeting older adults, and, to our knowledge, none specifically in Newfoundland and Labrador (NL). OBJECTIVE: This study aimed to assess Facebook advertising as an economical means of recruiting a representative sample of adults aged 35 to 74 years in NL for a cross-sectional health survey. METHODS: Facebook advertising was used to recruit for a Web-based survey on cancer awareness and prevention during April and May 2018; during recruitment, additional advertisements were targeted to increase representation of demographics that we identified as being underrepresented in our sample. Sociodemographic and health characteristics of the study sample were compared with distributions of the underlying population to determine representativeness. Cramer V indicates the magnitude of the difference between the sample and population distributions, interpreted as small (Cramer V=0.10), medium (0.30), and large (0.50). Sample characteristics were considered representative if there was no statistically significant difference in distributions (chi-square P>.01) or if the difference was small (V≤0.10), and practically representative if 0.10

Genetic associations in community context: a mixed model approach identifies a functional variant in the RBP4 gene associated with HDL-C dyslipidemia.

BACKGROUND: The objective of this study was to examine individual and community factors that influence high-density lipoprotein cholesterol (HDL-C) dyslipidemia in Newfoundland and Labrador (NL), a genetically isolated population in Canada with a high prevalence of HDL-C dyslipidemia. METHODS: First, a group of single nucleotide polymorphisms from 10 metabolic trait candidate genes was tested using a multivariate logistic regression model. The significant SNPs were entered into the second phase, where a mixed logistic model incorporated the community disease risk factors together with the individual factors as the fixed part of the model and the geographic region as a random effect. RESULTS: Analysis of 1489 subjects (26.9% HDL-C dyslipidemia) identified rs3758539, a non-coding variant in the 5'UTR of RBP4, to be associated with HDL-C dyslipidemia (odds ratio = 1.45, 95% confidence interval = 1.08-1.97, p = 0.01). The association remained significant, and the effect size did not change after the incorporation of individual and community risk factors from 17 geographic regions (odds ratio: 1.41, 95% confidence interval = 1.03-1.93, p = 0.03) in NL. Besides this variant, sex, BMI, and smoking also showed significant associations with HDL-C dyslipidemia, whereas no role was identified for the community factors. CONCLUSIONS: This study demonstrates the use of community-level data in a genetic association testing. It reports a functional variant in the promoter of RBP4, a gene directly involved in lipoprotein metabolism, to be associated with HDL-C dyslipidemia. These findings indicate that individual factors are the main reason for a higher prevalence of HDL-C dyslipidemia in the NL population.

Challenges with access to healthcare from the perspective of patients living with HIV: a scoping review & framework synthesis.

Accessing healthcare can be difficult but the barriers multiply for people living with HIV (PLHIV). To improve access and the health of PLHIV, we must consider their perspectives and use them to inform standard practice. A better understanding of the current literature related to healthcare access from the perspective of PLHIV, can help to identify evidence gaps and highlight research priorities and opportunities. To identify relevant peer-reviewed publications, search strategies were employed. Electronic and grey literature databases were explored. Articles were screened based on their title and abstract and those that met the screening criteria, were reviewed in full. Data analysis was conducted using a collaborative approach that included knowledge user consultation. Initial concepts were extracted, summarized and through framework synthesis, developed into emerging and final themes. From 20,678 articles, 326 articles met the initial screening criteria and 64 were reviewed in full. The final themes identified, in order of most to least frequent were: Acceptability, Availability, Accessibility, Affordability, Other Barriers, Communication, Satisfaction, Accommodation, Preferences and Equity in Access. The most frequently discussed concepts related to negative interactions with staff, followed by long wait times, limited household resources or inability to pay fees, and fear of one's serostatus being disclosed. Knowledge users were in agreement with the categorization of initial concepts and final themes; however, some gaps in the literature were identified. Specific changes are critical to improving access to healthcare for PLHIV. These include improving availability by ensuring staff and healthcare professionals have proper training, cultivating acceptability and reducing stigma through improving HIV awareness, increasing accessibility through increased HIV information for PLHIV and improved dissemination of this information to increase patient knowledge and health awareness. Finally, ensuring proper protocols are implemented and followed to guarantee patient confidentiality and overall satisfaction with healthcare services are recommended.

Six-year time-trend analysis of dyslipidemia among adults in Newfoundland and Labrador: findings from the laboratory information system between 2009 and 2014.

BACKGROUND: Dyslipidemia, an increased level of total cholesterol (TC), triglycerides (TG), low-density-lipoprotein cholesterol (LDL-C) and decreased level of high-density-lipoprotein cholesterol (HDL-C), is one of the most important risk factors for cardiovascular disease. We examined the six-year trend of dyslipidemia in Newfoundland and Labrador (NL), a Canadian province with a historically high prevalence of dyslipidemia. METHODS: A serial cross-sectional study on all of the laboratory lipid tests available from 2009 to 2014 was performed. Dyslipidemia for every lipid component was defined using the Canadian Guidelines for the Diagnosis and Treatment of Dyslipidemia. The annual dyslipidemia rates for each component of serum lipid was examined. A fixed and random effect model was applied to adjust for confounding variables (sex and age) and random effects (residual variation in dyslipidemia over the years and redundancies caused by individuals being tested multiple times during the study period). RESULTS: Between 2009 and 2014, a total of 875,208 records (mean age: 56.9 ± 14.1, 47.6% males) containing a lipid profile were identified. The prevalence of HDL-C and LDL-C dyslipidemia significantly decreased during this period (HDL-C: 35.8% in 2009 [95% CI 35.5-36.1], to 29.0% in 2014 [95% CI: 28.8-29.2], P = 0.03, and LDL-C: 35.2% in 2009 [95% CI: 34.9-35.4] to 32.1% in 2014 [95% CI: 31.9-32.3], P = 0.02). A stratification by sex, revealed no significant trend for any lipid element in females; however, in men, the previously observed trends were intensified and a new decreasing trend in dyslipidemia of TC was appeared (TC: 34.1% [95% CI 33.7-34.5] to 32.3% [95%CI: 32.0-32.6], p < 0.02, HDL-C: 33.8% (95%CI: 33.3-34.2) to 24.0% (95% CI: 23.7-24.3)], P < 0.01, LDL-C: 32.9% (95%CI:32.5-33.3) to 28.6 (95%CI: 28.3-28.9), P < 0.001). Adjustment for confounding factors and removing the residual noise by modeling the random effects did not change the significance. CONCLUSION: This study demonstrates a significant downward trend in the prevalence of LDL-C, HDL-C, and TC dyslipidemia, exclusively in men. These trends could be the result of males being the primary target for cardiovascular risk management.

Open Availability of Patient Medical Photographs in Google Images Search Results: Cross-Sectional Study of Transgender Research.

BACKGROUND: This paper focuses on the collision of three factors: a growing emphasis on sharing research through open access publication, an increasing awareness of big data and its potential uses, and an engaged public interested in the privacy and confidentiality of their personal health information. One conceptual space where this collision is brought into sharp relief is with the open availability of patient medical photographs from peer-reviewed journal articles in the search results of online image databases such as Google Images. OBJECTIVE: The aim of this study was to assess the availability of patient medical photographs from published journal articles in Google Images search results and the factors impacting this availability. METHODS: We conducted a cross-sectional study using data from an evidence map of research with transgender, gender non-binary, and other gender diverse (trans) participants. For the original evidence map, a comprehensive search of 15 academic databases was developed in collaboration with a health sciences librarian. Initial search results produced 25,230 references after duplicates were removed. Eligibility criteria were established to include empirical research of any design that included trans participants or their personal information and that was published in English in peer-reviewed journals. We identified all articles published between 2008 and 2015 with medical photographs of trans participants. For each reference, images were individually numbered in order to track the total number of medical photographs. We used odds ratios (OR) to assess the association between availability of the clinical photograph on Google Images and the following factors: whether the article was openly available online (open access, Researchgate.net, or Academia.edu), whether the article included genital images, if the photographs were published in color, and whether the photographs were located on the journal article landing page. RESULTS: We identified 94 articles with medical photographs of trans participants, including a total of 605 photographs. Of the 94 publications, 35 (37%) included at least one medical photograph that was found on Google Images. The ability to locate the article freely online contributes to the availability of at least one image from the article on Google Images (OR 2.99, 95% CI 1.20-7.45). CONCLUSIONS: This is the first study to document the existence of medical photographs from peer-reviewed journals appearing in Google Images search results. Almost all of the images we searched for included sensitive photographs of patient genitals, chests, or breasts. Given that it is unlikely that patients consented to sharing their personal health information in these ways, this constitutes a risk to patient privacy. Based on the impact of current practices, revisions to informed consent policies and guidelines are required.

Health and health service use of very elderly Newfoundlanders.

OBJECTIVE: To develop a better understanding of the current health status and health care use of the population of very elderly Newfoundlanders to inform policy makers, decision makers, and health care providers about aspects of the health care system that might be in higher demand in the near future. DESIGN: Descriptive analysis using data from the Newfoundland and Labrador component of the Canadian Primary Care Sentinel Surveillance Network database for the 2013 calendar year. SETTING: Newfoundland. PARTICIPANTS: A total of 1204 Newfoundlanders aged 80 years and older. MAIN OUTCOME MEASURES: Encounters with family physicians, medications used, hospitalizations, emergency department (ED) visits, laboratory tests, and mortality were described and compared by sex, age, and location (rural vs urban). RESULTS: Compared with men, women were prescribed more medications (P = .01), were less likely to be hospitalized (P = .007), were more likely to visit an ED (P = .049), and died less frequently (P = .001). Compared with those aged 90 and older, those aged 80 to 89 made more visits to their family doctors (P = .001) and were prescribed more medications (P = .001). Predictably, those aged 90 and older died more frequently than their younger counterparts did (P = .001). Compared with those in rural communities, urban dwellers were prescribed more medications (P = .031), were hospitalized more often (P = .001), were more likely to visit the ED (P = .002), were more likely to have laboratory tests ordered (P = .001), died more frequently (P = .023), and visited their family physicians more frequently (P = .001). CONCLUSION: Octogenarian women living in urban areas are the subcohort using the most resources. This might be owing to movement of the elderly to urban locations as they age.

From pipelines to pathways: the Memorial experience in educating doctors for rural generalist practice.

CONTEXT: This report describes the community context, concept and mission of The Faculty of Medicine at Memorial University of Newfoundland (Memorial), Canada, and its 'pathways to rural practice' approach, which includes influences at the pre-medical school, medical school experience, postgraduate residency training, and physician practice levels. Memorial's pathways to practice helped Memorial to fulfill its social accountability mandate to populate the province with highly skilled rural generalist practitioners. Programs/interventions/initiatives: The 'pathways to rural practice' include initiatives in four stages: (1) before admission to medical school; (2) during undergraduate medical training (medical degree (MD) program); (3) during postgraduate vocational residency training; and (4) after postgraduate vocational residency training. Memorial's Learners & Locations (L&L) database tracks students through these stages. The Aboriginal initiative - the MedQuest program and the admissions process that considers geographic or minority representation in terms of those selecting candidates and the candidates themselves - occurs before the student is admitted. Once a student starts Memorial's MD program, the student has ample opportunities to have rural-based experiences through pre-clerkship and clerkship, of which some take place exclusively outside of St. John's tertiary hospitals. Memorial's postgraduate (PG) Family Medicine (FM) residency (vocational) training program allows for deeper community integration and longer periods of training within the same community, which increases the likelihood of a physician choosing rural family medicine. After postgraduate training, rural physicians were given many opportunities for professional development as well as faculty development opportunities. Each of the programs and initiatives were assessed through geospatial rurality analysis of administrative data collected upon entry into and during the MD program and PG training (L&L). Among Memorial MD-graduating classes of 2011-2020, 56% spent the majority of their lives before their 18th birthday in a rural location and 44% in an urban location. As of September 2016, 23 Memorial MD students self-identified as Aboriginal, of which 2 (9%) were from an urban location and 20 (91%) were from rural locations. For Year 3 Family Medicine, graduating classes 2011 to 2019, 89% of placement weeks took place in rural communities and 8% took place in rural towns. For Memorial MD graduating classes 2011-2013 who completed Memorial Family Medicine vocational training residencies, (N=49), 100% completed some rural training. For these 49 residents (vocational trainees), the average amount of time spent in rural areas was 52 weeks out of a total average FM training time of 95 weeks. For Family Medicine residencies from July 2011 to October 2016, 29% of all placement weeks took place in rural communities and 21% of all placement weeks took place in rural towns. For 2016-2017 first-year residents, 53% of the first year training is completed in rural locations, reflecting an even greater rural experiential learning focus. LESSONS LEARNED: Memorial's pathways approach has allowed for the comprehensive training of rural generalists for Newfoundland and Labrador and the rest of Canada and may be applicable to other settings. More challenges remain, requiring ongoing collaboration with governments, medical associations, health authorities, communities, and their physicians to help achieve reliable and feasible healthcare delivery for those living in rural and remote areas.

Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes.

INTRODUCTION: Rural recruitment and retention of physicians is a global issue. The Faculty of Medicine at Memorial University of Newfoundland, Canada, was established as a rural-focused medical school with a social accountability mandate that aimed to meet the healthcare needs of a sparse population distributed over a large landmass as well as the needs of other rural and remote areas of Canada. This study aimed to assess whether Memorial medical degree (MD) and postgraduate (PG) programs were effective at producing physicians for their province and rural physicians for Canada compared with other Canadian medical schools. METHODS: This retrospective cohort study included medical school graduates who completed their PG training between 2004 and 2013 in Canada. Practice locations of study subjects were georeferenced and assigned to three geographic classes: Large Urban; Small City/Town; and Rural. Analyses were performed at two levels. (1) Provincial level analysis compared Memorial PG graduates practicing where they received their MD and/or PG training with other medical schools who are the only medical school in their province (n=4). (2) National-level analysis compared Memorial PG graduates practicing in rural Canada with all other Canadian medical schools (n=16). Descriptive and bivariate analyses were performed. RESULTS: Overall, 18 766 physicians practicing in Canada completed Canadian PG training (2004-2013), and of those, 8091 (43%) completed Family Medicine (FM) training. Of all physicians completing Canadian PG training, 1254 (7%) physicians were practicing rurally and of those, 1076 were family physicians. There were 379 Memorial PG graduates and of those, 208 (55%) completed FM training and 72 (19%) were practicing rurally, and of those practicing rurally, 56 were family physicians. At the national level, the percentage of all Memorial PG graduates (19.0%) and FM PG graduates (26.9%) practicing rurally was significantly better than the national average for PG (6.4%, p<0.000) and FM (12.9%, p<0.000). Among 391 physicians practicing in Newfoundland and Labrador (NL), 257 (65.7%) were Memorial PG graduates and 247 (63.2%) were Memorial MD graduates. Of the 163 FM graduates, 148 (90.8%) were Memorial FM graduates and 118 (72.4%) were Memorial MD graduates. Of the 68 in rural practice, 51 (75.0%) were Memorial PG graduates and 31 (45.6%) were Memorial MD graduates. Of the 41 FM graduates in rural practice, 39 (95.1%) were Memorial FM graduates and 22 (53.7%) were Memorial MD graduates. Two-sample proportion tests demonstrated Memorial University provided a larger proportion of its provincial physician resource supply than the other four single provincial medical schools, by medical school MD for FM (72.4% vs 44.3%, p<0.000) and for overall (63.2% vs 43.5% p<0.000), and by medical school PG for FM (90.8 % vs 72.0%, p<0.000). CONCLUSION: This study found Memorial University graduates were more likely to establish practice in rural areas compared with the national average for most program types as well as more likely to establish practice in NL compared with other single medical schools' graduates in their provinces. This study highlights the impact a comprehensive rural-focused social accountability approach can have at supplying the needs of a population both at the regional and rural national levels.

Identification of Dyslipidemic Patients Attending Primary Care Clinics Using Electronic Medical Record (EMR) Data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) Database.

The objective of this study was to define the optimal algorithm to identify patients with dyslipidemia using electronic medical records (EMRs). EMRs of patients attending primary care clinics in St. John's, Newfoundland and Labrador (NL), Canada during 2009-2010, were studied to determine the best algorithm for identification of dyslipidemia. Six algorithms containing three components, dyslipidemia ICD coding, lipid lowering medication use, and abnormal laboratory lipid levels, were tested against a gold standard, defined as the existence of any of the three criteria. Linear discriminate analysis, and bootstrapping were performed following sensitivity/specificity testing and receiver's operating curve analysis. Two validating datasets, NL records of 2011-2014, and Canada-wide records of 2010-2012, were used to replicate the results. Relative to the gold standard, combining laboratory data together with lipid lowering medication consumption yielded the highest sensitivity (99.6%), NPV (98.1%), Kappa agreement (0.98), and area under the curve (AUC, 0.998). The linear discriminant analysis for this combination resulted in an error rate of 0.15 and an Eigenvalue of 1.99, and the bootstrapping led to AUC: 0.998, 95% confidence interval: 0.997-0.999, Kappa: 0.99. This algorithm in the first validating dataset yielded a sensitivity of 97%, Negative Predictive Value (NPV) = 83%, Kappa = 0.88, and AUC = 0.98. These figures for the second validating data set were 98%, 93%, 0.95, and 0.99, respectively. Combining laboratory data with lipid lowering medication consumption within the EMR is the best algorithm for detecting dyslipidemia. These results can generate standardized information systems for dyslipidemia and other chronic disease investigations using EMRs.

Patient satisfaction with chronic HIV care provided through an innovative pharmacist/nurse-managed clinic and a multidisciplinary clinic.

BACKGROUND: Pharmacist/nurse-led clinics are an established model for many chronic diseases but not yet for HIV. At our centre, patients with HIV are seen by a multidisciplinary team (physician, nurse, pharmacist, social worker) at least yearly. Some attend an HIV-specialist pharmacist/nurse clinic (or "nonphysician clinic," NPC) for alternate biannual visits. Our objective was to assess patient satisfaction with care received through both clinics. METHODS: The Patient Satisfaction Survey for HIV Ambulatory Care (assesses satisfaction with access to care, clinic visits and quality of care) was administered by telephone to adults who attended either clinic between January and July 2014. Descriptive statistics described patient characteristics and satisfaction scores. Fisher's exact test compared satisfaction scores between the NPC and multidisciplinary clinic (MDC). Multivariate logistic regression examined associations between overall satisfaction with care and clinic type and patient characteristics (e.g., age, disease duration). RESULTS: Respondents were very satisfied with the overall quality of HIV care in both the NPC and MDC (89% vs 93%, respectively, p = 0.6). Patients from both clinics expressed satisfaction with access to care, treatment plan input, their provider's knowledge of the newest developments in HIV care and explanation of medication side effects, with no significant differences noted. Significantly more MDC patients reported being asked about housing/finances, alcohol/drug use and whether they needed help disclosing their status. Patient characteristics were not significantly associated with satisfaction with overall quality of care. CONCLUSION: Patients are satisfied with both clinics, supporting NPC as an innovative model for chronic HIV care. Comparison of outcomes between clinics is needed to ensure high-quality care.