Prioritizing and Implementing Primary Care Performance Measures for Ontario.

In the fall of 2014, Health Quality Ontario released A Primary Care Performance Measurement Framework for Ontario. Recognizing the large number of recommended measures and the limited availability of data related to those measures, the Steering Committee for the Primary Care Performance Measurement (PCPM) initiative established a prioritization process to select two subsets of high-value performance measures - one at the system level and one at the practice level. This article describes the prioritization process and its results and outlines the initiatives that have been undertaken to date to implement the PCPM framework and to advance primary care performance measurement and reporting in Ontario. Establishing a framework for primary care measurement and prioritizing system- and practice-level measures are essential steps toward system improvement. Our experience suggests that the process of implementing a performance measurement system is inevitably non-linear and incremental.

Social and Geographic Determinants of Hysterectomy in Ontario: A Population-Based Retrospective Cross-Sectional Analysis.

OBJECTIVES: This study sought to determine whether social factors (neighbourhood education and income) and geographic factors (urban or rural dwelling and local service area) are associated with hysterectomy rates, proportion of hysterectomies performed minimally invasively, and hysterectomy complication and readmission rates in Ontario. METHODS: The Canadian Institute for Health Information Discharge Abstract Database was used to perform a population-based retrospective cross-sectional study on women who had an abdominal, vaginal, and laparoscopic hysterectomy in 2007 for benign gynaecologic conditions in hospitals in Ontario, Canada. Crude and age-standardized rates of hysterectomy, proportion of hysterectomy performed minimally invasively (vaginal or laparoscopic), and rates of surgical complications were analyzed by neighbourhood educational attainment, neighbourhood income, rural or urban residency, and health service delivery area (Canadian Task Force Classification of Study Design II). RESULTS: A total of 13 511 women who underwent hysterectomy were included. Age-standardized hysterectomy rates were higher for the lowest neighbourhood educational quartile compared with the highest (relative risk [RR] 1.49; 95% CI 1.39-1.60), higher with rural compared with urban dwelling (RR 1.54; 95% CI 1.47-1.61), varied with local health service delivery area (Local Health Integration Network [LHIN]) (range 133.4-439.5 per 100 000 women), and also varied non-linearly with neighbourhood income quintile. Proportion of hysterectomies performed minimally invasively did not vary with neighbourhood education or income, were higher for rural compared with urban areas (RR 1.10; 95% CI 1.03-1.19), and varied with LHIN (range 30.0-62.9 per 100 hysterectomies). Surgical complications varied with neighbourhood educational quartile, but not with income or urban or rural residence. CONCLUSIONS: Considerable social and geographic variation exists in rates of hysterectomy in Ontario, whereas only geographic variation is seen in use of minimally invasive routes. Surgical complication rates vary only by neighbourhood education. Such findings suggest inequities in hysterectomy practice in Ontario, and there is a need to evaluate factors influencing patients' decision making, physicians' clinical and surgical practice, and health system policies to help address the observed disparities.

Design considerations for supervised consumption facilities (SCFs): preferences for facilities where people can inject and smoke drugs.

BACKGROUND: Supervised consumption facilities (SCFs) aim to improve the health and well-being of people who use drugs by offering safer and more hygienic alternatives to the risk environments where people typically use drugs in the community. People who smoke crack cocaine may be willing to use supervised smoking facilities (SSFs), but their facility design preferences and the views of other stakeholders have not been previously investigated in detail. METHODS: We consulted with people who use drugs and other stakeholders including police, fire and ambulance service personnel, other city employees and city officials, healthcare providers, residents, and business owners (N = 236) in two Canadian cities without SCFs and asked how facilities ought to be designed. All consultations were audio-recorded and transcribed. Thematic analyses were used to describe the knowledge and opinions of stakeholders. RESULTS: People who use drugs see SSFs as offering public health and safety benefits, while other stakeholders were more sceptical about the need for SSFs. People who use drugs provided insights into how a facility might be designed to accommodate supervised injection and supervised smoking. Their strongest preference would allow both methods of drug use within the same facility with some form of physical separation between the two based on different highs, comfort regarding exposure to different methods of drug administration, and concerns about behaviours often associated with smoking crack cocaine. Other stakeholders raised a number of SSF implementation challenges worthy of consideration. CONCLUSION: Decision-makers in cities considering SCF or SSF implementation should consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs.

Gender differences in stroke care and outcomes in Ontario.

BACKGROUND: Studies of potential gender differences in stroke care and outcomes have yielded inconsistent findings. The Project for an Ontario Women's Health Evidence-based Report study measured established stroke care indicators in a large, representative sample of women and men with stroke or transient ischemic attack (TIA) admitted to acute care institutions in the province of Ontario, Canada. METHODS: The Registry of the Canadian Stroke Network performs a biennial audit on a random sample of 20% of patients with stroke or TIA seen at more than 150 acute care institutions across Ontario. We used data from the 2004/05 audit to compare stroke care by gender, with stratification by age and neighborhood income. RESULTS: The sample consisted of 4,046 patients (51% women). There were no significant gender differences in the use of thrombolysis, neuroimaging, carotid imaging, dysphagia screening, antithrombotic therapy, or neurology and other consultations. Women with ischemic stroke or TIA were less likely than men to be prescribed statins or undergo carotid imaging and endarterectomy within 6 months of stroke; women were more likely than men to receive antihypertensives. There were no significant gender differences in readmission or mortality rates after stroke. INTERPRETATION: In this population-based study, we found little evidence of gender differences in stroke care or outcomes other than lipid-lowering therapy, carotid imaging, and endarterectomy. Further study is needed to assess the contribution of the provincial stroke strategy in eliminating gender differences in management of acute stroke and to better understand and target remaining gender differences in management.

Invasive bacterial diseases in northern Canada.

International Circumpolar Surveillance (ICS) is a population-based invasive bacterial disease surveillance network. Participating Canadian regions include Yukon, Northwest Territories, Nunavut, and northern regions of Québec and Labrador (total population 132,956, 59% aboriginal). Clinical and demographic information were collected by using standardized surveillance forms. Bacterial isolates were forwarded to reference laboratories for confirmation and serotyping. After pneumococcal conjugate vaccine introduction, crude annual incidence rates of invasive Streptococcus pneumoniae decreased from 34.0/100,000 population (1999-2002) to 23.6/100,000 population (2003-2005); substantial reductions were shown among aboriginals. However, incidence rates of S. pneumoniae, Haemophilus influenzae, and group A streptococci were higher in aboriginal populations than in non-aboriginal populations. H. influenzae type b was rare; 52% of all H. influenzae cases were caused by type a. Data collected by ICS contribute to the understanding of the epidemiology of invasive bacterial diseases among northern populations, which assists in formulation of prevention and control strategies, including immunization recommendations.

Can a community evidence-based asthma care program improve clinical outcomes?: a longitudinal study.

RATIONALE: Asthma is associated with significant morbidity. Previous studies highlight significant variations in asthma management approaches within primary care settings where the adoption of published asthma guidelines is typically suboptimal. OBJECTIVE: To determine whether the implementation of an evidence-based asthma care program in community primary care settings leads to improved clinical outcomes in asthma patients. METHODS, MEASUREMENTS, AND MAIN RESULTS: A community-based participatory research project was implemented at 8 primary care practices across Ontario, Canada, consisting of elements based on the Canadian Asthma Consensus Guidelines (asthma care map, program standards, management flow chart and action plan). A total of 1408 patients aged 2-55 years participated. Conditional logistic regression analyses were used to calculate the odds ratios (OR) comparing baseline to follow-up while adjusting for age, gender, socioeconomic status and other covariates. At 12-month follow-up, there were statistically significant reductions in self-reported asthma exacerbations from 77.8% to 54.5% [OR = 0.35; 95% confidence interval (CI): 0.28-0.43]; emergency room visits due to asthma from 9.9% to 5.5% (OR = 0.47; 95% CI: 0.32-0.62); school absenteeism in children from 19.9% to 10.2% (OR = 0.37; 95% CI: 0.25-0.54); productivity loss in adults from 12.0% to 10.3% (OR = 0.49; 95% CI: 0.34-0.71); uncontrolled daytime asthma symptoms from 62.4% to 41.4% (OR = 0.34; 95% CI: 0.27-0.42); and uncontrolled nighttime asthma symptoms from 46.4% to 25.4% (OR = 0.29; 95% CI: 0.23-0.37). CONCLUSIONS: Development and implementation of a community-based primary care asthma care program led to risk reductions in exacerbations, symptoms, urgent health service use and productivity loss related to asthma.

Graduates of northern Ontario family medicine residency programs practise where they train.

OBJECTIVE: To examine where graduates of the Northeastern Ontario Family Medicine (NOFM) residency program in Sudbury and the Family Medicine North (FMN) program in Thunder Bay practise after graduation, using cross-sectional and longitudinal analyses. METHODS: Data from the Scott's Medical Database were examined. All physicians who graduated from NOFM and FMN between 1993 and 2002 were included in this analysis. Differences in the location of first practice between NOFM and FMN graduates were tested using chi-squared tests. Logistic regression analyses were used to examine the impact of the training program on a physician's first, as well as continuing, practice location. RESULTS: Between 1993 and 2002, FMN graduates were 4.56 times more likely (95% confidence interval [CI] 2.34-8.90) to practise in rural areas, compared with NOFM graduates, but NOFM graduates were 2.50 times more likely than FMN graduates (95% CI 1.35-4.76) to practise in northern Ontario. There was no statistically significant difference between the graduates of the 2 programs in the likelihood of working in either northern Ontario or a rural area. About two-thirds (67.5%) of all person-years of medical practice provided by NOFM and FMN graduates took place in northern Ontario or rural areas outside the north. CONCLUSION: NOFM and FMN have been successful in producing family physicians to work in northern Ontario and rural areas. Results from this study add to the growing evidence from Canada and abroad that rural or northern medical education and training increases the likelihood that the graduates will practise in rural or northern communities.

Duration of rural training during residency: rural family physicians prefer 6 months.

OBJECTIVE: To determine whether rural family physicians thought they had received enough months of rural exposure during family medicine residency, how many months of rural exposure those who were satisfied with their training had had, and how many months of rural exposure those who were not satisfied with their training wanted. DESIGN: Mailed survey. SETTING: Rural Canada. PARTICIPANTS: Rural family physicians who had graduated between 1991 and 2000 from a Canadian medical school. MAIN OUTCOME MEASURES: Respondents' opinions about whether their exposure to rural medicine during training had been adequate. RESULTS: Response rate was 59% (382/651). After excluding physicians who had not had Canadian family medicine residency training, 348 physicians remained, and of those, 58% thought they had had adequate rural exposure during residency. Median duration of rural training among those who thought they had had enough rural exposure was 6 months; median duration of rural exposure among those who thought they had not had enough was 2 months. Median duration of rural exposure desired by those who thought they had not had enough rural training was 6 months. Some physicians wanted much more than 6 months of rural training; for example, one quarter of those satisfied with their rural training had had 10 or more months of rural rotations. Fewer than 1% of respondents thought they had received too much rural training. There was no significant difference in number of months of rural training preferred by men and women (P = .94). One third of respondents had graduated from rural-focused family practice residency programs. Rural program graduates were more likely than non-rural program graduates to report that the duration of their rural training was adequate (84% vs 46%, P < .0001) and to report more mean months of rural exposure (8.9 vs 3.4; P < .0001). CONCLUSION: Typical rural family physicians prefer to have 6 months of rural exposure during residency. This finding is consistent with the recommendation of a College of Family Physicians of Canada committee that rural family medicine training programs offer at least 6 months of rural rotations. Almost half of rural family physicians wished they had had more rural training. Both rural-focused and non-rural-focused programs should consider providing opportunities for pursuing elective rotations in rural areas in addition to mandatory rotations if they want to respond to these preferences for training.

Factors influencing family physicians to enter rural practice: does rural or urban background make a difference?

OBJECTIVE: To examine where rural physicians grew up, when during their training they became interested in rural medicine, factors influencing their decision to practise rural medicine, and differences in these measures according to rural or urban upbringing. DESIGN: Mailed survey. SETTING: Rural Canada. PARTICIPANTS: Rural family physicians who graduated between 1991 and 2000 from a Canadian medical school. MAIN OUTCOME MEASURES: Backgrounds of recently graduated rural physicians, when physicians first became interested in rural practice during training, and most influential factors in decisions to practise rural medicine. RESULTS: Response rate was 59% (382/651). About 33% of rural physicians grew up in communities of less than 10 000 people, 44% in cities of 10 000 to 499 999 people, and 23% in cities of more than 500 000 people. Physicians raised in rural areas were more likely than those raised in urban areas to have some interest in rural family practice at the start and end of medical school (90% vs 67% at the start, 98% vs 91% at the end, respectively, P < .0001). Physicians raised in urban areas were more likely to state that rural medical training was the most influential factor in their choice of rural practice (19% vs 9%, P = .015). Other factors cited as influential were the challenge of rural practice (24% for both urban and rural upbringing), rural lifestyle (14% for urban and 18% for rural upbringing) and, for physicians raised in rural areas, having grown up or spent time in a rural area (27% for rural and 4.1% for urban upbringing, P < .001). Financial incentives were least frequently cited as the most influential factor (7.5% for urban and 4.9% for rural upbringing, P = .35). CONCLUSION: Although other studies have suggested that physicians with a rural upbringing are more likely to practise rural medicine and policy makers might still wish to target students raised in rural areas as candidates for rural medicine, this study shows that physicians raised in urban areas remain the main source of human resources for rural communities. They account for two thirds of new physicians in rural areas. Education in rural medicine during medical training has a stronger influence on physicians raised in urban areas than on physicians raised in rural areas. Undergraduate and postgraduate training periods, therefore, offer an important opportunity for recruiting physicians raised in urban areas to rural practice.

Regional variation in HIV prevalence and risk behaviours in Ontario injection drug users (IDU).

OBJECTIVES: To measure HIV prevalence, risk behaviours, and further service needs in needle exchange programs throughout Ontario, and to conduct regional comparisons. METHODS: Injection drug users (IDU) recruited through the efforts of needle exchange programme (NEP) staff in 9 Ontario cities during 1997-98 completed questionnaires about their drug use and behaviours and provided saliva and/or dried blood samples for anonymous unlinked HIV testing. RESULTS: Demographic and drug use characteristics of participants showed great regional variation. HIV prevalence by region ranged from 1.4% to 14.7%. In addition to region, HIV positivity was associated with injecting for more than 5 years, use of (powder) cocaine, use of crack, binge injection (10 or more times per day at least once in the previous 6 months), and being a longer-term NEP user. Sharing of injection equipment, and especially of other drug injection materials such as water and cookers, remain important issues, although much of the sharing reported is with only one other person. Unmet demand for methadone treatment was identified despite changes in regulation of methadone provision designed to make it more accessible. CONCLUSIONS: This study suggested significant further HIV prevention needs among IDU throughout Ontario. There is also evidence of potential to provide additional services such as methadone at NEPs if the required resources are invested. NEPs that have succeeded in gaining the trust of high-risk IDU offer a means to provide access to needed services.