Reducing use of coagulation tests in a family medicine practice setting: An implementation study.

Introduction: Clinicians often order the international normalized ratio (INR) and activated partial thromboplastin time (APTT) to evaluate for the possibility of inherited bleeding disorders despite sensitivities and specificities of 1%-2%. The most accurate tool to evaluate for bleeding disorders is a validated bleeding assessment tool (BAT). Our aim was to reduce coagulation testing by >50% in a large family practice in Ontario, Canada. Methods: We conducted an implementation study from May 2016 to February 2020. Iterative interventions included introduction of a validated BAT into the electronic medical record (EMR); removal of the APTT as a prepopulated selection from the laboratory requisition; and education targeting family medicine teams and laboratory personnel. The primary outcome was the rate of pre- and post-APTT testing. Creatinine testing was the control. Data were analyzed via an interrupted time series analysis using Stata 13. Results: Immediately following education of the laboratory personnel on coagulation testing, the APTT rate level dropped by 1.26 tests per 100 patient visits per month (p < 0.001) and was sustained until the end of the study. Meanwhile, the PT/INR and creatinine testing rate levels did not change (rate level = -0.02 per 100 visits per month, p = 0.79 and 0.49, p = 0.22 respectively). There was good uptake of the BAT following integration and 18/88 (20%) obtained a referral to hematology after BAT completion. Conclusions: Multidisciplinary, iterative interventions reduced APTT testing and enabled the use of BATs to guide hematology referrals in a large family practice.

Development of a low resource exercise rehabilitation application for musculoskeletal disorders to help underserved patients in a primary care setting.

Objective: We set out to create a Family Medicine EHR (electronic health record) embedded exercise application. This was done to evaluate the utility of the exercise app for providers and to understand the usefulness of the exercise app from the perspective of patients. Methods: This exercise application was developed through an iterative process with repeated pre-testing and feedback from an interprofessional team and embedded into the EHR at an academic family medicine clinic. Anecdotal feedback from patients was used to inform pre-testing adaptations. Results: The application required six iterations prior to clinical utility. It had several features that clinicians and patients felt were beneficial. These features involved a customizable exercise directory with pre-made templated plans which could be further modified. To overcome accessibility barriers, the application was developed to include digital and printable copies with an integrated direct email option for ease of remote sharing with patients. Conclusion: A customizable, open-source exercise application was developed to facilitate provider exercise prescription and support patient self-management. This project may be useful for other providers interested in developing similar programs to address musculoskeletal conditions in their patients. Next steps are to undertake pilot testing of the app with broader provider and patient feedback.

Objectif: Concevoir une application d'exercices intégrés au DES (dossier de santé électronique) de la médecine familiale. Cela visait à évaluer l'utilité de l'application d'exercices pour les prestataires et à en comprendre l'utilité du point de vue des patients. Méthodologie: Cette application d'exercices a été élaborée au moyen d'un processus itératif mettant en oeuvre une mise à l'essai répétée et une rétroaction d'une équipe interprofessionnelle et intégrée dans le DES d'une clinique universitaire de médecine familiale. Une rétroaction secondaire de patients a contribué aux adaptations de mise à l'essai. Résultats: L'application a dû être répétée six fois avant l'utilité clinique. Selon les cliniciens et les patients, plusieurs fonctions ont présenté un avantage. Il s'agissait notamment d'un répertoire d'exercices personnalisable assorti de modèles de plans préconçus et modifiables par la suite. Afin de surmonter les obstacles d'accessibilité, l'application était conçue pour comprendre des versions numériques et imprimables dotées d'une option de courriel direct intégré pour faciliter le partage à distance avec les patients. Conclusion: Une application d'exercices personnalisable et ouverte visait à faciliter la prescription d'exercices par les prestataires et à soutenir le traitement autonome des patients. Ce projet peut être utile à d'autres prestataires souhaitant élaborer des programmes semblables pour traiter les problèmes musculosquelettiques de leurs patients. Les étapes suivantes consistent à entreprendre des mises à l'essai de l'application avec un retour d'information plus large de la part des prestataires et des patients.

Electronic communication between family physicians and patients: Findings from a multisite survey of academic family physicians in Ontario.

OBJECTIVE: To assess the proportion of academic family physicians using e-mail with patients and to explore related attitudes, barriers, and facilitators. DESIGN: A 47-item questionnaire was created after a literature review, discussions with study team members, pretesting, and pilot testing. The questionnaire was disseminated electronically from June to August 2017. SETTING: Ontario. PARTICIPANTS: All family physicians affiliated with the Department of Family and Community Medicine at the University of Toronto. MAIN OUTCOME MEASURES: Physician practices using e-mail (including barriers to and facilitators of e-mail use with patients), use of e-mail with other health care providers, use of communication technologies other than e-mail, and demographic and practice information. RESULTS: A total of 1553 surveys were disseminated and 865 responses received (56% response rate). Overall, 610 respondents met inclusion criteria. Of these respondents, 43% (265 of 610) personally sent e-mails to patients in a typical week. An additional 21% (126 of 610) reported that they did not personally e-mail patients, but their clinic staff did. Patient convenience and a decrease in the need for telephone communication were the most commonly noted reasons for e-mail use. Facilitators of e-mail use included integration with the electronic medical record, enhanced e-mail access control, security features, and financial compensation. Barriers to e-mail use included privacy and security concerns, concerns about inappropriate e-mail use by patients, and the creation of unrealistic expectations about physician availability. CONCLUSION: E-mail use between academic family physicians and patients was found to be much higher than shown in previous studies of Canadian physicians. This finding might have been owing to unique aspects of academic medicine, remuneration via capitation, or other factors. Efforts to increase physician use of e-mail with patients should address concerns related to privacy and security, electronic medical record integration, and financial compensation.

Ten tips for advancing a culture of improvement in primary care.

Embracing practice-based quality improvement (QI) represents one way for clinicians to improve the care they provide to patients while also improving their own professional satisfaction. But engaging in care redesign is challenging for clinicians. In this article, we describe our experience over the last 7 years transforming the care delivered in our large primary care practice. We reflect on our journey and offer 10 tips to healthcare leaders seeking to advance a culture of improvement. Our organisation has developed a cadre of QI leaders, tracks a range of performance measures and has demonstrated sustained improvements in important areas of patient care. Success has required deep engagement with both patients and clinicians, a long-term vision, and requisite patience.

Family physician satisfaction with two different academic compensation schemes.

BACKGROUND AND OBJECTIVES: A growing body of evidence suggests that comprehensive relative-value-based incentive plans (CRVPs) are more effective at tracking and improving academic productivity than other types of academic compensation schemes (ACSs). However, there is little literature to date exploring physician satisfaction with CRVPs. METHODS: Physicians in two academic family medicine departments in Toronto, Ontario, completed an anonymous satisfaction survey. One of these departments used a CRVP to compensate for non-clinical activities; the control group used a monthly stipend based on full-time equivalents (FTEs). RESULTS: When compared with controls, physicians compensated by a CRVP were more likely to increase their involvement in non-clinical activities, to report being "very satisfied" with their ACS, to feel that their ACS made them "more likely" to continue working in their department, and to feel that their ACS was "fair." CONCLUSIONS: Physicians in a family medicine department that used a CRVP felt a greater sense of sense of satisfaction and fairness in terms of their compensation for non-clinical activities. CRVP physicians also perceived an increased involvement in academic activities, were more likely to continue to work in their current department, and to feel that the compensation for non-clinical activities was adequate.

Quantifying the reduction in nonmedical costs after the introduction of a rural county hospital in Ecuador.

OBJECTIVE: This study attempts to quantify the impact of the introduction of local second-level health services on nonmedical costs (NMCs) for residents of the rural Ecuadorian county of La Maná. METHODS: NMCs for patients accessing second-level health care were assessed by using a quasi-experimental pre- and postintervention study design. In 2007, before local second-level health care services existed, and then in 2008, after the introduction of second-level health care services in the form of a county hospital, 508 patients from the county who sought second-level health care were interviewed. RESULTS: Mean NMCs per patient per illness episode were US$ 93.58 before the county hospital opened and US$ 12.62 after it opened. This difference was largely due to reductions in transport costs (US$ 50.01 vs. US$ 4.28) and food costs (US$ 25.38 vs. US$ 7.28) (P < 0.001 for each category). CONCLUSIONS: NMCs can be decreased sevenfold with the introduction of a county hospital in a rural province previously lacking second-level health care. Introduction of rural second-level health care reduces financial barriers and thus may increase access to these health services for poorer patients in rural communities.

Quantifying the reduction in nonmedical costs after the introduction of a rural county hospital in Ecuador / Cuantificación de la reducción de los costos no médicos mediante la apertura de un hospital en un cantón rural del Ecuador

OBJECTIVE: This study attempts to quantify the impact of the introduction of local second-level health services on nonmedical costs (NMCs) for residents of the rural Ecuadorian county of La Maná. METHODS: NMCs for patients accessing second-level health care were assessed by using a quasi-experimental pre- and postintervention study design. In 2007, before local second-level health care services existed, and then in 2008, after the introduction of second-level health care services in the form of a county hospital, 508 patients from the county who sought second-level health care were interviewed. RESULTS: Mean NMCs per patient per illness episode were US$ 93.58 before the county hospital opened and US$ 12.62 after it opened. This difference was largely due to reductions in transport costs (US$ 50.01 vs. US$ 4.28) and food costs (US$ 25.38 vs. US$ 7.28) (P < 0.001 for each category). CONCLUSIONS: NMCs can be decreased sevenfold with the introduction of a county hospital in a rural province previously lacking second-level health care. Introduction of rural second-level health care reduces financial barriers and thus may increase access to these health services for poorer patients in rural communities.

OBJETIVO: Este estudio tiene por objeto cuantificar la repercusión de la introducción de servicios de salud locales de segundo nivel sobre los costos no médicos para los residentes del cantón rural ecuatoriano de La Maná. MÉTODOS: Se evaluaron los costos no médicos de los pacientes que tuvieron acceso a atención médica de segundo nivel mediante un estudio cuasiexperimental de análisis previo y posterior a la intervención. En el 2007 (antes de que existieran servicios locales de este tipo) y en el 2008 (después de la introducción de atención médica de segundo nivel representada por el hospital del cantón) se entrevistaron a 508 pacientes del cantón que requirieron atención médica de segundo nivel. RESULTADOS: Los costos no médicos medios por paciente y por episodio de enfermedad fueron de US$ 93,58 antes de la apertura del hospital local y de US$ 12,62 después de la inauguración del establecimiento. Esta diferencia se debió en gran parte a la reducción de los costos de transporte (US$ 50,01 frente a US$ 4,28) y de los costos de alimentación (US$ 25,38 frente a US$ 7,28) (P < 0,001 para cada categoría). CONCLUSIONES: Es posible reducir los costos no médicos a una séptima parte mediante la apertura de un hospital local en una zona rural que anteriormente carecía de atención médica de segundo nivel. La introducción de atención médica de segundo nivel en una zona rural reduce los obstáculos financieros y, por lo tanto, podría aumentar el acceso a estos servicios de salud para los pacientes más pobres en las comunidades rurales.