Distress experienced by lung cancer patients and their family caregivers in the first year of their cancer journey.

OBJECTIVES: Diagnosis of cancer is emotionally threatening not only for patients but also for their family caregivers (FC) who witness and share much of the illness experience. This study compares distress experienced by lung cancer patients and their FC during the year following the diagnosis. METHODS: A prospective cohort study of 206 patients recently diagnosed with inoperable lung cancer (participation rate 79.5%) and 131 FC (participation rate 63.6%) was conducted in an ambulatory oncology clinic in Quebec City (Canada). They completed validated questionnaires regarding their personal and psychological characteristics (Hospital and Anxiety Depression Scale-HADS), in the first months after the diagnosis of lung cancer and after 6 and 12 months. Univariate, bivariate, and linear mixed models were conducted to compare patient and FC distress. RESULTS: At baseline, 7.8% of patients reported distress (HADS total score >15) and their mean distress score was 7.0 ± 4.9 (range 0-42). In contrast, 33.6% of FC presented significant distress and their mean distress score was 12.0 ± 7.2 (P < 0.0001). Proportions of patients and FC with distress remained relatively stable at 6 and 12 months, and at every time point, FC reported higher levels of distress compared to their relative with cancer (P < 0.0001). Comparable trends were found when looking at the mean scores of distress, anxiety, and depression throughout the study. SIGNIFICANCE OF RESULTS: Being diagnosed with lung cancer and going through its different phases seems to affect more FC than patients. The psychological impact of such diagnosis appears early after the diagnosis and does not significantly change over time. These findings reinforce the importance for oncology teams, to include FC in their systematic distress screening program, in order to help them cope with their own feelings and be able to play their role in patient support and care throughout the cancer journey.

Continuity of Cancer Care and Collaboration Between Family Physicians and Oncologists: Results of a Randomized Clinical Trial.

PURPOSE: Collaboration between family physicians (FPs) and oncologists can be challenging. We present the results of a randomized clinical trial of an intervention designed to improve continuity of care and interprofessional collaboration, as perceived by patients with lung cancer and their FPs. METHODS: The intervention included (1) supplying FPs with standardized summaries related to each patient, (2) recommending that patients see their FP after receiving the cancer diagnosis, (3) supplying the oncology team with patient information resulting from FP visits, and (4) providing patients with priority access to FPs as needed. A total of 206 patients with newly diagnosed lung cancer were randomly assigned to the intervention (n = 104) or control group (n = 102), and 86.4% of involved FPs participated. Perceptions of continuity of care and interprofessional collaboration were assessed every 3 months for patients and at baseline and at the end of the study for FPs. Patient distress and health service utilization were also assessed. RESULTS: Patients and FPs in the intervention group perceived better interprofessional collaboration (patients: P <.0001; FPs: P = .0006) than those in the control group. Patients reported better informational continuity (P = .001) and management continuity (P = .05) compared to the control group, but no differences were found for FPs (information: P = .22; management: P = .13). No effect was found with regard to patient distress or health service utilization. CONCLUSIONS: This intervention improved patient and FP perception of interprofessional collaboration, but its effectiveness on continuity of care was less clear for FPs than for patients. Additional strategies should be considered to sustainably improve continuity of care and interprofessional collaboration.

Le nouveau programme formel de mentorat du Collège québécois des médecins de famille.

PROBLÈME À L'ÉTUDE: Les stress inhérents à l'entrée en pratique peuvent décourager les futurs médecins de choisir la médecine de famille. Le Québec fait face à des problèmes de recrutement de médecins de famille en clinique pour remplacer ceux qui s'acheminent vers la retraite. Le mentorat s'avère être un moyen prometteur de soutenir la relève en médecine de famille. OBJECTIF DU PROGRAMME: Aider les médecins de famille en début de pratique à composer de manière satisfaisante avec les enjeux et les défis inhérents à l'insertion professionnelle et à leur développement personnel et professionnel. DESCRIPTION DU PROGRAMME: D'une durée de 12 mois, il se caractérise par des dyades mentoré-mentor, à l'initiative des mentorés; des moyens de soutien aux mentors, dont une communauté de pratique; des modalités de rencontres favorisant la participation de mentorés et de mentors provenant de diverses régions géographiques du Québec. CONCLUSION: L'engagement et le soutien des mentorés et des mentors sont des facteurs essentiels de réussite, mais aussi des défis organisationnels pour la pérennité de programmes formels de mentorat auprès des nouveaux médecins de famille du Québec.

Quebec College of Family Physicians' new formal mentorship program.

PROBLEM ADDRESSED: The stresses that arise during the first years of practice can discourage future physicians from choosing family medicine. Quebec is experiencing challenges in recruiting clinical family physicians to replace those nearing retirement. Mentorship is a promising approach that supports future family physicians. OBJECTIVE OF PROGRAM: To help family physicians at the beginning of their practice to adequately cope with the issues and challenges that come with professional integration and their personal and professional development. PROGRAM DESCRIPTION: A 12-month program that pairs mentors with mentees, on the mentee's initiative; it provides supports for mentors (such as a community of practice), and it comprises meeting formats that encourage the participation of mentees and mentors from different geographic regions across Quebec. CONCLUSION: Engaging and supporting mentees and mentors are essential to success, but might also present organizational challenges to sustaining formal mentorship programs for new family physicians in Quebec.

Psychometric analysis of the TRANSIT quality indicators for cardiovascular disease prevention in primary care.

OBJECTIVE: To assess a selection of psychometric properties of the TRANSIT indicators. DESIGN: Using medical records, indicators were documented retrospectively during the 14 months preceding the end of the TRANSIT study. SETTING: Primary care in Quebec, Canada. PARTICIPANTS: Indicators were documented in a random subsample (n = 123 patients) of the TRANSIT study population (n = 759). INTERVENTIONS: For every patient, the mean compliance to all indicators of a category (subscale score) and to the complete set of indicators (overall scale score) were established. To evaluate test-retest and inter-rater reliabilities, indicators were applied twice, two months apart, by the same evaluator and independently by different evaluators, respectively. To evaluate convergent validity, correlations between TRANSIT indicators, Burge et al. indicators and Institut national d'excellence en santé et en services sociaux (INESSS) indicators were examined. MAIN OUTCOME MEASURES: Test-retest reliability, inter-rater reliability, and convergent validity. RESULTS: Test-retest reliability, as measured by intraclass correlation coefficients (ICCs) was equal to 0.99 (0.99-0.99) for the overall scale score while inter-rater reliability was equal to 0.95 (0.93-0.97) for the overall scale score. Convergent validity, as measured by Pearson's correlation coefficients, was equal to 0.77 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to Burge et al. indicators and to 0.82 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to INESSS indicators. CONCLUSIONS: Reliability was excellent except for eleven indicators while convergent validity was strong except for domains related to the management of CVD risk factors.

External facilitators and interprofessional facilitation teams: a qualitative study of their roles in supporting practice change.

BACKGROUND: Facilitation is a powerful approach to support practice change. The purpose of this study is to better understand the facilitation roles exercised by both external facilitators and interprofessional facilitation teams to foster the implementation of change. Building on Dogherty et al.'s taxonomy of facilitation activities, this study uses an organizational development lens to identify and analyze facilitation roles. It includes a concise definition of what interprofessional facilitation teams actually do, thus expanding our limited knowledge of teams that act as change agents. We also investigate the facilitation dynamics between change actors. METHODS: We carried out a qualitative analysis of a 1-year process of practice change implementation. We studied four family medicine groups, in which we constituted interprofessional facilitation teams. Each team was supported by one external facilitator and included at least one family physician, one case manager nurse, and health professionals located on or off the family medicine group's site (one pharmacist, plus at least one nutritionist, kinesiologist, or psychologist). We collected our data through focus group interviews with the four teams, individual interviews with the two external facilitators, and case audit documentation. We analyzed both predetermined (as per Dogherty et al., 2012) and emerging facilitation roles, as well as facilitation dynamics. RESULTS: A non-linear framework of facilitation roles emerged from our data, based on four fields of expertise: change management, project management, meeting management, and group/interpersonal dynamics. We identified 72 facilitation roles, grouped into two categories: "implementation-oriented" and "support-oriented." Each category was subdivided into themes (n = 6; n = 5) for clearer understanding (e.g., legitimation of change/project, management of effective meetings). Finally, an examination of facilitation dynamics revealed eight relational ties occurring within and/or between groups of actors. CONCLUSIONS: Facilitation is an approach used by appointed individuals, which teams can also foster, to build capacity and support practice change. Increased understanding of facilitation roles constitutes an asset in training practitioners such as organizational development experts, consultants, facilitators, and facilitation teams. It also helps decision makers become aware of the multiple roles and dynamics involved and the key competencies needed to recruit facilitators and members of interprofessional facilitation teams.

Facilitating Implementation of Interprofessional Collaborative Practices Into Primary Care: A Trilogy of Driving Forces.

Implementing interprofessional collaborative practices in primary care is challenging, and research about its facilitating factors remains scarce. The goal of this participatory action research study was to better understand the driving forces during the early stage of the implementation process of a community-driven and patient-focused program in primary care titled "TRANSforming InTerprofessional cardiovascular disease prevention in primary care" (TRANSIT). Eight primary care clinics in Quebec, Canada, agreed to participate by creating and implementing an interprofessional facilitation team (IFT). Sixty-three participants volunteered to be part of an IFT, and 759 patients agreed to participate. We randomized six clinics into a supported facilitation ("supported") group, with an external facilitator (EF) and financial incentives for participants. We assigned two clinics to an unsupported facilitation ("unsupported") group, with no EF or financial incentives. After 3 months, we held one interview for the two EFs. After 6 months, we held eight focus groups with IFT members and another interview with each EF. The analyses revealed three key forces: (1) opportunity for dialogue through the IFT, (2) active role of the EF, and (3) change implementation budgets. Decision-makers designing implementation plans for interprofessional programs should ensure that these driving forces are activated. Further research should examine how these forces affect interprofessional practices and patient outcomes.

Priority interventions to improve the management of chronic non-cancer pain in primary care: a participatory research of the ACCORD program.

PURPOSE: There is evidence that the management of chronic non-cancer pain (CNCP) in primary care is far from being optimal. A 1-day workshop was held to explore the perceptions of key actors regarding the challenges and priority interventions to improve CNCP management in primary care. METHODS: Using the Chronic Care Model as a conceptual framework, physicians (n=6), pharmacists (n=6), nurses (n=6), physiotherapists (n=6), psychologists (n=6), pain specialists (n=6), patients (n=3), family members (n=3), decision makers and managers (n=4), and pain researchers (n=7) took part in seven focus groups and five nominal groups. RESULTS: Challenges identified in focus group discussions were related to five dimensions: knowledge gap, "work in silos", lack of awareness that CNCP represents an important clinical problem, difficulties in access to health professionals and services, and patient empowerment needs. Based on the nominal group discussions, the following priority interventions were identified: interdisciplinary continuing education, interdisciplinary treatment approach, regional expert leadership, creation and definition of care paths, and patient education programs. CONCLUSION: Barriers to optimal management of CNCP in primary care are numerous. Improving its management cannot be envisioned without considering multifaceted interventions targeting several dimensions of the Chronic Care Model and focusing on both clinicians and patients.

Providing high-quality care in primary care settings: how to make trade-offs.

OBJECTIVE: To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care. DESIGN: Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices. SETTING: Three regions of Quebec. PARTICIPANTS: Health care professionals and staff of 5 PC practices. METHODS: Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed. MAIN FINDINGS: The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters. CONCLUSION: Irrespective of their models, PC practices' pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.

Pharmacotherapeutic management of chronic noncancer pain in primary care: lessons for pharmacists.

PURPOSE: Describe the pharmacotherapeutic management of primary-care patients with chronic noncancer pain, assess their satisfaction with pain treatment, and identify the determinants of their satisfaction. METHODS: A cohort study was conducted in Quebec (Canada). Patients reporting chronic noncancer pain with an average pain intensity of at least 4 on a 0-10 scale (10= worst possible pain) and having an active analgesic prescription from a primary-care physician were recruited. They completed a telephone interview and a self-administered questionnaire to document their pain, emotional well-being, satisfaction with treatment, and barriers/beliefs/attitudes about pain and its treatment. Information on pharmacotherapy was based on an administrative provincial database and pharmacies' charts. Determinants of patients' satisfaction were identified using multivariate linear regression models. RESULTS: Four hundred and eighty six patients participated. Their mean age was 58.4 years and they had had pain for a mean of 11.7 years (standard deviation, ±11.1) at an average pain intensity of 6.5 in the past week. Although 90% reported adverse gastrointestinal effects, 36.4% and 54.4% of these patients took no over-the-counter or prescribed medication for constipation or nausea, respectively. On a scale from 0-100, the mean overall satisfaction score was 64.7 (95% confidence interval [CI] =63.5-65.9). Patient satisfaction was low, particularly regarding the "information about pain and its treatment" (mean 50.6; 95% CI =47.6-53.7) and "treatment efficacy" (mean 53.6; 95% CI =51.5-55.6) subscales. The overall treatment satisfaction score decreased with more pain disability, probable depression and anxiety, more barriers to pain treatment, higher incidence of nausea, and use of over-the-counter analgesics. CONCLUSION: In primary care, patients' level of satisfaction with their pain treatment is not optimal. This study underlines how the expanded scope of practice of community pharmacists may allow them to play a pivotal role in providing information, discussing barriers to pain treatment, and monitoring pain disability, and by appropriately managing pharmacotherapy to optimize effectiveness while minimizing adverse effects.

Development of an interprofessional program for cardiovascular prevention in primary care: A participatory research approach.

BACKGROUND: The chronic care model provides a framework for improving the management of chronic diseases. Participatory research could be useful in developing a chronic care model-based program of interventions, but no one has as yet offered a description of precisely how to apply the approach. OBJECTIVES: An innovative, structured, multi-step participatory process was applied to select and develop (1) chronic care model-based interventions program to improve cardiovascular disease prevention that can be adapted to a particular regional context and (2) a set of indicators to monitor its implementation. METHODS: Primary care clinicians (n = 16), administrative staff (n = 2), patients and family members (n = 4), decision makers (n = 5), researchers, and a research coordinator (n = 7) took part in the process. Additional primary care actors (n = 26) validated the program. RESULTS: The program targets multimorbid patients at high or moderate risk of cardiovascular disease with uncontrolled hypertension, dyslipidemia or diabetes. It comprises interprofessional follow-up coordinated by case-management nurses, in which motivated patients are referred in a timely fashion to appropriate clinical and community resources. The program is supported by clinical tools and includes training in motivational interviewing. A set of 89 process and clinical indicators were defined. CONCLUSION: Through a participatory process, a contextualized interventions program to optimize cardiovascular disease prevention and a set of quality indicators to monitor its implementation were developed. Similar approach might be used to develop other health programs in primary care if program developers are open to building on community strengths and priorities.

Characteristics of primary care practices associated with high quality of care.

BACKGROUND: No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. METHODS: We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. RESULTS: The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care. INTERPRETATION: We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

Effects of continuing professional development on clinical performance: results of a study involving family practitioners in Quebec.

OBJECTIVE: To evaluate the link between the quantity and quality of continuing professional development (CPD) activities completed by family physicians in Quebec and the quality of their practice. DESIGN: Retrospective analysis of data collected during professional inspection visits (PIVs). SETTING: Quebec. PARTICIPANTS: Three groups were created from among Quebec family physicians who had been subject to PIVs (peer evaluation) by the Collège des médecins du Québec between 1998 and 2005. Group 1 was composed of physicians who were members of the College of Family Physicians of Canada, which requires participation in 250 hours of CPD in every 5-year cycle. Group 2 was composed of family physicians who were not members of the College of Family Physicians of Canada but who had declared at least 50 hours a year of CPD on their Collège des médecins du Québec annual notice of assessment for the same period. Group 3 was composed of family physicians who had declared fewer than 10 hours of CPD a year. MAIN OUTCOME MEASURES: During the PIV, the following characteristics were examined: record keeping, quality and number of hours of CPD activities, and quality of professional practice based on 3 components- clinical investigation, accuracy of diagnosis, and appropriateness of treatment plan and follow-up. RESULTS: The factors associated with a high quality of practice were privileges in a hospital or local community health centre (institution) and a substantial number of accredited CPD hours (Mainpro-M1, Credit I, or Mainpro-C). The factors associated with a poor quality of practice were advanced age of the physician, absence of privileges in an institution (hospital or local community health centre), and participation in CPD activities that were more informal, such as reading and non-accredited activities (Mainpro-M2). CONCLUSION: This study supports earlier research showing that CPD activities of sufficient quality and quantity are correlated with a high quality of professional practice by family physicians.

Priorities for action to improve cardiovascular preventive care of patients with multimorbid conditions in primary care--a participatory action research project.

BACKGROUND: Cardiovascular disease (CVD) prevention in patients with multimorbid conditions is not always optimal in primary care (PC). Interactive collaborative processes involving PC community are recommended to develop new models of care and to successfully reshape clinical practices. OBJECTIVE: To identify challenges and priorities for action in PC to improve CVD prevention among patients with multimorbid conditions. METHODS: Physicians (n = 6), nurses (n = 6), community pharmacists (n = 6), other health professionals (n = 6), patients (n = 6) and family members (n = 6), decision makers (n = 6) and researchers (n = 6) took part in a 1-day workshop. Using the Chronic Care Model (CCM) as a framework, participants in focus groups and nominal groups identified the challenges and priorities for action. RESULTS: Providing appropriate support to lifestyle change in patients and implementing collaborative practices are challenging. Priorities for action relate to three CCM domains: (i) improve the clinical information system by providing computerized tools for interprofessional and interinstitutional communication, (ii) improve the organization of health care and delivery system design by enhancing interprofessional collaboration, especially with nurses and pharmacists, and creating care teams that include a case manager and (iii) improve self-management support by giving patients access to nutritionists, to personalized health care plans including lifestyle recommendations and to other resources (community resources, websites). CONCLUSIONS: To optimize CVD prevention, PC actors recommend focussing mainly on three CCM domains. Electronic medical records, collaborative practices and self-management support are perceived as pivotal aspects of successful PC prevention programme. Developing and implementing such models are challenging and will require the mobilization of the whole PC community.

Patient, primary care physician and specialist expectations of primary care physician involvement in cancer care.

BACKGROUND: In Canada, many health authorities recommend that primary care physicians (PCP) stay involved throughout their patients' cancer journey to increase continuity of care. Few studies have focused on patient and physician expectations regarding PCP involvement in cancer care. OBJECTIVE: To compare lung cancer patient, PCP and specialist expectations regarding PCP involvement in coordination of care, emotional support, information transmission and symptom relief at the different phases of cancer. DESIGN: Canadian survey of lung cancer patients, PCPs and cancer specialists PARTICIPANTS: A total of 395 patients completed questionnaires on their expectations regarding their PCP participation in several aspects of care, at different phases of their cancer. Also, 45 specialists and 232 community-based PCP involved in these patients' care responded to a mail survey on the same aspects of cancer care. RESULTS: Most specialists did not expect participation of the PCP in coordination of care in the diagnosis and treatment phases (65% and 78% respectively), in contrast with patients (83% and 85%) and PCPs (80% and 59%) (p < 0.0001). At these same phases, the best agreement among the 3 groups was around PCP role in emotional support: 84% and more of all groups had this expectation. PCP participation in symptom relief was another shared expectation, but more unanimously at the treatment phase (p = 0.85). In the advanced phase, most specialists expect a major role of PCP in all aspects of care (from 81% to 97%). Patients and PCP agree with them mainly for emotional support and information transmission. CONCLUSION: Lung cancer patient, PCP and specialist expectations regarding PCP role differ with the phase of cancer and the specific aspect of cancer care. There is a need to reach a better agreement among them and to better define PCP role, in order to achieve more collaborative and integrated cancer care.

Physician-pharmacist collaborative care in dyslipidemia management: the perception of clinicians and patients.

BACKGROUND: Collaborative practices allow physicians and pharmacists to comanage pharmacotherapy to maximize the benefits of medication regimens. The Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia (TEAM) study compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention, where pharmacists requested laboratory tests and adjusted medication dosage, to the usual care (UC) for patients under treatment with lipid-lowering medication. OBJECTIVE: In a qualitative study nested within the TEAM study, the perceptions of physicians, pharmacists, and patients regarding the PPCC model, interprofessional collaboration, and the clinicians' willingness to implement the model in their practice were explored. METHODS: In the area of Montreal (Quebec, Canada), TEAM study participants assigned to the PPCC group were invited to participate. Individual semistructured interviews with physicians (n=7) and 2 six-member focus groups with pharmacists (n=12) and patients (n=12) were analyzed using a phenomenological approach. RESULTS: The vast majority of participants reported PPCC was more structured and systematic than the UC they had received previously, wherein physicians prescribe and adjust pharmacotherapy and pharmacists provide the counseling and dispense medications. Many patients felt they received better follow-up and reported being reassured and well informed, making them more inclined to care for themselves better. These feelings were attributed largely to the pharmacists' accessibility and ability to communicate with them easily. Given the physician shortage, physicians perceived interprofessional collaboration as almost inevitable. They considered PPCC to be safe and effective. However, obstacles were also identified. Physicians were concerned that it might alter their special relationship with patients and threaten their overall medical follow-up. Pharmacists felt enthusiastic about their new role, but found PPCC time consuming and thought it might not be applicable to all the patients. CONCLUSIONS: PPCC model was highly appreciated by patients, and clinicians saw it as beneficial to patients. However, several obstacles still have to be overcome before the model can be implemented in the current health care context.

Family physician involvement in cancer care and lung cancer patient emotional distress and quality of life.

PURPOSE: This study aims to describe emotional distress and quality of life (QoL) of patients at different phases of their lung cancer and the association with their family physician (FP) involvement. METHODS: A prospective study on patients with lung cancer was conducted in three regions of Quebec, Canada. Patients completed, at baseline, several validated questionnaires regarding their psychosocial characteristics and their perceived level of FP involvement. Emotional distress [profile of mood states (POMS)] and QoL [European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30)] were reassessed every 3-6 months, whether patients had metastasis or not, up to 18 months. Results were regrouped according to cancer phase. Mixed models with repeated measurements were performed to identify variation in distress and QoL. RESULTS: In this cohort of 395 patients, distress was low at diagnosis (0.79 ± 0.7 on a 0-4 scale), raising to 1.36 ± 0.8 at the advance phase (p < 0.0001). Patient's global QoL scores significantly decreased from the diagnosis to the advance phase (from 66 to 45 on a 0-100 scale; p < 0.0001). At all phases of cancer, FP involvement was significantly associated with patients' distress (p = 0.0004) and their global perception of QoL (p = 0.0080). These associations remained statistically significant even after controlling for age, gender, and presence of metastases. CONCLUSIONS: This study provides new knowledge on patients' emotional distress and QoL with cancer evolution and, particularly, their association with FP involvement. Other studies should be conducted to further explore FP role in cancer supportive care.

Family physician involvement in cancer care follow-up: the experience of a cohort of patients with lung cancer.

PURPOSE: There has been little research describing the involvement of family physicians in the follow-up of patients with cancer, especially during the primary treatment phase. We undertook a prospective longitudinal study of patients with lung cancer to assess their family physician's involvement in their follow-up at the different phases of cancer. METHODS: In 5 hospitals in the province of Quebec, Canada, patients with a recent diagnosis of lung cancer were surveyed every 3 to 6 months, whether they had metastasis or not, for a maximum of 18 months, to assess aspects of their family physician's involvement in cancer care. RESULTS: Of the 395 participating patients, 92% had a regular family physician but only 60% had been referred to a specialist by him/her or a colleague for the diagnosis of their lung cancer. A majority of patients identified the oncology team or oncologists as mainly responsible for their cancer care throughout their cancer journey, except at the advanced phase, where a majority attributed this role to their family physician. At baseline, only 16% of patients perceived a shared care pattern between their family physician and oncologists, but this proportion increased with cancer progression. Most patients would have liked their family physician to be more involved in all aspects of cancer care. CONCLUSIONS: Although patients perceive that the oncology team is the main party responsible for the follow-up of their lung cancer, they also wish their family physicians to be involved. Better communication and collaboration between family physicians and the oncology team are needed to facilitate shared care in cancer follow-up.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study.

BACKGROUND: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. METHODS: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients' adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. RESULTS: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was -0.2 mmol/L (95% confidence interval [CI] -0.3 to -0.1), and the adjusted reduction was -0.05 (95% CI -0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). INTERPRETATION: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Physician-pharmacist collaborative care for dyslipidemia patients: knowledge and skills of community pharmacists.

INTRODUCTION: In a physician-pharmacist collaborative-care (PPCC) intervention, community pharmacists were responsible for initiating lipid-lowering pharmacotherapy and adjusting the medication dosage. They attended a 1-day interactive workshop supported by a treatment protocol and clinical and communication tools. Afterwards, changes in pharmacists' knowledge, their skills, and their satisfaction with the workshop were evaluated. METHODS: In a descriptive study nested in a clinical trial, pharmacists assigned to the PPCC intervention (n = 58) completed a knowledge questionnaire before and after the workshop. Their theoretical skills were evaluated with the use of a vignette approach (n = 58) after the workshop and their practical skills were assessed by direct observation with study patients (n = 28). RESULTS: The mean (SD) overall knowledge score was 45.8% (12.1%) before the workshop; it increased significantly to 89.3% (8.3%) afterwards (mean difference: 43.5%; 95% CI: 40.3%-46.7%). All the pharmacists had an overall theoretical-skill score of at least 80%, the minimum required to apply the PPCC in the trial. From 92.9% to 100% of the pharmacists' interventions with study patients complied with the treatment protocol. DISCUSSION: In primary care, a short continuing-education program based on a specific treatment protocol and clinical tools is necessary and probably sufficient to prepare pharmacists to provide advanced pharmaceutical care.