Profiling patterns of patient experiences of access and continuity at team-based primary healthcare clinics (Canada): a latent class analysis.

BACKGROUND: Access to primary healthcare services is a core lever for reducing health inequalities. Population groups living with certain individual social characteristics are disproportionately more likely to experience barriers accessing care. This study identified profiles of access and continuity experiences of patients registered with a family physician working in team-based primary healthcare clinics and explored the associations of these profiles with individual and organizational characteristics. METHODS: A cross-sectional e-survey was conducted between September 2022 and April 2023. All registered adult patients with an email address at 104 team-based primary healthcare clinics in Quebec were invited to participate. Latent class analysis was used to identify patient profiles based on nine components of access to care and continuity experiences. Multinomial logistic regression models were fit to analyze each profile's association with ten characteristics related to individual sociodemographics, perceived heath status, chronic conditions and two related to clinic area and size. RESULTS: Based on 87,155 patients who reported on their experience, four profiles were identified. "Easy access and continuity" (42% of respondents) was characterized by ease in almost all access and continuity components. Three profiles were characterized by diverging access and/or continuity difficulties. "Challenging booking" (32%) was characterized by patients having to try several times to obtain an appointment at their clinic. "Challenging continuity" (9%) was characterized by patients having to repeat information that should have been in their file. "Access and continuity barriers" (16%) was characterized by difficulties with all access and continuity components. Female gender and poor perceived health significantly increased the risk of belonging to the three profiles associated with difficulties by 1.5. Being a recently arrived immigrant (p = 0.036), having less than a high school education (p = 0.002) and being registered at a large clinic (p < 0.001) were associated with experiencing booking difficulties. Having at least one chronic condition (p = 0.004) or poor perceived mental health (p = 0.048) were associated with experiencing continuity difficulties. CONCLUSIONS: These results highlight individual social and health characteristics associated with increased risk of experiencing healthcare access difficulties, such as immigration status and education level and/or continuity difficulties when having a chronic condition and poor perceived mental health. Facilitating appointment booking for recently arrived immigrants and patients with low education, integrating interprofessional collaboration practices for patients with chronic conditions and improving care coordination and communication for patients with mental health needs are recommended.

Factors associated with patients' experience of access to their multidisciplinary primary health care clinic: A multilevel analysis.

BACKGROUND: Understanding patients' experiences accessing primary health care (PHC) is necessary to improve service organisation. This study aims to examine individual, organisational, and contextual factors associated with patients' experience of accessing the multidisciplinary PHC clinic to which they are attached. METHODS: This cross-sectional study builds on survey data collected in multidisciplinary PHC clinics located in 14 regions in the province of Quebec (Canada). Between September 2022 and June 2023, an online questionnaire was sent to patients with an email contact and attached to a family physician. Two patient-reported experience measures were assessed: (1) difficulty obtaining an appointment with their regular family physician or nurse practitioner and (2) perceived unmet healthcare needs. A self-reported online questionnaire based on the advanced access model was also sent to PHC professionals and administrative staff to assess the use of advanced access strategies in their practice. Multilevel logistic regression models were fit. Stratified analyses were conducted according to the number of consultations received. FINDINGS: In total, 122,397 patients and 847 family physicians, 97 nurse practitioners and 347 administrative staff nested into 104 clinics answered the survey. In the overall sample, having a chronic disorder was the only individual factor associated with the patient experience of access. Organizational factors including estimation of demand and supply, use of a referral algorithm, and strategies to optimise consultations were associated with a better access experience. Patients from medium size clinics compared to small clinics had better experiences of care for both outcomes. Stratified analysis indicated similar results for patients who consulted at the clinic 1-5 times in the last 12 months as observed in the overall sample. CONCLUSIONS: This study indicates that enhancing organizational processes can improve patients' access experiences.

The Use of Vignettes to Improve the Validity of Qualitative Interviews for Realist Evaluation.

Although realist evaluation (RE) requires multiple data collection methods, qualitative interviews are considered most valuable and are most frequently used. The guiding principles of RE may limit the emergence of new Context-Mechanism-Outcome (CMO) configurations by evoking particular underlying mechanisms. This paper proposes a new method for conducting semi-structured interviews in the RE context by drawing on the literature and examining the ability of vignettes to explore perceptions about specific situations. Vignettes are developed based on researchers' knowledge of the setting and program theory and are updated through an iterative process throughout data collection. Interviews focus on situations illustrated in the vignette to capture variations in interviewees' perceptions. This method constrains interviewees to using retroduction to identify the hidden underlying mechanisms that link contextual elements to outcomes based on their experiences. This method allows researchers to focus on CMO configurations without evoking mechanisms, which contributes to the rigor of the method.

Redirection of low-acuity emergency department patients to nearby medical clinics using an electronic medical support system: effects on emergency department performance indicators.

BACKGROUND: Overcrowded emergency departments (EDs) are associated with higher morbidity and mortality and suboptimal quality-of-care. Most ED flow management strategies focus on early identification and redirection of low-acuity patients to primary care settings. To assess the impact of redirecting low-acuity ED patients to medical clinics using an electronic clinical decision support system on four ED performance indicators. METHODS: We performed a retrospective observational study in the ED of a Canadian tertiary trauma center where a redirection process for low-acuity patients was implemented. The process was based on a clinical decision support system relying on an algorithm based on chief complaint, performed by nurses at triage and not involving physician assessment. All patients visiting the ED from 2013 to 2017 were included. We compared ED performance indicators before and after implementation of the redirection process (June 2015): length-of-triage, time-to-initial-physician-assessment, length-of-stay and rate of patients leaving without being seen. We performed an interrupted time series analysis adjusted for age, gender, time of visit, triage category and overcrowding. RESULTS: Of 242,972 ED attendees over the study period, 9546 (8% of 121,116 post-intervention patients) were redirected to a nearby primary medical clinic. After the redirection process was implemented, length-of-triage increased by 1 min [1;2], time-to-initial assessment decreased by 13 min [-16;-11], length-of-stay for non-redirected patients increased by 29 min [13;44] (p < 0.001), minus 20 min [-42;1] (p = 0.066) for patients assigned to triage 5 category. The rate of patients leaving without being seen decreased by 2% [-3;-2] (p < 0.001). CONCLUSION: Implementing a redirection process for low-acuity ED patients based on a clinical support system was associated with improvements in two of four ED performance indicators.

Comparing the implementation of advanced access strategies among primary health care providers.

The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p = .001) and nurses (p < .001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p = .015) and nurses (p < .001). Nurses created more alternatives to in-person visits than family physicians (p < .001) and coordinated health and social services more than family physicians (p = .003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p = .003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended.

Enhancing interprofessional collaboration for unattached patients in primary care.

This project explored an interprofessional collaboration initiative at Clinique Indigo which aimed to improve comprehensive care for unattached patients in Quebec's primary care system. Throughout the project, physicians and non-physician health professionals alike became more actively engaged in the care of patients lacking a regular primary care provider. The project successfully demonstrated that defining a common vision for "well care" within the clinic and integrating diverse professionals could significantly improve quality of care for unattached patients, evidenced by an increase from 13% to 43% in comprehensive care provision. However, the initiative also faced challenges, including professional turnover and gaps in primary care training, suggesting critical areas for future improvement in healthcare policy and practice. These results support expanded interprofessional approaches in primary care to address systemic care disparities in universal healthcare settings such as this one caused by the differential or absence of attachment to a primary care provider.

Barriers and facilitators influencing parental adherence to prevention strategies for deformational plagiocephaly: Results from a scoping review.

BACKGROUND: Deformational plagiocephaly can be prevented in many healthy infants if strategies are implemented early after birth. However, despite efforts to disseminate accurate information, parental adherence to evidence-based prevention strategies is a challenge. To date, factors - barriers and facilitators - influencing parental adherence to strategies have yet to be identified in a comprehensive manner. OBJECTIVES: This scoping review aims to identify and synthesize current evidence on barriers and facilitators impacting adherence of parents of newborns to deformational plagiocephaly prevention strategies. METHODS: This review followed the Joanna Briggs Institute (JBI) process guidelines. Seven electronic (Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, SPORTDiscus, Academic Search Complete, AMED, PsychINFO and Scopus) and two grey literature (Health Systems Evidence and Grey Literature Report) databases were searched. Studies published between 2001 and 2022 were included. The deductive thematic data analysis used was guided by the Capability, Opportunity, Motivation Behavioral Model (COM-B) of health behaviour change. RESULTS: From a total of 1172 articles, 15 met the eligibility criteria. All components of the COM-B framework were identified. Capability-psychological and opportunity-environmental factors dominated the literature, whereas capability-physical, motivation and, in particular, opportunity-social factors were understudied. The most often reported barriers were a lack of knowledge of deformational plagiocephaly and the associated prevention strategies, ambiguous or inconsistent messaging, intolerance of babies to prone positioning and a lack of time. The most frequently reported facilitators were an awareness of deformational plagiocephaly, postural asymmetry and prevention strategies, skill acquisition with practice, accurate convincing information, scheduled time and environmental organization to position the baby at home. DISCUSSION: Recommendations focused on diffusing accurate and detailed information for parents. Our review also suggests a gap regarding the comprehensive identification of factors influencing parental adherence to deformational plagiocephaly prevention strategies. Further studies exploring comprehensive opportunity-social and motivation factors influencing parental adherence to deformational plagiocephaly prevention strategies are warranted to inform prevention programmes and foster better infant outcomes.

Nursing practice and teleconsultations in a pandemic context: A mixed-methods study.

AIM: To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic. BACKGROUND: Teleconsultation use increased rapidly during the COVID-19 pandemic. Its implementation has been documented for physicians and specialists, but knowledge is still limited in nursing practice. DESIGN: A sequential mixed-methods study. METHODS: Phase 1: A cross-sectional e-survey with 98 nurses (64 nurse clinicians [NCs] and 34 nurse practitioners [NPs]) was conducted in 2020 in 48 teaching primary care clinics in Quebec (Canada). Phase 2: Semi-structured interviews with four NCs and six NPs were conducted in 2021 in three primary care clinics. This study adheres to STROBE and COREQ guidelines. RESULTS: During the pandemic, telephone was the principal teleconsultation modality used by NPs and NCs compared to other teleconsultation modalities (text messages, email and video). The only variable associated with a higher likelihood of using teleconsultations was type of professional (NCs). Video consultation was almost absent from the modalities used. The majority of participants reported several facilitators to using teleconsultations in their work (e.g. web platforms and work-family balance) and for patients (e.g. rapid access). Some barriers to utilisation were identified (e.g. lack of physical resources) for successful integration of teleconsultations at the organisational, technological and systemic levels. Participants also reported positive (e.g. assessment of cognitive deficiency) and negative (e.g. rural population) impacts of using teleconsultations during a pandemic that made the use of teleconsultations complex. CONCLUSION: This study highlights the potential for nurses to use teleconsultations in primary care practice and suggests concrete solutions to encourage their implementation after the pandemic. RELEVANCE TO CLINICAL PRACTICE: Findings emphasize the need for updated nursing education, easy-to-use technology and the strengthening of policies for the sustainable use of teleconsultations in primary health care. IMPLICATIONS FOR THE PROFESSION: This study could promote the sustainable use of teleconsultations in nursing practice. REPORTING METHOD: The study adhered to relevant EQUATOR guidelines; the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as the study focused on the use of teleconsultation among health professionals, specifically primary care nurses.

Ten years later: A portrait of the implementation of the advanced access model in Quebec.

Since 2012, implementation of the advanced access model in primary care has been highly recommended across Canada to improve timely access. We present a portrait of the implementation of the advanced access model 10 years after its large-scale implementation across the province of Quebec. In total, 127 clinics participated in the study, with 999 family physicians and 107 nurse practitioners responding to the survey. Results show that opening schedules for appointments over a period of 2 to 4 weeks has largely been implemented. However, reserving consultation time for urgent or semi-urgent conditions was implemented by less than half and planning supply and demand for 20% or more of the upcoming year by fewer than one fifth of respondents. More strategies need to be put in place to react to imbalances when they occur. We demonstrate that strategies based on individual practice change are more often implemented than those requiring changes at the clinic.

Assessment tools for reflection in healthcare learners: A scoping review.

Reflection has been integrated in many healthcare educations programs to achieve deeper learning and improve professional practice. A variety of evaluation tools are used to assess reflection, but few guides are available to inform educators in their choice of a relevant evaluation tool. The aim of this paper is to identify all existing evaluation tools published along with their strengths and weaknesses. A review strategy retrieved tools available in Medline, PsychInfo, CINALH and Eric databases. The procedures outlined by Munn and colleagues were used to synthetize the information. Additionally, the reflection dimensions assessed in each tool (when sufficient information was available) were analyzed deductively, using thematic analysis according to the Killion and Todnem framework. Subthemes were identified inductively. Forty-five papers were identified, reporting on 34 different tools. The tools were based on a variety of theoretical models. Some had evidence of adequate validity and fidelity. Eleven components of reflection were identified across tools. No tool encompassed all components, but most tools included between three and five components. Context surrounding evaluation should be carefully considered when choosing an evaluation tool for reflection. There is a need for further research to validate the psychometric properties of reflection evaluation tools.

Cultural Safety as an Outcome of a Dynamic Relational Process: The Experience of Inuit in a Mainstream Residential Addiction Rehabilitation Centre in Southern Canada.

Few addiction treatment options are available in Arctic Canada, leading many Inuit to seek treatment programs in southern cities. We conducted a case study to understand what contributes to a culturally safe experience for Inuit in a mainstream addiction rehabilitation centre in Southern Canada. We carried out more than 700 hours of participant observation, in addition to semi-structured interviews and member-checking activities with 20 Inuit residents, 18 staff and four managers. Data were analysed using an inductive interpretative process. Throughout their journey in the program, Inuit navigated through contrasting situations and feelings that we grouped under six broad themes: having Inuit peers, having limitations imposed on one's ways of being and doing, facing ignorance and misperceptions, having conversations and dialogue, facing language barriers and being in a supportive and caring environment. This study highlights how cultural safety varies according to people, context and time, and relates to developing trustful relationships.

Acceptability of Pediatric Telerehabilitation Interventions Provided by Physical Therapists and Occupational Therapists-A Scoping Review.

AIMS: The purpose of this scoping review was to explore the available literature and identify gaps regarding the acceptability of telerehabilitation interventions provided by pediatric physical therapists and occupational therapists. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) framework to guide this scoping review. We systematically searched eight scholarly databases (CINAHL, Medline, SPORTDiscus, AMED, APA PsychInfo, SCOPUS, PEDro, OTseeker), five gray literature databases (MedlinePlus, Gray Literature Report, OpenGrey, National Institute for Health, ProQuest Dissertation & Theses Global [PQDT]), conducted a manual search of selected references and contacted international experts. We included articles published between 2000 and 2021. Acceptability was defined in accordance with the Theoretical Framework of Acceptability of Sekhon et al. RESULTS: From a total of 1567 unique references, 123 were deemed eligible for full-text review. Eighteen studies published between 2011 and 2021 were included in this review. Even though every aspect of the Theoretical Framework of Acceptability was assessed from a variety of angles, a complete appreciation of the concept is still lacking for pediatric telerehabilitation. CONCLUSIONS: This review highlights important gaps in our knowledge regarding the acceptability of pediatric telerehabilitation interventions and supports the need for further research focusing on the subject.

Characteristics, barriers and facilitators of initiatives to develop interprofessional collaboration in rural and remote primary healthcare facilities: a scoping review.

INTRODUCTION: Despite strong evidence supporting interprofessional collaboration (IPC) and the documented need for collaborative practice in primary health care (PHC), initiatives to promote IPC in rural and remote PHC facilities have not been extensively studied. The purpose of this article is to map interprofessional education (IPE) and interprofessional practice (IPP) initiatives implemented to promote IPC in rural and remote PHC facilities, and identify barriers and facilitators to their implementation. METHODS: A scoping review was conducted. After two reviewers filtered titles and abstracts, 94 retained articles were subsequently screened. Finally, 23 articles were selected and analyzed using a directed content analysis approach in NVivo v12. RESULTS: Only 10 articles focused on the implementation of initiatives to improve IPC, while the majority reported barriers and facilitators. The most common IPE initiatives were workshops, courses, discussion groups and simulations, while IPP initiatives fell into two main categories: clinical or technological tools. Limited human resources, understanding of roles, and knowledge of context as well as traditional roles, were identified as barriers. Team size, past experience and relationships, connection to community, flexibility and openness, and financial support were facilitators to developing IPC. CONCLUSION: Deployment of IPC in rural and remote PHC facilities is critical given the various challenges faced in these clinical settings. The facilitators identified in this literature review are specific to rural and remote clinical settings and provide hope that new initiatives more tailored to rural and remote settings will be implemented and evaluated in the future to improve IPC and care delivery.

Intra- and inter-evaluator reliability of the MyotonPRO for the assessment of the viscoelastic properties of caesarean section scar and unscarred skin.

BACKGROUND: The clinical evaluation of viscoelastic properties of the Caesarean section (C-section) scar, such as stiffness and elasticity, is usually carried out using subjective scales and palpation techniques. There is currently no reliable and valid tool that objectively quantifies these properties. The MyotonPRO could fill this gap. MATERIALS AND METHODS: Nineteen healthy women aged between 21 and 40 years with C-section scars participated in this reliability study. Two points, one on the scar and one on unscarred skin, were measured four times successively with the MyotonPRO by three independent evaluators on the same day. The intra-class correlation (ICC) coefficients were estimated using a two-factor ANOVA to determine the inter- and intra-rater reliability. The capacity of the MyotonPRO to discriminate the viscoelastic properties of the C-Section scar against unscarred skin was assessed using the Wilcoxon signed rank test. RESULTS: The intra- and inter-rater reliability of the viscoelastic property measurements was good to excellent (ICC 0.99-1.00 and 0.87-0.98, respectively). There was no significant difference between C-section scar and unscarred skin in terms of elasticity (P = .737). Significant differences between C-section scars and unscarred skin tissue were observed for tone (P < .001), stiffness (P < .001), creep (P < .001), and mechanical stress relaxation time (P < .001). CONCLUSION: The MyotonPRO is a reliable tool for an objective measurement of the viscoelastic properties of the C-section scar and unscarred skin. The MyotonPRO can discriminate the viscoelastic properties of the C-section scar against the unscarred skin, for tone, stiffness, creep and relaxation times, but not for elasticity.

Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services.

BACKGROUND: The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS: Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION: Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.

Communication and Interprofessional Collaboration in Primary Care: From Ideal to Reality in Practice.

To improve patient-centered care, many health care systems are mandating interprofessional collaboration (IPC). However, in many primary care contexts, IPC is still nascent and fraught with tension. Communication is thought to be a key determinant of IPC, but few studies empirically examine IP communication practices. Therefore, we report here on the qualitative portion of a mixed methods pilot study investigating observed IPC and communication in primary care clinics in Quebec, Canada. Studying actual communication practices to understand collaborative activities, we seek to investigate how the ideals of patient centeredness and clinical democracy put forward in the IP literature stack up against actual IPC practice in primary care. Qualitative data was gathered by shadowing health professionals in two primary care clinics, and analyzed through thematic coding. A typology of observed IP practices was created and compared to the continuum of interprofessional collaborative practice. Further analysis focused on how participants made sense of their collaboration, especially why, how and with whom they collaborated. Findings were grouped into three categories of communicative actions: coordinating sequential efforts; assisting others' sensemaking; and working to understand together. Implications for practice and future research are discussed.

Nurse staffing practices and adverse events in acute care hospitals: The research protocol of a multisite patient-level longitudinal study.

AIMS: We describe an innovative research protocol to: (a) examine patient-level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing. DESIGN: A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015-December 2019. METHODS: Patients in the cohort will be followed from admission until 30-day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time-varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high-impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure-to-rescue; (b) in-hospital falls; (c) hospital-acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non-linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020. DISCUSSION: To our knowledge, this study is the first multisite patient-level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial.

BACKGROUND: Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care. METHODS: In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis. RESULTS: A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79]. CONCLUSIONS: Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

Implementing a fracture follow-up liaison service: perspective of key stakeholders.

Fracture liaison services (FLS) have been shown to prevent efficiently subsequent fragility fractures (FF). However, very few studies have examined their implementation in depth. The purpose of this research was to identify factors influencing the implementation of a FLS at three sites in Quebec, Canada. From 2013 to 2015, individual and group interviews focused on experiences of FLS stakeholders, including implementation committee members, coordinators, and orthopaedic surgeons and their teams. Emerging key implementation factors were triangulated with the FLS patients' clinico-administrative data. The Consolidated Framework for Implementation Research guided the analysis of perceived factors influencing four intervention outputs: investigation of FF risk (using the FRAX score), communication with the participant primary care provider, initiation of anti-osteoporosis medications (when relevant), and referral to organized fall prevention activities (either governmental or community based). Among the 454 FLS patients recruited to the intervention group, 83% were investigated for FF risk, communication with the primary care provider was established for 98% of the participants, 54% initiated medication, and 35% were referred to organized fall prevention activities. Challenges related to restricted rights to prescribe medication and access to organized fall prevention activities were reported. FLS coordinator characteristics to overcome those challenges included self-efficacy beliefs, knowledge of community resources, and professional background. This study highlighted the importance of enabling access to services for subsequent FF prevention, consolidating the coordinator's role to facilitate a more integrated intervention, and involving local leaders to promote the successful implementation of the FLS.

Evaluation of the implementation and associated effects of advanced access in university family medicine groups: a study protocol.

BACKGROUND: Timely access in primary health care is one of the key issues facing health systems. Among many interventions developed around the world, advanced access is the most highly recommended intervention designed specifically to improve timely access in primary care settings. Based on greater accessibility linked with patients' relational continuity and informational continuity with a primary care professional or team, this organizational model aims to ensure that patients obtain access to healthcare services at a time and date convenient for them when needed regardless of urgency of demand. Its implementation requires a major organizational change based on reorganizing the practices of all the administrative staff and health professionals. In recent years, advanced access has largely been implemented in primary care organizations. However, despite its wide dissemination, we observe considerable variation in the implementation of the five guiding principles of this model across organizations, as well as among professionals working within the same organization. The main objective of this study is to assess the variation in the implementation of the five guiding principles of advanced access in teaching primary healthcare clinics across Quebec and to better understand the influence of the contextual factors on this variation and on outcomes. METHODS: This study will be based on an explanatory sequential design that includes 1) a quantitative survey conducted in 47 teaching primary healthcare clinics, and 2) a multiple case study using mixed data, contrasted cases (n = 4), representing various implementation profiles and geographical contexts. For each case, semi-structured interviews and focus group will be conducted with professionals and patients. Impact analyses will also be conducted in the four selected clinics using data retrieved from the electronic medical records. DISCUSSION: This study is important in social and political context marked by accessibility issues to primary care services. This research is highly relevant in a context of massive media coverage on timely access to primary healthcare and a large-scale implementation of advanced access across Quebec. This study will likely generate useful lessons and support evidence-based practices to refine and adapt the advanced access model to ensure successful implementation in various clinical contexts facing different challenges.