INSPIRE PHC - Primary Health CAre Program:INnovations Strengthening PrImary Healthcare REsearch
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OSSU - PHC Research Rounds

 

 

 
   
       

 

2017
Jan 2017

Engaging Patients for Primary Heath Care Research

Dr. Simone Dahrouge, Bruyère Research Institute
Authors: Danielle Rolfe, PhD and Simone Dahrouge, PhD

Patient involvement in healthcare planning and quality improvement is now law (Excellent Care for All Act, 2010, Ontario Regulation 187/15). Patient involvement leads to better quality healthcare for all, including care that meets patients' needs and results in patient-oriented outcomes. As healthcare innovations are often developed through research, involvement of patients in research is also important. Few primary health care (PHC) researchers, however, have experience engaging patients in research studies, despite its potential to increase the relevance and acceptability of PHC research interventions, and the likelihood that findings will be used in practice. The purpose of this presentation is to describe the provincial PHC Patient Engagement Resource Centre which aims to increase patient engagement in PHC research. The Access to Resources in the Community (ARC) Project is presented as an example of a productive collaboration with patients for PHC research.

The PHC Patient Engagement Resource Centre
The PHC Patient Engagement Resource Centre is supported by an Ontario SPOR Support Unit for patient-oriented primary healthcare research (INSPIRE-PHC) and is being developed by two PHC researchers with experience in qualitative methods and patient engagement. The Resource Centre supports PHC researchers to collaborate with patients in various aspects of research, including defining a research question, planning a project, recruiting patients, collecting and analyzing data, and disseminating findings. The Centre offers PHC researchers access to:

- an online catalogue of resources on patient engagement;
-practical advice about when and how to effectively engage patients;
-a network of researchers with experience in patient engagement;
-a Patient Advisory Board to receive feedback about researchers' projects involving
  patient engagement.

Promotion of the Resource Centre is planned for relevant PHC meetings (e.g., Association of Family Health Teams of Ontario, Association of Ontario Health Centers) and research conferences (e.g., Family Medicine Forum, Trillium Research Day).

The Access to Resources in the Community (ARC) Project
The ARC project is funded by the Canadian Institutes for Health Research and the Ministry of Health and Long-Term Care. The goal of ARC is to increase equitable access to community-based PHC for vulnerable populations. Patients were initially consulted via interviews and focus groups about the barriers they face in accessing community-based PHC resources. Three patients, representing diverse target communities (seniors, new Canadians, mental health and addictions) were then invited to a steering committee to collaborate with PHC researchers, health planners, providers, and community organizations to design, implement and evaluate an intervention to increase access. These patients have also been involved to varying degrees in recruiting research participants and disseminating information about the study to their respective communities and other PHC researchers.

Implications and Conclusion
Patient engagement can improve the quality of healthcare services and research, but support is required to help researchers to know when and how to engage patients. The process of engaging patients as part of developing a Resource Centre (including a Patient Advisory Board), and collaborating with patients for the ARC project offers practical lessons about building and sustaining effective relationships with patients for PHC research.

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Feb 2017

Ontario Data Support Starfield's Theory on Practice Quality and Cost

Dr. Carol Mulder, Association of Family Health Teams of Ontario (AFHTO)
Authors:
- Carol Mulder, Association of Family Health Teams of Ontario (AFHTO)
- Rick Glazier, Institute of Clinical Evaluative Sciences •
- Frank Sullivan, UTOPIAN, University of Toronto Practice-Based Research Network

Context: : Barbara Starfield observed that the relationship between patients and primary care providers is the foundation of a sustainable healthcare system and therefore should be the focus of primary care measurement. We hypothesised that quality measured this way should be associated with lower costs. This study was only possible through the voluntary contributions of primary care performance data by members of the Association of Family Health Teams of Ontario (AFHTO), who together deliver comprehensive, interdisciplinary team-based primary care to about one quarter of Ontarians.

Objective: Measure primary care quality in a way that reflects the patient-provider relationship and test relationship to per capita healthcare costs.

Design:  Observational study of patient experience survey, EMR and administrative data contributed to Data to Decisions (D2D) a summary of primary care data that are currently available, comparable and meaningful to providers. A composite quality measure was generated according to importance of each component to patients in their relationship with their provider. We analyzed reliability and conducted multivariate regression of relationship between the composite quality measure and per capita cost. Participants: 137 of 184 AFHTO members voluntarily contributed practice characteristics and performance data, describing care for approximately 2 million patients (15% of Ontario's population).

Outcomes: Relationship between quality and per capita healthcare cost.

Results: The composite quality measure incorporated 14 indicators, balancing patient priorities with system priorities. Higher quality was associated with lower per capita healthcare costs, explaining approximately 50% of variation in costs, taking patient complexity and rurality into account. Patients studied were less likely to be immigrants and have many co-morbidities and more likely to be older and live in rural, higher-income settings.

Future research: Work is underway to facilitate more current measurement of both cost and quality to increase the usefulness of these data to support and measure the impact of efforts to improve quality. In addition, the relationship between quality and cost, while encouraging, will explored to better understand variation (if any) in the strength of the relationship in different patient populations. Finally, work continues to balance the inherent challenges of composite measures in terms of face-validity and perceived actionability with the advantage of reducing the number of measures and breadth of coverage of the multiple domains of primary care.

Conclusions: It is possible for front-line providers to measure quality in a way that reflects providers' priorities, what matters to patients regarding the patient-doctor relationship AND contributes to healthcare system sustainability. The composite quality measure represents a promising option for measurement and support of primary care performance that can lead to increased healthcare system sustainability. It also represents a potentially feasible alternative for front-line providers disenchanted with "body part" measures.

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March 2017

HealtheSteps™: A healthy lifestyle prescription program designed to address common risk factors for chronic disease

Dr. Robert J. Petrella, MD, PhD, FCFP, FACSM, Western University

Background:  Physical inactivity is one of the leading causes of chronic disease in Canadian adults. With less than 50% of Canadian adults reaching the recommended amount of daily physical activity, there is an urgent need for effective programs targeting this risk factor. HealtheSteps™ is a healthy lifestyle prescription program, developed from an extensive research base to address risk factors for chronic disease such as physical inactivity, sedentary behaviour and poor eating habits. HealtheSteps™ participants are provided with in-person lifestyle coaching and access to eHealth technologies delivered in community-based primary care clinics and health care organizations.

Methods:  To determine the effectiveness of Healthesteps™, a pragmatic randomized controlled trial was conducted in 5 clinic settings in Southwestern Ontario. Participants were individually randomized to either the intervention (HealtheSteps™ program) or comparator (Wait-list control). There were 3 phases of the HealtheSteps™ program, lasting 6 months each; the active phase consisted of bi-monthly in-person coaching with access to a full suite of eHealth technology supports; the maintenance phase I, the in-person coaching was removed, but participants still had access to the full suite of eHealth technology supports; the final stage, maintenance phase II, access to the full suite of eHealth technology supports was removed and participants only had access to publicly available resources and tools. The intervention and comparator group had variety of health behaviours and indicators measured at the study start and at 6 months; following 6-month measurements, the wait list control group was given the opportunity to start HealtheSteps™ at their designated site. Additional follow-up of only the intervention group occurred at 12 and 18 months. Process and economic evaluations of the HealtheSteps™ program were also conducted alongside this trial.

Results and Conclusions: This trial aimed to determine the effectiveness of the program in increasing physical activity levels and improving other health behaviours and indicators, the acceptability of the HealtheSteps™ program, and the direct cost for each person participating in the program as well as the costs associated with delivering the program at the different community sites. Preliminary analyses related to the outcome evaluation indicate that the intervention group improved their physical activity and healthful eating to a greater extent than the comparator group by 6 months. Results also suggest that the intervention group maintained these improvements to 12 months. These results will be used to inform program optimization and scaling up of the program into additional community-based primary care sites.

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May 2017

Incentives and Disincentives for Improving Quality of Care for Depression and Anxiety in Ontario Family Health Teams

Rachelle Ashcroft, University of Toronto
Research Team:
Dr. Rachelle Ashcroft rachelle.ashcroft@utoronto.ca
Factor-Inwentash Faculty of Social Work, University of Toronto
Dr. Kwame McKenzie, Welleseley Institute, Toronto, Ontario
Dr. Simone Dahrouge, C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario
Dr. Jose Silveira, Mental Health and Addiction Program, St. Joseph's Health Centre, Toronto, Ontario
Dr. Matthew Menear, Department of Family Medicine and Emergency Medicine, Université Laval, Quebec City, Quebec

Background:  Primary health care (PHC) is well situated to lead the prevention, treatment, management, and coordination needs of patients with common mental disorders (CMDs) such as depression and anxiety disorders. CMDs are highly prevalent, affecting more than one in five Canadians over their lifetime. Although treatment of CMDs in PHC can be effective, many patients struggle to access quality care for CMDs in these settings. Family Health Teams (FHTs) are an interprofessional model of PHC intended to address problems of access and quality and respond to the need for better chronic disease prevention and management. Promoting interprofessional care practices is widely recognized as a key strategy for improving access to high-quality care for CMDs in PHC.

Objective: (1) To develop a comprehensive model that describes and links the financial and non-financial incentives that can be leveraged by Ontario's policy makers to improve the quality of care for CMDs in Ontario's FHTs. (2) To inform Ontario's plan to provide regional access to mental health resources currently within FHTs.

Approach:  Our CIHR-funded interdisciplinary research team (social work, psychiatry, primary care organization) has conducted individual interviews with a diverse group of FHTs across Ontario and with healthcare professionals (e.g. family physicians, nurse practitioners, nurses, social workers, psychologists, occupational therapists, executive directors, psychiatrists) working in these settings, which can help us understand how various financial and non-financial incentives and disincentives influence their ability to provide evidence-based collaborative care for CMDs. We also recruited other stakeholders knowledgeable about mental health funding and service delivery in FHTs (e.g. community mental health providers, policymakers, leaders of professional organizations). We will have approximately 100 individual interviews at completion of this project.

Results: We will present initial findings from the first 50 interviews with healthcare professionals from FHTs (42 physicians, psychiatrists, executive directors, nurses, social workers, counsellors, occupational therapists, systems navigator, psychologist); community informants (5 community organization leaders, community mental health workers, physician leader); and policy informants (3 MOH and provincial association representatives). Participants represented 15 FHTs and spanned 9 Local Health Integration Networks (LHINs). Quality care dimensions being explored in this study are: technical care, access, equity, structural, person-centeredness, and efficiency. These quality care dimensions are helping guide identification of the range of non-financial and financial incentives and disincentives that exist at the clinical care, organizational, LHIN, and provincial policy levels. Categories of incentives and disincentives that influence the quality of care for CMDs include: physician remuneration, education, organizational structures, referral processes, and methods of intersectoral collaboration.

Conclusions:The model we develop aims to provide information on key financial and non-financial incentives that can help guide how interprofessional PHC teams can be structured for the optimal prevention and management of CMDs and can help inform the challenges and opportunities that LHINs will face to make the interprofessional members of FHTs available to other practices regionally.

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June 2017

Synthesizing and translating primary healthcare research findings into policy options

Dr. Lisa Dolovich – University of Toronto
Presented by: Lisa Dolovich, Professor, Leslie Dan Faculty of Pharmacy, University of Toronto
Co-Author(s):
Lisa Dolovich, Simone Dahrouge, Onil Bhattacharyya, Richard Glazier, Michael Green, Noah Ivers, Clare Liddy, Leslie Meredith, Sandra Regan , Merrick Zwarenstein, Moira Stewart

Background:  Ontario has gone through significant primary care reform, which has been studied by the Innovations Strengthening Primary Healthcare through Research (INSPIRE-PHC) Ontario-based program and network. This project describes the initial findings from a synthesis of INSPIRE-PHC findings, combining observational studies and trials of new practice and system level approaches along with policy implications. A descriptive narrative synthesis of project findings was conducted. Summary findings from each project were generated according to 11 pre-specified themes: ehealth, equity, patient perspective, patient engagement, team based care, access, vulnerable populations, gender, health policy, improvement in health status, and health economics. Research leads worked iteratively in small or large groups and individually to identify, discuss and synthesize findings from across studies. Attention was given to similarities and differences between findings of different studies, patterns in the data, changes in findings over time and the meaning of the data within the context and history of the Ontario health system. Thirty-one projects were synthesized. Projects were anchored in primary care but connected to other sectors including community/home care, in-home care, speciality care, and hospitals. A variety of research methods were used with emphasis on use of health administrative data, randomized controlled trials, program evaluation, surveys, systematic reviews and qualitative analyses. Preliminary synthesis demonstrates that primary healthcare practice and policy innovations are making progress in improving access and system integration, encouraging team based care, engaging community, and improving quality of care. Data platforms are emerging to support population based planning and care delivery. Several promising approaches are being scaled regionally, but special consideration of urban/rural context is required. Many quality domains were targeted; improvements in one domain were often balanced by potential risks for other areas. Research findings support health care reform that promotes the principles of primary healthcare and accompanying policies and practices. Comprehensive outcomes measurement in primary care is needed. Ongoing evaluation of new policy implemented structures or innovations emerging from decision maker priorities is essential to understanding progress towards health system reform goals.

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Sept 2017

Nothing about me without me: applying citizen engagement methods in a Family Health Team

Tara Kiran, Sam Davie, Katie Dainty, Peter McLeod

Background: Engaging patients is increasingly regarded as essential to advancing quality improvement in 1healthcare. However, there are barriers to effective patient engagement including time, money, and the representativeness of patient advisors. It is unclear what methods primary care organizations can use to overcome these barriers and meaningfully engage patients in healthcare improvement.

Methods: In 2016, our Family Health Team partnered with Mass LBP to apply methods of citizen engagement in a primary care setting. Our goal was to have patients and families help us improve the typical medical visit. We emailed an invitation to attend a one-day patient engagement session to 10,000 of our patients. 350 patients volunteered their time and from these patients, we randomly selected 36 volunteers who were representative of our practice based on responses to a few demographic characteristics. Volunteers attended a structured engagement session. We evaluated the initiative using a post-session survey and qualitative ethnographic methods.

Results: We were successful in bringing together a representative group of patients to provide us with concrete recommendations that we embedded into our 2016-17 Quality Improvement Plan. 100% of patients who attended the day said the day met their expectations and that they enjoyed the experience. Preliminary results from the ethnographic research suggest three important factors for a successful patient engagement event: setting the stage, storytelling, and reframing the patient role. 

Conclusion: It is possible to use methods of citizen engagement to convene a representative group of patients to provide recommendations for improvement in a primary care setting.

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2016
Jan 2016

Patient data on the run: Provider perceptions of secondary use of anonymized health information

Ester Moher, PhD, Psychology, Children's Hospital of Eastern Ontario's Research Institute
Authors: Ester Moher, William Hogg, Sharon Johnston, Mehdi Ammi, Khaled El Emam

A growing problem facing health researchers and health care professionals is getting access to linked and anonymized individual-level patient data sets, for purposes of research, accountability and improved care. Providers, however, may be reluctant to share patient data. The current research examines when providers are comfortable sharing patient data for purposes of secondary use. We survey providers' willingness to share across several variables, including type of record shared, degree if individuation of data, nature of record (electronic versus paper), to whom data is shared with, who benefits from sharing directly, and how familiar the provider is with sharing procedures. Providers (Ontario physicians and residents) were asked to read and respond to six vignettes, where variables of interest were varied and counterbalanced.

Providers displayed a greater willingness to share data with universities (over private and non-government firms), and preferred to share survey and aggregate (relative to individual-level records)--suggesting a preference for reducing risk in the event of breach. However, providers also noted a preference for sharing electronic records (vs. paper records), suggesting that ease of sharing is important.

As we move from paper to electronic records, and adapt practice to include mobile devices, email, and wearable technology, the challenges facing providers of care have increased. Understanding the unique challenges for providers to sharing anonymized health records is an important step in moving toward improved research and quality of care.

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Feb 2016

Access to Primary Health Care and Utilization of Walk In Clinics and Emergency Rooms in Ontario.

Dr. Michael Green

Objectives: Canada ranks poorly in same or next day access to primary health care and has high rates of utilization of emergency rooms and walk in clinics.  This study examines the barriers to PHC access and reasons for use of ERs and walk in clinics as reported by patients.

Approach:   Data was obtained from the Primary Care Access Survey, a random dial telephone survey of Ontario residents between 2006-2010 (N=38,795). Questions asked included self reported healthcare utilization, access to and barriers for accessing primary health care, and reasons for use of ERs and walk in clinics. Data was pooled into calendar years to assess trends over time. A disaggregated analysis for sex differences was included. Differences between patients self reporting rostering with a reformed PHC model practice and those who were not aware of being rostered were also assessed.

Results:   Most (93%) respondents reported having a family physician. 15% of patients with an FP reported difficulties making appointments when sick. Wait times did not change over time. The mean wait time for a appointment when sick was 3.6 days, but 20% of respondents reported waits over a week. ER and walk-in clinic use was similar, with about 22% reporting using each of these services in the past year. Convenience (31%) and lack of availability of their regular FP (41%) were the most common reasons for use of walk in clinics.  In contrast need for ER services due to the type or severity of illness was the most common reason for going the ER (63.5%) followed by lack of availability of FP (16.2%).   When stratified by wait time for an appointment with their FP when sick, there was no difference between groups with respect to walk in clinic use, and only a modest increase (5% absolute difference) in ER use for patients who reported having same or next day access and those waiting over 6 days.

Conclusions:   While access to a regular source of PHC is high, timely access when sick remains a problem. The impact of improving access to PHC on ER utilization is uncertain, as wait times to see an FP as reported by patients has only a modest relationship with ERs use and most patients report using the ER for reasons other than difficulty with accessing their usual source of care.

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Mar 2016

Improving quality of care for adults with developmental disability in primary care: Implementing the annual health check in Ontario family health teams.

Janet Durbin, Ian Casson, Avra Selick, Laurie Green, Andrea Perry, Natasha Spassiani, and Yona Lunsky

Health Care Access Research and Developmental Disabilities (H-CARDD) Program
Ontario adults with developmental disabilities have high health complexity, yet typically experience poor health management including high rates of avoidable hospitalizations. The Canadian Consensus Guidelines for Primary Care of Adults with Developmental Disabilities (2011) recommend   an annual ‘health check’ as a way to proactively address their health issues, but uptake in Ontario is quite poor. We studied the implementation of ‘health checks’  in three family health teams located in different regions , and examined implementation barriers and facilitators.

With each team we used a staged implementation approach that included obtaining staff buy-in; defining new staff roles, training, and EMR supports; initial delivery; and refinement. We employed a mixed methods approach to evaluate the effort, combining survey data with qualitative analysis of implementation logs, focus groups and individual interviews of FHT staff, patients and caregivers.

The ‘Health check’ was successfully implemented in 2 of the 3 teams, with one early drop out. Implementation was facilitated by the presence of a senior clinician champion, and building on existing processes (e.g., resident education, EMR point of care tools. Key to sustainability are developing systematic approaches for identifying patients with developmental disabilities and establishing  mechanisms for ongoing monitoring and improvement. Processes for taking full advantage of the interdisciplinary team in patient management need more exploration.
Implementation of the health check is feasible. If it is to become more standard in Ontario, fitting within the broader QI agenda is key. Processes for spreading the intervention to sites with different practice characteristics and facilitation resources are being explored, including Health Links.

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April 2016

Innovative Models Promoting Access-to-Care Transformation (IMPACT): A collaboration of researchers, decision makers, providers and community members to improve access to primary health care for vulnerable populations

Simone Dahrouge, Director, CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Deputy Chair, Department of Family Medicine, University of Ottawa, Danielle Rolfe, PhD, is a Senior Research Associate at the C.T. Lamont Primary Health Care Research Centre at the Bruyère Research Institute.

Problem Definition: Connecting individuals with community-based primary health care (PHC) programs is within the scope of primary care, but providers often lack the tools and time to identify their patients’ needs and suggest appropriate programs. Providers are particularly under-resourced to support their more complex patients who face social barriers related to mental health, low literacy or poverty. 

Potential Solution: IMPACT is a 5-year research project involving six regions in Australia and Canada (including Ontario) with the goal of improving access (broadly defined) to PHC for vulnerable populations. Each region has identified its local priorities, access gaps and is developing an intervention to address these gaps.   In Ontario, the direction of the project has been informed by an intensive process of (i) consultation with primary care researchers, Champlain LHIN decision makers, providers, community organizations and their members, (ii) engagement with the community, and (iii) consideration of research evidence to ensure relevance of the intervention to the local context. This presentation will describe the priority setting exercise used to establish the local PHC access issue, and findings from patients, caregivers and provider interviews on PHC needs, barriers and potential solutions. A description will also be provided of the planned intervention to support vulnerable populations to get the PHC they need by increasing providers’ and community members’ awareness of community-based programs. The intervention will leverage existing provincial initiatives that promote access to community resources such as www.healthline.ca and 2-1-1.

Potential Impact: Informed by local partnerships and community engagement processes, the IMPACT project aims to support members of vulnerable populations to achieve better health through improved connection to community-based PHC resources. Given the inclusion of province-wide initiatives like thehealthline.ca, and the Ministry’s commitment to putting patients first, the project’s outcomes are both relevant and scalable across Ontario.

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May 2016

Deimplementation Of Opioid Prescribing In Primary Care: A Systems Approach

Dr. Peter Selby, Centre for Addiction and Mental Health, Toronto

Despite attempts at increased awareness and attempts to improve prescribing of opioids in primary care settings with the release of guidelines, opioid prescribing continues to escalate and cause harm. Recent evidence suggests that better treatment of acute pain with fewer opioids, judicious use of opioids for chronic pain and recognition and treatment of those who are addicted is required. However, simple education is not adequate and requires a systems approach to understand the dynamics involved in the continuation of the prescription cycle. This presentation will provide a summary of the existing opioid epidemic in Ontario and propose a model for deimplemention prescribing in primary care settings. This will be based on existing models and infrastructure that considers scalability and maintenance in the long term.

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June 2016

Primary care patients' perceptions of access to care in Ontario: An analysis of the QUALICO PC Patient Experiences Survey

Authors: Kamila Premji, Bridget L. Ryan, William E. Hogg, Walter Wodchis

Objective:  Canada has been criticised for poor access to primary care compared to other developed countries.  Ontario in particular has received recent attention for poor access following reports from the Commonwealth Fund Study and Health Quality Ontario.  We sought to better understand Ontario patients’ perceptions around access to their primary care practice.

Design:  A cross-sectional study using data from the Quality and Costs of Primary Care (QUALICO PC) Patient Experiences Survey.

Setting:  Ontario primary care clinics.

Participants: Adult primary care patients participating in the Ontario QUALICO PC study.

Outcome Measures:  Using conceptual mapping to previously validated primary care access scales, 11 QUALICO PC survey items were selected to study patient-perceived access.  These items were analysed both individually and as a Composite Access Score with a possible range of 1.0 (lowest access) to 2.0.  A mixed effects multiple linear regression analysis was done to explore the relationship between the Composite Access Score and patient characteristics.

Results:  The mean Composite Access Score was 1.78 (SD 0.16).  Most patients (68%) waited more than one day for their appointment.  The majority (96%) stated it was easy to obtain their appointment and that they obtained that appointment as soon as they wanted (87%).  In the multivariable analysis, being older, being born in Canada, better self-reported health, and increased frequency of visits to a doctor were associated with higher Composite Access Scores.

Conclusion:  Despite previous criticisms of access to primary care based on the metric of same-day or next-day access, this study found that almost all Ontario patients belonging to primary care practices were able to get an appointment when they wanted it and felt favourably about a wide variety of dimensions of access.

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Sept 2016

Development and assessment of a list of essential medications for a high-income country

Dr. Nav Persaud

Background: Some evidence supports the use of a short list of essential medicines to improve prescribing. We aimed to create a preliminary essential medicines list for use in Canada.

Methods:The 2013 WHO Model List of Essential Medicines was initially adapted by the research team. Fourteen Canadian clinicians then gave suggestions for changes to the list. Literature relevant to each unique suggestion was gathered and presented to three clinician-scientists who used a modified nominal group technique to make recommendations on the suggested changes. Prescribing audits of two Toronto-based family health teams were then performed to identify common prescriptions that were not on the draft list. Literature relevant to each commonly prescribed medication was again gathered and shared with the clinician-scientist review panel to determine if each should be added to the list. The audits were then completed based on the final list to provide a preliminary assessment of the list.

Results:The multi-step process produced a list of 125 medications. These medications covered 91% and 93% of prescriptions at the inner city clinic and at the suburban sites, respectively. 93% of the patients seen at the inner city clinic and 96% of the patients seen at the suburban clinic had all or all but one of their medications covered by the list.

Interpretations: A preliminary short list of essential medicines was developed that covered most but not all prescriptions at two primary care sites. The list should be further refined based on wider input.

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Nov 2016

Quality of care for patients with multimorbidity at nurse practitioner-led clinics: a multiple case study

Dr. Roberta Heale, Laurentian University

Affiliation: Laurentian University School of Nursing

Authors: Roberta Heale NP-PHC, DNP, PhD(c), Susan James RM PhD, Elizabeth Wenghofer PhD, Marie Luce Garceau PhD

Statement of Purpose:   Nurse practitioners have been providing safe and effective primary health care in Canada for decades, however, there are ongoing barriers to practice. The development of Nurse Practitioner-Led Clinics (NPLCs) in Ontario held promise for NPs to practice to their full potential, however, there have been no studies of the NPLC model. A multiple case study was undertaken to evaluate the quality of care for patients with diabetes and multimorbidity at NPLCs.

Methods:  Five NPLCs, all in underserved areas in the mid-northern region of the province, were included in the study. Data collection included a chart audit, NP interviews, organizational information and grey literature. Cross case analysis was conducted and four, interrelated themes emerged about the quality of care of patients with diabetes and multimorbidity at the NPLCs.

Results and Conclusions: The study confirmed that the NP is the primary care provider at NPLCs, which has a positive impact on the quality of care. The NP leadership role is enhanced by organizational processes and by the limited physician consultation available in these clinics. A hold on NP salaries in primary health care in the province for ten years has contributed to poor NP recruitment and retention at NPLCs. This, along with insufficient health care resources in the communities where NPLCs are located and high patient vulnerability, has negatively influenced the quality of care. Strategies including mentoring and changes to funding offer possible solutions to improve the quality of care at NPLCs.

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Dec 2016

Did introduction of patient enrolment models with mandatory after-hours provision reduce emergency department utilization?

Tara Kiran, Rahim Moineddin, Alex Kopp, Eliot Frymire, Rick Glazier

Background:  In the last fifteen years, more than 11 million Ontarians have transitioned to a patient enrolment model that includes mandatory after-hours service provision. It is unclear, however, whether mandating after-hours services in primary care resulted in a change in emergency department utilization.

Methods:  We conducted a retrospective cohort analysis using linked administrative data. We analyzed data for Ontario residents 19 years and older who transitioned to a patient enrolment model between April 1, 2003 to March 31, 2014 and lived outside rural areas (n= 8,946,398). We examined trends in primary care and emergency department use over time. For residents who had a minimum of three years of data available before and after the year of transition, we used segmented negative binomial regression to assess the impact of transition to an enrolment model on the emergency department visit rate. Resident age, neighbourhood income quintile, co-morbidity, and morbidity were included as time-varying co-variates and resident sex as a stable variable in the model. The model also included calendar year to account for secular trends.

Preliminary Results:  Between 2003 and 2014, the crude rate of emergency department visits rose from 333 to 370 per 1000 persons. During the same period, the proportion of primary care visits that occurred on the weekend rose from 2.2% to 3.7%, but there was a secular decrease in both the primary care visit rate and continuity with the primary care physician. In the year after transition to a medical home, there was a 4.2% (95% CI, 3.8% to 4.5%) step increase in the emergency department visit rate. In the years following transition, the baseline trend in the emergency department visit rate increased by 3.6% (95% CI 3.5% to 3.7%) per year.

Conclusions: Transition to a patient enrolment model with mandated after-hours services was associated with an increase in emergency department use despite an increasing trend in the proportion of primary care visits that occurred on the weekend. Improvements in access to care may have been offset by secular decreases in continuity with a physician and the primary care visit rate. Ongoing efforts to mandate after-hours care as a means to reducing emergency department use should be rigorously evaluated to ensure reforms meet stated objectives.

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2015
Jan 2015

Facilitators and Barriers of Chronic Disease Prevention and Management Programs in Two Canadian Provinces: Processes and Results of a Realist Synthesis

Judith B. Brown (Western University), Bridget L. Ryan (Western University), Luan Januzi (Western University), Maud-Christine Chouinard (Université du Québec à Chicoutimi), Frances Gallagher (Université de Sherbrooke), Christine Loignon (Université de Sherbrooke), Bouhali Tarek (Université de Sherbrooke), Boubacar-Bayero Diallo (Université de Sherbrooke)

CONTEXT: Many Chronic Disease Prevention and Management (CDPM) programs, linked to Primary Care (PC) reform, are ongoing in Canada. While some of these programs have been formally evaluated, synthesis of facilitators and barriers of these programs is still required. Members of the research team of the "Patient-Centred Innovations for Persons with Multimorbidity" (PACE in MM) project are conducting a realist synthesis (RS) based on an environmental scan of CDPM programs in two Canadian provinces (Quebec and Ontario) reflecting different contexts, healthcare systems and languages.

OBJECTIVES: To identify and explore the barriers and facilitators of CDPM programs linked to PC reform by conducting a RS of these programs in two Canadian provinces (Quebec and Ontario).

DESIGN: The RS comprises five main phases: 1) clarifying the scope of the synthesis; 2) searching and appraising the evidence; 3) appraising the quality of the data; 4) extracting the data; and 5) evaluating the data. The operational process of the RS comprises the following activities: 1) Content and activities description (purpose, concepts, quality criteria); 2) Material preparation; 3) Preliminary data exploration; 4) Peer audit with key stakeholders; 5) Analysis of one program; 6) Evaluation and feedback; 7) Interviews with programs; 8) Data analysis; 9) Report and dissemination. A bilingual Committee was composed of five researchers, two analysts and a coordinator. Throughout the duration of the project, biweekly meetings were held where members had the opportunity to discuss work in progress. In addition, the two data analysts had a weekly meeting and simultaneously coded the data using innovative technologies (videoconferences, Nvivo Server, eHealth Ontario Community). The Committee developed a numbers of key documents for the functioning of the analysis process: glossary of terms, terms of a bilingual team, description of the Committee rules and functions, objectives and deliverables of the timeline, checklist of collected data table, journal of coding, and analysis process procedures.

RESULTS: Twelve CDPM programs in Ontario and Quebec were included in the RS. The preliminary results of the RS identified main CMOs (context-mechanism-outcome) configurations that reflect positive and negative outcomes in these CDPM programs in four domains: 1) Mechanisms related to the Chronic Care Model: community resources and policies, self-management support, decision support, evidence-based practice, clinical information system, organization of health care, prepared and proactive teams; 2) Mechanisms related to self-management; 3) Mechanisms related to primary care reform: governance, information technology, local or regional network of health care services, interprofessional collaboration; and 4) Mechanisms of innovations: focus on multimorbidity, patient-centred partnership, patient-centred coordination/integration/transition. Additional mechanisms were related to accessibility, patient vulnerability and patient involvement in services planning.

CONCLUSION: This RS will facilitate an alignment of CDPM programs to promising innovations on patient-centred PC for persons with multimorbidity. The rigorous process by which this RS is conducted will ensure a better reproducibility of the results in two provinces given the contextual differences in the health care systems and languages. The CMOs identified in this research will inform the next steps of the PACE in MM project.
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Feb 2015

Identification of Structural Components of Primary Care Practices Associated with Lower Hospital Utilization

Authors: J. Pang1, MSc (C); W. P. Wodchis2, PhD ; W. E. Hogg3, MSc MClSc MD; J. Barnsley, PhD4

1 MSc student, Institute of Health Policy Management Evaluation, University of Toronto.
2 Associate professor, Institute of Health Policy Management and Evaluation, University of Toronto; research scientist, Rehabilitation Institute, and adjunct scientist, Institute for Clinical Evaluative Sciences in Toronto
3 Executive director, the Canadian Primary Health Care Research and Innovation Network (CPHCRIN), and professor and senior research adviser, the Department of Family Medicine, University of Ottawa and C.T. Lamont Primary Health Care Research Centre of the Élisabeth Bruyère Research Institute in Ottawa
4 Associate professor, Institute of Health Policy Management and Evaluation, University of Toronto; adjunct scientist, Institute for Clinical Evaluative Sciences in Toronto

Purpose: The patient-centred medical home (PCMH) is an increasingly popular primary care (PC) delivery model. This study intends to determine the extent to which primary care practices have in place structural components of PCMH, and whether these are associated with better patient outcomes in Ontario.

Methodology: Cross-sectional observational study with linked PC survey and health administrative data completed as a sub-study within the Quality and Cost of Primary Care study, a 34-country PC performance measurement study. One Ontario family/general practice physician per practice was eligible to enroll. Separate surveys completed by participating physicians and 9 of their patients were used to measure the extent to which PC practices have in place structural components of PCMH. Survey data were linked with administrative data for all participating physicians' patients to capture non-urgent emergency department (ED) visits and ambulatory care sensitive (ACS) hospitalizations. Hierarchical logistic regression models are being used to determine the relationship between PC practice characteristics and patient hospital utilization.

Results: Survey data was collected from 183 PC practices and 1,706 patients. There was varying attainment of PCMH among Ontario respondents. Ninety-six percent of patients reported that it was easy to get an appointment, 68% reported different healthcare providers work together effectively in their care and 78% reported it was not difficult to get referral to a medical specialist and 67% of PC practices use electronic medical records (EMR) to support prevention/follow-up reminders. Based on the Canadian PCMH definition, we expect that the patients in PC practices with higher accessibility to care, use of interprofessional teams, coordination of care, use of EMR to support patient safety and quality improvement, and access to resources/funding availability will have fewer ED visits and ACS hospitalizations.

Implications: Results from linked comprehensive PC survey data with health administrative data in Ontario may support evidence-based decisions for ongoing PC reform in Ontario.
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March 2015

Teams Advancing Patient Experience: Strengthening Quality: TAPESTRY

Lisa Dolovich, McMaster University

OBJECTIVE: The objectives of TAPESTRY are to help older adults stay healthy at home using an interprofessional primary health care team delivery approach that integrates trained community volunteers, system navigation, community engagement, and use of technology; and to adopt this team approach as a scalable and sustainable model for care across jurisdictions and illnesses or health conditions. TAPESTRY capitalizes on current system strengths, knits together new TAPESTRY approaches with existing initiatives and moves the resultant system forward. Providing teams with tools to foster interprofessional and interagency collaboration or to have access to virtual team members are solutions woven into TAPESTRY. A browser based Personal Health Record is the core IT component of the TAPESTRY program, the PHR is augmented with a web-based application, TAPP, which is additionally tightly integrated with an Electronic Medical Record. This interoperable system of application facilitates data collection by a volunteer, within the community on behalf of and data dissemination to the patient, the patient's formal clinical circle-of-care and the patient's advocates. This presentation will share learnings from the initial development and implementation of TAPESTRY within a 2-site Family Health Team (FHT). Developmental evaluation was used to understand key decisions made during the formative development of TAPESTRY and the data that validated these decisions.
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April 2015

An international scoping review of models for scaling up healthcare delivery innovations to widespread practice; and the creation of a nose to tail toolkit for facilitating successful development, implementation and scale up of health innovations

Merrick Zwarenstein, Director, Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University

OVERVIEW: Canada has been criticized, notably by Barbara Starfield, the North American guru on Primary Care, for being 10 years behind many other countries in primary care system design and delivery. This is NOT because we fail to innovate- in recent years an enormous amount of money has been spent in Ontario and Canada on primary care innovation. Instead we have been criticized for our unsystematic approach to policy and implementation of innovation, and described as "addicted" to pilot projects. Promising innovations frequently stall after the pilot stage, due to failure of implementation planning and execution. Other innovations are implemented widely without evaluation, either at pilot or full implementation stages.

Is there a politically feasible and practical approach to identification of promising interventions, integration of these innovations into policy and widespread implementation that could assist us in overcoming the Canadian gap between innovation and effective delivery of primary care? We present here the results of an international scoping review of frameworks which have been used to study the connections between health care delivery innovation, policy and widespread implementation.

This review has identified the many stages and issues to be considered during the health innovation process. Importantly, this review has informed our development of a toolkit that could be used by decision makers (along with innovators and end users) to optimize selection, scale up and sustainability of innovation in the Ontario primary care delivery system, within the existing system of care and concordant with overall policy priorities.
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May 2015

Urban Telemedicine IMPACT Plus (TIP): An Innovative Interdisciplinary Model for Coordinated Complex Care

Pauline Pariser, University of Toronto

OVERVIEW: Telemedicine IMPACT PLUS (TIP) is an innovative, proactive interdisciplinary model of care for serving complex patients and supporting their solo primary care providers (PCPs). The model recognizes the "perfect storm" created by an aging demographic within a health care system founded on treating acute illness. Currently, disconnected serial consultations based on single disease entities do not reduce the burden of chronic illness for these patients nor provide coordinated care planning for their PCPs. TIP built upon the success of IMPACT PLUS, a Bridges evaluated inter-professional care model. By marrying the power of a skilled inter-professional team, including general internist and psychiatrist, to telemedicine technology, TIP aims to provide one stop coordinated real-time care planning in the PCP office or at home. Evidence from the literature found that intensive inter-professional care was successful in reducing health care costs with at least equivalent outcomes for complex populations. Preliminary results from the IMPACT PLUS evaluation demonstrate high patient, provider and caregiver satisfaction with this model of care. TIP has been implemented across the Toronto Central LHIN to offer clinics since 2013. Through TIP, both the complex patient and family physician are connected to an interdisciplinary care team over a 1-hour consultation through secure videoconferencing technology. The teams leverage inter-disciplinary support from FHTs to focus on critical issues identified by patient, family and PCP. A dedicated TIP nurse facilitator, as care coordinator, provides pre- and post-clinic follow-up supports to all stakeholders.

To date, qualitative ratings have been consistently high (88-95% among patients and caregivers and 100% by PCPS). The plan is to perform a 6 month retrospective study assessing impact on ED visits, hospitalizations, reduction in medication use and referrals to consultants. The Toronto Central LHIN is interested in assessing the scalability of the model, and has secured base salary funding for the TIP program's continued operations. The TIP model has implications for immediate opportunities to enhance primary care reform, and to leverage and increase the capacity of existing resources in our healthcare system.
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June 2015

Seamless Care Optimizing the Patient Experience: Testing a Scalable Model of Care Coordination in a HealthLinks Primary Care Integration Project

Noah Ivers (University of Toronto), Gillian Hawker, Pauline Pariser, Onil Bhattacharrya

Background: Many practices are not well equipped to address the needs of complex, high-risk patients. These family physicians (FPs) could benefit from a care coordination strategy. However, most primary care providers only have a small number of patients at high-risk for recurrent visits to hospital, suggesting that care coordination based in small practices will not be cost effective. A centralized, scalable approach to care coordination is needed. Such an approach has been developed and evaluated in the Seamless Care Optimizing the Patient Experience (SCOPE) initiative, in the MidWest Toronto HealthLink.

Methods: FPs whose patients had a high number of emergency (ER) visits were identified. A multi-faceted strategy was used for engagement. The intervention includes a single number to access a nurse navigator, CCAC coordinator, or internist on-call. In addition, an ER flagging system alerts the team when a SCOPE patient arrives, prompting a multidisciplinary care plan.

Results: Since the project launched in September 2012, the volume of contacts to S.C.O.P.E. for all services has been increasing steadily week-over-week spikes following FP engagement events. Impact on ER visits and admissions using administrative data at ICES will be presented using an interrupted time series design with matched cohort.

Discussion: We will describe key lessons from SCOPE1 and discuss how we have refined the intervention for the next stages of the intervention. In particular, we will present early results from SCOPE2, a cluster-randomized trial conducted in the HealthLink, funded by the MOHLTC-HSRF that will measure impact of the intervention on all aspects of the "Triple Aim".

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Oct 2015

Considering immigrant populations in Ontario Health Equity Impact Assessments

Dr. Kevin Pottie (University of Ottawa), Branka Agic, Doug Archibald, Ayesha Ratnayake, April McInnis, Natalie Kaiman

Background:: The Ontario MOHLTC has developed a Health Equity Impact Assessment (HEIA) as a pragmatic tool to reduce of health inequities. A recent systematic scoping review on Health Impact Assessments however reported that only 40/688 mentioned immigrants and 2/688 considered immigrants in the recommendations. This project sought to develop a supplement to improve the inclusion of immigrants in HEIA process.

Methods: An international consensus meeting in Ottawa 2014 led to a draft supplement (MOHLTC, International Organization for Migration, Ottawa Public Health, Cochrane Equity Methods Group, Local Immigrant Partnerships, and HEIA researchers. The team then used a mixed methods study to pilot and finalize the supplement. The 31 participants included public health and immigrant stakeholders in Ottawa, Toronto and Kingston. Data was collected on equity quizzes and analyzed in SPSS and 15 interviews were audiotaped, transcribed and then analyzed using framework analysis.

Results: The supplement generated enthusiasm at the expert and HEIA stakeholder level. The following themes emerged from the analysis: migrants are a priority population for HEIA but there are unique complexities of cultural dynamics and evidence-based data. Local immigrant partnerships were identified as untapped resources and a need for support for decision makers. Participants also suggested additional design supports such as a decision trees and implementation support to achieve effectiveness and adoption.

Implications: A unique supplement now exists. Next steps include strategic implementation, building local immigrant partnerships (LIP), training modules and workshops for key community and immigrant stakeholders and publishing it as an Ontario HEIA tool.

Acknowledgement: We would like to thank the CIHR and the MOHLTC for funding our consensus meeting and pilot studies.

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Nov 2015

An Economic Comparison of Specialist Remuneration Models for eConsult Services

Clare Liddy MD, MSc, CCFP, FCFP, (C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada, Department of Family Medicine), Fanny McKellips, Paul Drosinis MPH, Catherine Deri Armstrong PhD, Erin Keely MD, FRCPC

Background: Provincial governments have long recognized the importance of reducing wait times for patients to receive timely care from specialists. The Champlain BASE (Building Access to Specialists through eConsultation) eConsult service is well-established in a large health region in Ontario, and has been providing eConsult services since 2010. Understanding the most cost-effective method of remunerating specialists is of critical importance as utilization and adoption of eConsult services continue to increase.

Objective: To understand the cost implications of the different proposed specialist remuneration models using utilization data from the Champlain BASE eConsult service.

Methods: All eConsults completed between April 1, 2014 and March 31, 2015 were included. We calculated costs under each of the three proposed specialist remuneration models: 1) $200 per hour pro-rated to the self-reported time it takes to complete the eConsult; 2) fee for service model 3) a flat sessional fee for three hours per week.

Preliminary Results: 3,670 eConsults were completed during the study period. The estimated costs for specialist remuneration for models 1, 2, and 3 were $167,783, $190,488, and $2,128,842 respectively.

Impact: There are large differences in costs depending on the remuneration model. We found model 1 to be the most cost effective, although additional models will be analyzed. This result is important for the province and other jurisdictions in making decisions for the best model to use for specialist remuneration.

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Dec 2015

Those left behind from Ontario's primary care reforms

Tara Kiran, Alex Kopp, Rick Glazier, University of Toronto, ICES

Background: Over the last decade, Ontario physicians have voluntarily transitioned from traditional fee-for-service to new Patient Enrolment Models (PEMs) that incorporate blended capitation. We assessed the characteristics of patients whose physicians have not transitioned to a PEM and compared their quality of care over time with patients receiving care from a PEM physician.

Methods:Our study used population-based administrative database. We stratified patients by whether they received care from a comprehensive fee-for-service physician or a PEM physician as of March 31, 2011. We compared patient characteristics in 2011 and calculated the proportion receiving recommended testing for diabetes and screening for cervical, breast, and colorectal cancer for each year between 2001 and 2011.

Results: Patients receiving care from a comprehensive fee-for-service physician (N=771,471, 6%) were more likely to be immigrants, live in urban areas, and live in a neighbourhood in the lowest income quintile compared to patients receiving care in PEMs (N=10,785,687, 82%). Patients receiving care from a fee-for-service physician in 2011 were less likely to receive recommended testing for diabetes (25% vs. 34%; adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.73 to 0.75) and less likely to receive screening for cervical (52% vs. 66%; adjusted RR 0.79, 95% CI 0.79 to 0.79), breast (58% vs. 73%; adjusted RR 0.80, 95% CI 0.80 to 0.81), and colorectal cancer (44% vs. 62%; adjusted RR 0.72, 95% CI 0.71 to 0.72) compared to patients in PEMs. The gaps in quality of care predated transitions to a PEM and widened between 2001 and 2011.

Conclusions: Ontario's primary care reforms have left behind a large number of patients. Those left behind are more likely to be poor, urban, and new immigrants. They have historically received lower quality care and the gaps in care have widened over time.

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2014
Jan 2014

THE QUALITY IMPROVEMENT & INNOVATION PARTNERSHIP LEARNING COLLABORATIVE PROGRAM: A MIXED-METHOD EVALUATION

Stewart B. Harris, MD, MPH, FCFP, FACPM, Michael Green, MD, MSc, FCFP, Judith Belle Brown, PhD, Sharon Roberts, PhD, Grant Russell, MBBS, FRACGP,MFM, PhD, Meghan Fournie, BHSc, Susan Webster-Bogaert, MA, Jyoti Kotecha, MPA, CChem MRSC, PhD(c), Han Han, PhD, Amardeep Thind, MD, PhD, Moira Stewart, PhD, Sonja Reichert, MD, MSc, CCFP, Richard Birtwhistle, MD, MSc, CCFP, FCFP

Context: The Quality Improvement and Innovation Partnership (QIIP), amalgamated into Health Quality Ontario, offered a quality improvement (QI) learning collaborative (LC) to interdisciplinary primary healthcare (PHC) teams. Objective: To measure the effect of the LC on diabetes care, colorectal cancer (CRC) screening and access to care and to understand the impact of a team approach on care management.

Design: A mixed-method evaluation: 1) process evaluation; 2) cluster, matched control, pre-post chart audit; 3) matched control, post, access survey; 4) Semi-structured, telephone interviews.

Setting: PHC teams in Ontario, Canada. Intervention: A QI LC program consisting of 3 learning sessions and additional supportive program activities over 16 months.

Participants: Randomly selected PHC practices for chart audit/survey and PHC team members and QIIP program administrator for interviews.

Main Outcome Measures: Proportion of patients with diabetes with an annual foot exam, mean A1C of patients not at target (≥7.3%), proportion of patients who had CRC screening, and mean number of days until the third-next available appointment (TNA).

Results: Program participants indicated that they developed an interdisciplinary approach to care, and understanding and respect for each other's role. There was no significant improvement compared to a control group in proportion of patient screened for CRC (p=.77) or a documented foot exam (p=.45), mean A1C (p=.10), and mean number days until the TNA (p=.22).

Conclusions: The QIIP LC was successful in building interdisciplinary team function; however, it did not significantly improve targeted outcomes compared to the control group.
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Feb 2014

THE PRESCRIBING TRENDS BY NURSE PRACTITIONERS TO OLDER ADULTS IN ONTARIO: 2000-2010

J. Tranmer, RN, PhD, L. VanDenKerkhof, RN, DrPH, D. Edge, RN, PhD., K. Sears, RN, PhD. , L. Levesque, BScPharm, PhD

Statement of Purpose: The goals of this study were to describe, from 2000 to 2010: (1) the trends in medication prescription to persons ≥ 65 years of age in Ontario by nurse practitioners (NPs), (2) the common classes of medication prescription and (3) the regional variation in prescription patterns by Local Health Integration Network (LHIN).

Methods: We conducted a population-based descriptive retrospective cohort study. All NPs registered in the Corporate Provider Database (CPDB), certified between 1 January 2000 and 31 December 2010 were identified. We then determined all prescription medications, from the Ontario Drug Benefit (ODB), they dispensed to patients 65 years of age and older during this time period. As a comparator, we identified all prescription medications dispensed to patients aged 65 years and older by family physicians identified in the ICES Physician Database (IPDB) in the same time period. To address the study objectives we employed a number of descriptive analyses.

Results: The number and proportion of NPs who dispensed medication to patients ≥65 years increased from 2000 to 2010 [44/340 (12.9%) to 888/1424 (62.4%)]. The number and proportion of medications dispensed for chronic conditions by NPs increased: in 2010, 9 out 10 medications dispensed were for chronic conditions. There was substantial variation in the proportion of NPs dispensing medication to the older population across LHINs. Central urban regions had the lowest proportion of NPs dispensing medications to older persons.

Conclusions: NP prescribing to older adults, and in particular medications related to chronic conditions, has increased substantially across the 10 years. The geographical variation suggests that the integration of NPs into primary health care has not been consistent across the province. The findings from this study provide a platform for further investigation into the nature and effect of NP practice on patient care.

For more information please contact: Dr. Joan Tranmer E-mail: tranmerj@kgh.kari.net
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Mar 2014

THE RELATIONSHIP BETWEEN INTER-PROFESSIONAL TEAM COLLABORATION AND PERCEIVED CAPACITY TO PROVIDE EFFECTIVE CLIENT-CENTERED MENTAL HEALTH CARE

Submitted on Behalf of the CAMH-Ryerson Collaborative for Client-Centred & Family Sensitive Care Elizabeth McCay, Kristin Cleverley, & Audrey Danaher Contact: Elizabeth McCay at Ryerson University bmccay@ryerson.ca

Background and Purpose: Effective health care teams can have a dramatic effect on quality of client-centred care across health care settings. Regardless, benefits have yet to be demonstrated in mental health setting, despite the fact that the mental health field has focused on the therapeutic relationship with clients and families frequently in the context of inter-professional teams. This ongoing study addresses the critical knowledge gap in connection between effective inter-professional collaboration and the capacity to provide exemplary client-centred care, specifically within mental health settings.

Methods: A cross-sectional correlational mixed method design was used to assess the relationship between inter-professional collaboration, team effectiveness, perceived attitudes toward team functioning and quality of care with perceived capacity to deliver client-centred care. Qualitative data was obtained through focus groups with families and individual client interviews.

Results: Preliminary quantitiative results demonstrate moderate to high levels of interdisciplinary team collaboration, effectiveness, as well as positive attitudes toward the essential role of interdisciplinary teams. Overall, quantitative results also demonstrated that care providers belief in the value of the team was significantly correlated with the capacity to provide client-centred care. Further higher levels of collaboration were found to significantly correlate with team effectiveness, as well as provider-rated capacity to engage in client-centred care. Qualitative data describe both similarities and differences in individual and family experiences of team functioning and client-centred care. Overall, individuals and families describe the value of working in partnership with inter-disciplinary teams and emphasize the need for consistent communication. Inter-professional collaboration is perceived by individuals and families as a necessary pre-condition for recovery, restoring hope, re-establishing connections and ultimately achieving quality of life.

Conclusions and Implications: Thus far, the study outcomes support the essential role of effective healthcare teams in achieving client-centred and family senstive care in mental health settings. The study findings provide baseline data to guide the development of future research directed toward the development and evaluation of interventions to strengthen effective inter-professional care to achieve effective client-centred and family sensitive care in mental health settings.

For more information please contact: Dr. Elizabeth McCay bmccay@ryerson.ca
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April 2014

USING AUDIT AND FEEDBACK TO IMPROVE QUALITY IN PRIMARY CARE

Noah Ivers, University of Toronto

Background: Audit and feedback is a common approach to quality improvement. However, wide variation has been observed in its effectiveness for improving quality of care. This presentation will present results from a Cochrane systematic review, plus a randomized trial with embedded qualitative process evaluation of feedback provided to family physicians (FPs) in Ontario.

Objectives: To describe best practices in the design and delivery of audit and feedback based on data and theory and to understand how to increase the usefulness of external audit and feedback for FPs.

Results: The systematic review included 140 randomized trials of audit and feedback, finding that the intervention often leads to small but potentially important improvements in professional practice. Feedback is more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In Ontario, FPs welcomed external audit and feedback and found that it increased awareness of gaps between ideal and actual performance, but this led mainly to 'trying harder' patient-by-patient rather than 'working smarter'. Practices with electronic records (EMR) often have inadequate infrastructure to conduct quality improvement in response to feedback.

Discussion: The impact of audit and feedback depends on how it is designed and delivered and on the resources available for action in practice. A new project using EMR data to provide hundreds of Ontario FPs with feedback on chronic disease management will be discussed.

For more information please contact: Dr. Noah Ivers, noahivers@gmail.com
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May 2014

WHAT WE MEASURE MATTERS!

Authors: Sharon Johnston MD, LLM , Bill Hogg, University of Ottawa

What we measure matters! Primary healthcare performance measurement and reporting in Canada has lagged well behind other countries. Across the country there is little good quality data publicly available to promote accountability or drive reform in the PHC system. The TRANSFORM pan-Canadian research team is launching a series of project aimed at improving the science and relevance of PHC performance measurement demonstrating the feasibility and usefulness of comparative and comprehensive practice-based PHC performance measurement and reporting at the regional level.

For more information please contact: Dr. Sharon Johnston SJohnston@bruyere.org or Dr. Bill Hogg whogg@uottawa.ca
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June 2014

SEAMLESS CARE OPTIMIZING THE PATIENT EXPERIENCE: TESTING A SCALABLE MODEL OF CARE COORDINATION IN A HEALTHLINKS PRIMARY CARE INTEGRATION PROJECT

Noah Ivers (University of Toronto), Gillian Hawker, Pauline Pariser, Onil Bhattacharrya

Background: Many practices are not well equipped to address the needs of complex, high-risk patients. Such patients are more often cared for by traditional, fee-for-service family physicians who tend to have less practice-based resources. These family physicians (FPs) could benefit from a care coordination strategy. However, most primary care providers only have a small number of patients at high-risk for recurrent visits to hospital, suggesting that care coordination based in small practices will not be cost effective. A centralized, scalable approach to care coordination is needed. Such an approach has been piloted in the Seamless Care Optimizing the Patient Experience (SCOPE) initiative, in the MidWest Toronto HealthLink.

Methods: FPs whose patients had a high number of emergency (ER) visits were identified. A multi-faceted strategy was used for engagement. The intervention includes a single number to access a nurse navigator, CCAC coordinator, or internist on-call. In addition, an ER flagging system alerts the team when a SCOPE patient arrives, prompting a multidisciplinary care plan.

Results: Since the project launched in September 2012, the volume of contacts to S.C.O.P.E. for all services has been increasing steadily week-over-week spikes following FP engagement events. Impact on ER visits and admissions is under evaluation using administrative data at ICES. Discussion: We will describe key lessons from SCOPE and discuss plans to refine the intervention in preparation for testing whether the initiative cost-effectively improves health outcomes and patient experiences in an MOHLTC-HSRF-funded randomized trial.

For more information please contact: Dr. Noah Ivers, noahivers@gmail.com
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Oct 2014

FORMATION OF DISEASE REGISTRIES IN A LARGE FAMILY HEATH TEAM (FHT): A Canadian Primary Care Sentinel Surveillance Network (CPCSSN) Demonstration project

Michelle Greiver, MD, MSc, CCFP, FCFP

Objective: Registries are foundational to quality improvement efforts in primary care, and benefit from standardized data to indicate the presence of conditions. Standardized coding for chronic diseases may not be present in Electronic Medical Records (EMRs), and data quality has been found to be problematic. Efforts are needed to improve and standardize data. We tested new team-based approaches and methods to standardize chronic disease coding in primary care EMRs.

Approach: 59 North York FHT family physicians, using two different EMRs and practicing out of 17 locations participated. We provided reporting software, the Data Presentation Tool (DPT) to the FHT's data manager. DPT uses EMR data that has been extracted, cleaned, merged and standardized by CPCSSN, and Health Profile free text encoded in SNOMED-CT. These improved data are returned to the FHT in the DPT. We used DPT to discover discrepancies between agreed upon coded entries in Health Profiles for five chronic diseases (diabetes-ICD9 250, COPD-496, hypertension-401, dementia-290, heart failure-428) and validated CPCSSN case definition algorithms or SNOMED-CT terms. After physician verification of discrepant data, data entry clerks re-entered coded data in the EMRs.

Results: 43% of patients with possible heart failure, 19% with diabetes, 37% with hypertension, 83% with COPD and 71% with dementia as indicated by CPCSSN algorithms or SNOMED-CT (for heart failure) did not have standard agreed upon codes in their Health Profile. Between 83% and 93% of physicians returned verified lists for each condition. 72% of the data were verified by the physicians. 51% of possible conditions were indicated as being positive for the condition queried. 10,708 health conditions already had standard codes and 2,397 new codes were added, for an increase in standardized coding of 22%. Key informants stressed the value of having data and registries to measure and monitor quality for chronic conditions; this was essentially not feasible using EMRs without access to cleaned, extracted data and reporting software.

Conclusions: Registries are foundational to quality improvement efforts targeting specific conditions. We demonstrated the feasibility of increasing data standardization to form disease registries for a large, distributed primary care team. This may be feasible in other primary care settings with access to cleaned data and reporting software such as DPT. Policies encouraging data standardization as well as support for larger scale data warehousing processes and return of data to primary care could allow this to be scaled up.

For more information please contact: Michelle Greiver, mgreiver@rogers.com
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Nov 2014

HealtheSteps Program for the Prevention of Chronic Diseases

Rob Petrella

"HealtheSteps™" (HeS) - a community-focused, evidence-based lifestyle prescription (Rx) program supported by personal healthy lifestyle coaching and innovative electronic health (eHealth) solutions - to promote long-term lifestyle behaviour change. HeS is the knowledge translation output of a 5-year, international CIHR team grant that investigated ways to prevent the cardiovascular complications of diabetes. In collaboration with health technology and industry partners, we continue to invest in developing and evaluating innovative eHealth tools for chronic disease self-management to extend the reach of HeS to all Canadians but particularly those in small urban, rural and remote regions. We have gone on to pilot HeS in First Nations communities, the workplace and in Family Health Care Teams. A curriculum has been developed not only for front-line workers and clinicians, but also the next generation of undergraduate and post-graduate trainees. Previous consultations with our research participants and knowledge user (KU) partners provided a clear message: to reach more Canadians at-risk for CD, we must provide communities with simple, practical tools and sustainable strategies to promote physical activity and healthy eating. To facilitate ongoing end-user engagement, we established a 150-member HeS Network representing academics, clinicians, community groups, governments and industry partners from across Canada. Together with the Dieticians of Canada, we have received $2.8 million in funding from PHAC (HealtheSteps: Exercise and Healthy Eating Prescriptions to Reduce the Risk of Diabetes in Rural and Remote 2013-16) as a signature program in their Canadian Diabetes Strategy, to launch HeS in four provinces and territories and to build two evidence-based Smartphone apps that will provide real-time tracking and virtual coaching for healthy eating and physical activity among Canadians at risk for diabetes.

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Dec 2014

Differences in Quality of Care Between Ontario's Primary Care Models

Tara Kiran 1,2,3 Alexander Kopp 3 Rick Glazier 1,2,3,4,5

1 Dept of Family and Community Medicine, St. Michael's Hospital, University of Toronto
2 Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital
3 Institute of Clinical Evaluative Sciences
4 Dalla Lana School of Public Health, University of Toronto
5 Institute for Health Policy, Management and Evaluation, University of Toronto

Background: Between 2002 and 2007, Ontario introduced new group models for primary care physicians that incorporated formal patient enrolment, blended physician payment, and in some cases, funding for other health disciplines. Only a handful of studies have compared differences in quality of care between models and none have compared changes in care over time.

Methods: We used linked administrative data to compare differences in quality of care between three types of Patient Enrolment Models (PEMs) (team-based capitation, non-team capitation, enhanced fee-for-service) and physicians practicing traditional fee-for-service. We stratified all Ontario residents (N=13,301,209) by the type of primary care model their physician was practicing in as of March 31, 2011. We performed a longitudinal analysis to determine the percent of eligible patients who received screening for cervical, breast, and colorectal cancer and evidence-based testing for diabetes for each year between 1999/2000 and 2010/2011. We used a Poisson regression model to compare quality of care between models in 2010/2011 after adjustment for patient and physician characteristics.

Preliminary Results: In 2010/2011, patients seeing physicians practicing in capitation models were more likely to receive breast cancer screening (RR [95%CI] team-based capitation: 1.07 [1.06-1.08]; non-team capitation: 1.04 [1.04-1.05] and recommended testing for diabetes (RR [95%CI] team-based capitation: 1.11 ([.08 – 1.14]; non-team capitation 1.08 [1.06-1.11]) than patients in enhanced fee-for-service models. However, there were minimal differences between PEMs for breast and colorectal cancer screening. Between 1999/2000 and 2010/2011, patients seeing a team-based capitation physician experienced a greater improvement in recommended testing for diabetes relative to those in other models but there were minimal relative changes in cancer screening rates between models. Patients seeing a physician practicing traditional fee-for-service were much less likely to receive any cancer screening or recommended testing for diabetes compared to patients in PEMs and these gaps in care were present even prior to the introduction of PEMs.

Interpretation: Quality of care was sometimes higher for capitation models compared to enhanced fee-for-service models but these differences were largely present prior to introduction of new primary care models. There were very small differences in care between team-based and non-team capitation models. The biggest gaps in care were for patients seeing physicians practicing traditional fee-for-service. Overall, investments in primary care in Ontario have not been directed at patients experiencing the largest gaps in care.

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2013
Sept 2013

QUANTIFYING HEALTH SERVICES USE FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Andrea S. Gershon, MD1,2,3,4, Jun Guan, MSc2, J. Charles Victor, MSc2,3, Roger Goldstein, MD4,5, Teresa To, PhD2,3,4.
1Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, 2Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, 3>University of Toronto, Toronto, Ontario, Canada,
4The Hospital For Sick Children, Toronto, Ontario, Canada, and 5Westpark Healthcare Centre, Toronto, Ontario, Canada.

Rationale: Chronic obstructive pulmonary disease (COPD), a common manageable condition, is a leading cause of death. A better understanding of its impact on health care systems would inform strategies to reduce its burden.

Objective:
To quantify health services use in a large, North American COPD population.

Methods: We conducted a cohort study using health administrative data from Ontario, a province with a population of 13 million and universal health care insurance. All individuals with physician diagnosed COPD in 2008 were identified and followed for 3 years. Proportions of all hospital visits, emergency department visits, ambulatory care visits, long term care residence places, and homecare by people made or used with COPD were determined and rates of each compared between people with and without COPD.

Measurements and Main Results:
A total of 853,438 individuals with COPD (11.8% of the population age 35 and older) were responsible for 24% of hospitalizations, 24% of emergency department visits, 21% of ambulatory care visits and filled 35% of long term care places and used 30% of homecare services. After adjusting for several factors, people with COPD had rates of hospital, emergency department and ambulatory care visits that were, respectively, 63%, 85%, and 48% higher rates than the rest of the population. Their rates of long term care and homecare use were 56% and 59% higher.

Conclusions : Individuals with COPD use large and disproportionate amounts of health services. Strategies that target this group are needed to improve their health and minimize their need for health services.

For more information please contact: Dr. Andrea Gershon E-mail: andrea.gershon@ices.on.ca
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Oct 2013

EMIGRATION PATTERN OF CANADIAN PHYSICIANS TO THE UNITED STATES: DRAMATIC CHANGE
T. R. Freeman*, S. Petterson**, A. Bazemore**, S. Finnegan**

*  Centre for Studies in Family Medicine, Department of Family Medicine, Western University, London, Ontario.
** The Robert Graham Center for Policy Research in Family Medicine and Primary Care, Washington, D.C.

Background: Graduates of Canadian medical schools immigrating to the United States for purposes such as post-graduate training or permanent residence have been a fixture in medical human resource planning for decades. Research published in 2007 found that the equivalent of the graduating classes of two average sized medical schools in Canada were leaving for the United States each year. Changes in the medical landscape of both countries prompted this review which is relevant to health human resource planning.

Methods: We conducted a cross-sectional analysis of the 2012 American Medical Association (AMA) Masterfile to identify and locate any graduates of Canadian schools of medicine that were working in the United States in direct patient care. The AMA Masterfile captures data on all physicians working in the United States, including demographics, origins, working addresses and location of training. We conducted frequency analysis by birth country, rural/urban practice location and school. We reviewed annual reports of the Canadian Resident Matching Service (CaRMS); the Canadian Post-MD Education Programs (CAPER); and the Canadian Collaborative Centre for Physician Resources (C3PR).

Results: Beginning in the early 1990s the number of Canadian medical school graduates locating in the U.S. reached an all-time high and then abruptly dropped off in 1995. Just over 50% of Canadian graduates in the U.S. came from one of four medical schools (McGill, University of Toronto, University of Alberta and University of Manitoba. Canadian medical graduates are going to the U.S. for post-graduate training in smaller numbers and, those who do train there, are less likely to remain there than at any time since the 1970's.

Interpretation: Canadian medical graduates decision to emigrate to the U.S. may be influenced by both 'push' and 'pull' factors. The relative strength of these factors changed and by 2004, more Canadian medical graduates were returning from abroad than were leaving and the current outflow is negligible. Both countries face current and projected shortages of physicians of all types, particularly in primary care, and the relative strengths of these factors will be critical to medical resource planning.

For more information please contact: Dr. Tom Freeman tfreeman@uwo.ca
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Nov 2013

NURSING CONTRIBUTIONS TO CHRONIC DISEASE MANAGEMENT IN PRIMARY CARE WITHIN ONTARIO, CANADA

Authors: Lukewich, J. RN, PhD(Student), Edge, D. S. RN, PhD, VanDenKerkhof, E. RN, DrPH, Tranmer, J. RN, PhD
Affiliation: School of Nursing, Queen's University, Kingston, Ontario

Statement of Purpose: Chronic diseases are most effectively managed within primary care. Nurses are well positioned within primary care to enhance the planning and delivery of healthcare resources. Although nurses of each regulatory designation working within primary care play important roles in the management of patients with chronic diseases, their specific roles and activities are not well understood. Therefore, the purpose of this study was to determine the roles and activities performed by nurses and the extent to which chronic disease management strategies have been implemented within primary care settings in Ontario, Canada.

Methods: A cross-sectional survey design was used. A questionnaire was administered to a random sample of primary care nurses, including registered practical nurses, registered nurses, and nurse practitioners, within Ontario, Canada, between May and July, 2011.

Results: Nurses engaged in a wide range of clinical activities related to chronic disease management. The percentage of nurse practitioners performing a given task was consistently higher than that of registered nurses and registered practical nurses and there was considerable overlap between the activities that registered nurses and registered practical nurses undertook. The implementation of chronic disease management strategies is not uniform across primary care practices in which the nurses worked.

Conclusions: As team-based primary care structures are becoming more prominent, it is important to clearly understand the nursing contribution to chronic disease management to optimize their role within interprofessional teams. It is also important to further explore the implementation of chronic disease management strategies within primary care across Canada.

For more information please contact: Julia Lukewich j.lukewich@gmail.com
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