Of the 750 physicians (678 family physicians and 72 community paediatricians) in the Ottawa region who were invited to participate, 147 physicians enrolled in the study over a 14 month period (see Table ). Eighty four outreach visits were provided to these physicians by the OT for purely educational purposes: these included small group educational sessions and one-on-one discussions with physicians. In the majority of cases, these sessions occurred before the participating physicians referred children to the project. The median length of a 'face-to-face' visit with a physician was 45 minutes (range = 1 to 120 minutes).
Sixty-four of the 147 physicians (44 family physicians and 20 community pediatricians) referred at least one child to the OT for assessment and collaborative care. Initially, physicians were limited to 3 referrals; however, as the study progressed, a few physicians asked if they could refer additional children and this was permitted. The number of children referred for collaborative care by each physician ranged from 1–5, mode = 1. A total of 125 children were referred and, of these children, 116 (92.8%) met the study inclusion criteria and were assessed by the OT. Children who were not seen were excluded due to age cut-off, previous diagnosis of other conditions (e.g., autism), and/or evidence of neurological conditions (e.g., seizure disorder). The age of children who received collaborative care ranged from 48 – 153 months (X = 96.3 months) and 87 (75%) were male.
Following assessment by the OT, 16 children (13.8%) were determined not to have motor delays substantial enough to warrant a diagnosis of DCD, according to study criteria. Cut-offs were based upon DSM IV diagnostic criteria [1
], and are outlined in more detail elsewhere [25
]. Another 12 children (10.3%) were determined to have motor impairment that was better explained by other conditions (orthopedic (1), trauma (3), and generalized delay (8)). The remaining 88 (76%) met research criteria for DCD; all but one were subsequently given a clinical diagnosis of DCD by their physician. In the one exception, the physician felt that environmental factors such as limited exposure to motor activities and family situation may have been the primary cause of the child's motor difficulties. The family did not return for consultation with the family physician, so further exploration of developmental versus environmental issues was not possible.
Pre-project knowledge and skill surveys were sent out to all 750 primary care physicians in the region. With a return rate of 25% (191 physicians), 91.1% of physicians reported that they were unaware of the condition of DCD and only 1.6% reported that they felt able to diagnose children with the condition. Post-project, the same survey was sent to all 750 physicians in the region, including physicians who had participated in the project and those who did not join the study. Two hundred and seventy-six questionnaires were returned for an overall regional return rate of 37%. The return rate for participating physicians was 61% (89/147) and 31% (187/603) for non-participating physicians. Table depicts the results from the post-project questionnaire, asking physicians to describe their knowledge about DCD and their skill in making the DCD diagnosis. Results indicate that 91% of physicians who received educational outreach and responded to the questionnaire reported that they have knowledge about DCD in comparison with non-participating physicians in the same community among whom only 17.6% reported familiarity with the condition. In response to the perceived skill question, 41.6% of participating physicians reported an ability to diagnose children who had DCD, while only 3.2% of non-participating physicians believed that they could make this diagnosis.
Knowledge and skills as reported by physician participants and physicians in the region, after project completion
Results of the post-project questionnaire asking physicians to rate the usefulness of the diagnostic tools and collaborative care process are presented in Table . Questionnaire responses are reported from the 33 physicians who received educational outreach and participated in collaborative care with the OT and the 54 physicians who received educational outreach, but did not refer a child.
Usefulness of project activities, as reported by physician participants*
Responses to questions asking physicians about their plans for continued use of the project materials were received from 32 physicians who received educational outreach and collaborative care, and from 52 physicians who received educational outreach only. All (100%) of physicians answering this question (n = 32) who received both services indicated that they would continue to use project materials and resources, and 59.4% (n = 19) reported that they would recommend/share the materials with a medical colleague. Most (90.4%) (n = 47) of the 52 responding physicians who received educational outreach only indicated that they would continue to use the project materials and 28.8% (n = 15) reported that they would recommend the materials to their colleagues.
Focus group results
Twenty four physicians (9 Family Physicians and 15 Pediatricians) who had completed both educational outreach and collaborative care at the time of the focus group were invited to attend. Four physicians attended the family medicine focus group and 13 physicians attended the paediatrician focus group. Physicians reported 'lack of availability' as their reason for not participating in the focus groups. Analysis of the transcripts indicated that both family physicians and pediatricians noted that they now had an increased awareness of the possible presence of DCD and had introduced regular screening techniques into their practices. These techniques ranged from routinely asking parents if they felt their children were "clumsy", observing the child taking off a shirt, or asking parents to complete a short questionnaire. As one pediatrician remarked, "It seems that all these kids are in my practice, I just didn't identify them before".
Both groups of physicians reported appreciating the opportunity to have a more in-depth evaluation by the OT of children whom they had screened as having possible DCD. Many in the pediatrician group found this evaluation critical for children whose difficulties appeared marginal on screening. "The ones you [identify on screening] are the obvious ones, but the ones that are in between, do they need it, do they not need it, where do you make the cut off point? You really need someone who can actually do that fine-tuning...We don't have time to do that."
Both groups of physicians found the educational outreach valuable. Family physicians were enthusiastic about the tools for screening and the educational materials for families. For example, one family physician noted, "I'm doing counseling, I'm telling the mom various different sports that might be better for them, where they succeed, where they may also develop some other skills...instead of setting them up for another failure. I think that's very important, and I've been doing that in the context of a physical." Another family physician identified a role for herself in the context of public education and remarked that she was now sharing the information about DCD with adult patients and friends who are teachers.