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1.  Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 
Canadian Family Physician  2014;60(5):433-438.
Abstract
Objective
To revise diagnostic strategies for Alzheimer disease (AD), update recommendations on symptomatic treatment of dementia, and provide an approach to rapidly progressive and early-onset dementias.
Composition of the committee
Experts and delegates representing relevant disciplines from diverse regions across Canada discussed and agreed upon revisions to the 2006 guidelines.
Methods
The GRADE (grading of recommendations, assessment, development, and evaluation) system was used to evaluate consensus on recommendations, which was defined as when 80% or more of participants voted for the recommendation. Evidence grades are reported where possible.
Report
Important for FPs, despite advances in liquid biomarkers and neuroimaging, the diagnosis of dementia in Canada remains fundamentally clinical. New core clinical criteria for the diagnosis of AD now recognize less common, nonamnestic forms. Early-onset dementia, a rare but important condition, should prompt referral to specialists with access to genetic counselors. Rapidly progressive dementia, poorly defined in the literature, is described to facilitate detection of this rare but important condition. There are new expanded indications for cholinesterase inhibitors beyond AD, as well as guidelines for their discontinuation, which had not been previously described. New evidence regarding use of memantine, antidepressants, and other psychotropic medications in dementia care is presented.
Conclusion
Several recommendations from the Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia are relevant to FPs. For guidelines to remain useful, family physicians should participate in all stages of the ongoing development process, including topic selection.
PMCID: PMC4020644  PMID: 24829003
2.  Quatrième conférence consensuelle sur le diagnostic et le traitement de la démence 
Canadian Family Physician  2014;60(5):e244-e250.
Résumé
Objectif
Revoir les stratégies diagnostiques de la maladie d’Alzheimer, actualiser les recommandations concernant le traitement des symptômes de démence et proposer une approche thérapeutique à la démence d’apparition précoce et d’évolution rapide.
Composition du comité
Des spécialistes et des délégués de diverses régions du Canada et représentant diverses disciplines pertinentes ont discuté et se sont mis d’accord sur les révisions à apporter aux lignes directrices de 2006.
Méthodologie
On a eu recours au système GRADE (grading of recommendations, assessment, development, and evaluation) pour évaluer le consensus concernant les recommandations, lequel était défini comme suit : lorsque 80 % ou plus des participants ont voté en faveur de la recommandation. La cote des données probantes est rapportée lorsque cela est possible.
Rapport
important pour les médecins de famille, malgré les progrès effectués dans les domaines des biomarqueurs liquidiens et de la neuro-imagerie, le diagnostic de démence au Canada demeure fondamentalement clinique. De nouveaux critères cliniques essentiels de diagnostic de la maladie d’Alzheimer en reconnaissent dorénavant les formes moins fréquentes et non amnestiques. La démence précoce, une affection rare, mais importante, devrait inciter les médecins à aiguiller les patients vers un spécialiste ayant accès à des conseillers en génétique. La démence d’évolution rapide, mal définie dans la littérature, faciliterait le dépistage de cette affection rare, mais importante. Les inhibiteurs de la cholinestérase sont maintenant indiqués pour le traitement d’affections autres que la maladie d’Alzheimer. Des lignes directrices concernant l’arrêt du traitement, lesquelles n’existaient pas auparavant, sont également apparues. De nouvelles données probantes sur le recours à la mémantine, aux antidépresseurs et à d’autres agents psychotropes dans le traitement de la démence sont aussi présentées.
Conclusion
Plusieurs recommandations de la Quatrième conférence consensuelle sur le diagnostic et le traitement de la démence intéresseront les médecins de famille. Pour assurer l’utilité des lignes directrices, les médecins de famille devraient participer à toutes les étapes du processus de formulation continu, y compris à la sélection des sujets.
PMCID: PMC4020660
3.  Multidisciplinary teams of case managers in the implementation of an innovative integrated services delivery for the elderly in France 
Background
The case management process is now well defined, and teams of case managers have been implemented in integrated services delivery. However, little is known about the role played by the team of case managers and the value in having multidisciplinary case management teams. The objectives were to develop a fuller understanding of the role played by the case manager team and identify the value of inter-professional collaboration in multidisciplinary teams during the implementation of an innovative integrated service in France.
Methods
We conducted a qualitative study with focus groups comprising 14 multidisciplinary teams for a total of 59 case managers, six months after their recruitment to the MAIA program (Maison Autonomie Integration Alzheimer).
Results
Most of the case managers saw themselves as being part of a team of case managers (91.5%). Case management teams help case managers develop a comprehensive understanding of the integration concept, meet the complex needs of elderly people and change their professional practices. Multidisciplinary case management teams add value by helping case managers move from theory to practice, by encouraging them develop a comprehensive clinical vision, and by initiating the interdisciplinary approach.
Conclusions
The multidisciplinary team of case managers is central to the implementation of case management and helps case managers develop their new role and a core inter-professional competency.
doi:10.1186/1472-6963-14-159
PMCID: PMC4021253  PMID: 24708721
Case management team; Multidisciplinary; Case managers; Integration
4.  Are non-attenders a concern for primary care practice? 
The article by Eshel et al. describes major differences, in terms of demography and health status, between elderly patients who did and those who did not visit primary care physicians for general health check-ups. The authors conclude that non-attenders are not at risk for developing health conditions.
While this study by Eshel et al. provides a better understanding of the primary care population, the conclusion (no need for reaching out to the non-attenders) should be viewed with caution. In this study, non-attenders ‘have a higher probability of being women, older, not married and from a lower socio-economic’ segment of the population, a population that is known to be at higher risk for chronic disease. In addition, outreach programs in primary care would be key in providing essential preventive measures for this vulnerable population (e.g., osteoporosis prevention, vaccination, lifestyle, etc.).
This is a commentary on http://www.ijhpr.org/content/2/1/7.
doi:10.1186/2045-4015-2-13
PMCID: PMC3635887  PMID: 23537209
5.  Diffusion of a collaborative care model in primary care: a longitudinal qualitative study 
BMC Family Practice  2013;14:3.
Background
Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process.
Methods
We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics.
Results
Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs.
Conclusion
CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.
doi:10.1186/1471-2296-14-3
PMCID: PMC3558442  PMID: 23289966
Primary care; Primary care physician; Nurses; Chronic disease; Collaboration; Health service research; Diffusion of innovation
6.  Ten years of integrated care: backwards and forwards. The case of the province of Québec, Canada 
International Journal of Integrated Care  2011;11(Special 10th Anniversary Edition):e004.
Introduction
Québec’s rapidly growing elderly and chronically ill population represents a major challenge to its healthcare delivery system, attributable in part to the system’s focus on acute care and fragmented delivery.
Description of policy practice
Over the past few years, reforms have been implemented at the provincial policy level to integrate hospital-based, nursing home, homecare and social services in 95 catchment areas. Recent organizational changes in primary care have also resulted in the implementation of family medicine groups and network clinics. Several localized initiatives were also developed to improve integration of care for older persons or persons with chronic diseases.
Conclusion and discussion
Québec has a history of integration of health and social services at the structural level. Recent evaluations of the current reform show that the care provided by various institutions in the healthcare system is becoming better integrated. The Québec health care system nevertheless continues to face three important challenges in its management of chronic diseases: implementing the reorganization of primary care, successfully integrating primary and secondary care at the clinical level, and developing effective governance and change management.
Efforts should focus on strengthening primary care by implementing nurse practitioners, developing a shared information system, and achieving better collaboration between primary and secondary care.
PMCID: PMC3111887  PMID: 21677842
integrated care; health care system; chronic disease; health policy; Quebec/Canada
7.  Diagnostic, design and implementation of an integrated model of care in France: a bottom-up process with a continuous leadership 
Purpose
To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.
Context
Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs).
Case description
In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.
Conclusions
The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.
PMCID: PMC3031805
integrated care models; leadership
8.  Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership 
Background
Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs).
Purpose
To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.
Results
In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.
Conclusion
The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.
PMCID: PMC2834925  PMID: 20216954
bottom-up process; leadership; change practices; services arrangements
9.  Healthcare professionals and managers' participation in developing an intervention: A pre-intervention study in the elderly care context 
Background
In order to increase the chances of success in new interventions in healthcare, it is generally recommended to tailor the intervention to the target setting and the target professionals. Nonetheless, pre-intervention studies are rarely conducted or are very limited in scope. Moreover, little is known about how to integrate the results of a pre-intervention study into an intervention. As part of a project to develop an intervention aimed at improving care for the elderly in France, a pre-intervention study was conducted to systematically gather data on the current practices, issues, and expectations of healthcare professionals and managers in order to determine the defining features of a successful intervention.
Methods
A qualitative study was carried out from 2004 to 2006 using a grounded theory approach and involving a purposeful sample of 56 healthcare professionals and managers in Paris, France. Four sources of evidence were used: interviews, focus groups, observation, and documentation.
Results
The stepwise approach comprised three phases, and each provided specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and expectations of healthcare professionals and managers. The second step involved holding focus groups in order to define the characteristics of a tailor-made intervention. The third step allowed validation of the findings. Using this approach, we were able to design and develop an intervention in elderly care that met the professionals' and managers' expectations.
Conclusion
This article reports on an in-depth pre-intervention study that led to the design and development of an intervention in partnership with local healthcare professionals and managers. The stepwise approach represents an innovative strategy for developing tailored interventions, particularly in complex domains such as chronic care. It highlights the usefulness of seeking out the insight of healthcare professionalnd managers and emphasizes the need to intervene at different levels. Further research will be needed in order to develop a more thorough understanding of the impacts of such strategies on the final outcomes of intervention implementations.
doi:10.1186/1748-5908-4-21
PMCID: PMC2678079  PMID: 19383132
10.  Fostering participation of general practitioners in integrated health services networks: incentives, barriers, and guidelines 
Background
While the active participation of general practitioners (GPs) in integrated health services networks (IHSNs) plays a critical role in their success, little is known about the incentives and barriers to their actual participation.
Methods
Data were gathered through semi-structured interviews and a mail survey with GPs enrolled in SIPA (system of integrated care for older persons) at 2 sites in Montreal. A total of 61 GPs completed the questionnaire, from which 22 were randomly selected for the qualitative study, with active and non-active participation in the IHSN.
Results
The key themes associated with GP participation were clinician characteristics, consequences perceived at the outset, the SIPA implementation process, relationships with the SIPA team and professional consequences. The incentive factors reported were collaborative practices, high rates of elderly and SIPA patients in their clienteles, concerns about SIPA, the selection of frail elderly patients, close relationships with the case manager, the perceived efficacy of SIPA, and improved professional practices. Barriers to GP participation included high expectations, GP recruitment, lack of information on SIPA, difficult relationships with SIPA geriatricians and deterioration of physician-patient relationships. Four profiles of participation were identified: 2 groups of participants active in SIPA and 2 groups of participants not active in SIPA. The active GPs were familiar with collaborative practices, had higher IHSN patient rates, expressed more concerns than expectations, reported satisfactory relationships with case managers and perceived the efficacy of SIPA. Both active and non-active GPs reported quality care in the IHSN and improved professional practice.
Conclusion
Throughout the implementation process, the participation of GPs in an IHSN depends on numerous professional (clinician characteristics) and organizational factors (GP recruitment, relationships with case managers). Our study provides guiding principles for establishing future integrated models of care. It suggests practical guidelines to support the active participation of GPs in these networks such as physicians with collaborative practices, recruitment of significant number of patients per physicians, the information provided and the accompaniment by geriatricians.
doi:10.1186/1472-6963-9-48
PMCID: PMC2664801  PMID: 19292905

Results 1-10 (10)