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2.  Care for Patients with Type 2 Diabetes in a Random Sample of Community Family Practices in Ontario, Canada 
Objective. Diabetes care is an important part of family practice. Previous work indicates that diabetes management is variable. This study aimed to examine diabetes care according to best practices in one part of Ontario. Design and Participants. A retrospective chart audit of 96 charts from 18 physicians was conducted to examine charts regarding diabetes care during a one-year period. Setting. Grimsby, Ontario. Main Outcome Measures. Glycemic screening, control and management strategies, documentation and counselling for lifestyle habits, prevalence of comorbidities, screening for hypertension, hyperlipidemia, and use of appropriate recommended preventive medications in the charts were examined. Results. Mean A1c was within target (less than or equal to 7.00) in 76% of patients (ICC = −0.02), at least 4 readings per annum were taken in 75% of patients (ICC = 0.006). Nearly 2/3 of patients had been counselled about diet, more than 1/2 on exercise, and nearly all (90%) were on medication. Nearly all patients had a documented blood pressure reading and lipid profile. Over half (60%) had a record of their weight and/or BMI. Conclusion. Although room for improvement exists, diabetes targets were mainly reached according to recognized best practices, in keeping with international data on attainment of diabetes targets.
PMCID: PMC3407621  PMID: 22852083
3.  Chronically ill Canadians’ experiences of being unattached to a family doctor: a qualitative study of marginalized patients in British Columbia 
BMC Family Practice  2012;13:69.
Unattached patients do not have a regular primary care provider. Initiatives are being developed to increase attachment rates across Canada. Most existing attention paid to patient unattachment has focused on quantifying the problem and health system costs. Our purpose is to qualitatively identify the implications of chronically ill patients’ experiences of unattachment for health policy and planning to provide policy-relevant insights for Canadian attachment initiatives.
Three focus groups were conducted with marginalized chronically ill individuals residing in a mid-sized city in British Columbia who are unattached to a family doctor. We use the term marginalized as a descriptor to acknowledge that by virtue of their low socio-economic status and lack of attachment the participants are marginalized in Canada’s health care system Focus groups were structured as an open conversation organized around a series of probing questions. They were digitally recorded and transcribed verbatim. Thematic analysis was employed.
Twenty-six individuals participated in the focus groups. The most common chronic illnesses reported were active drug addiction or recovery (and their associated symptoms), depression, arthritis, and hepatitis C. Participants identified life transitions as being the root cause for not having a family doctor. There was a strong sense that unsuccessful attempts to get a family doctor reflected that they were undesirable patients. Participants wanted to experience having a trusting relationship with a regular family doctor as they believed it would encourage greater honesty and transparency. One of the main health concerns regarding lack of access to a regular family doctor is that participants lacked access to preventative care. Participants were also concerned about having a discontinuous medical record due to unattachment.
Participants perceived that there are many benefits to be had by having attachment to a regular family doctor and that experiencing unattachment challenged their health and access to health care. We encourage more research to be done on the lived experience of unattachment in order to provide on-the-ground insights that policy-makers require in order to develop responsive, patient-centred supports and programs.
PMCID: PMC3412741  PMID: 22799280
4.  Self-reported teamwork in family health team practices in Ontario 
Canadian Family Physician  2011;57(5):e185-e191.
To determine the organizational predictors of higher scores on team climate measures as an indicator of the functioning of a family health team (FHT).
Cross-sectional study using a mailed survey.
Family health teams in Ontario.
Twenty-one of 144 consecutively approached FHTs; 628 team members were surveyed.
Main outcome measures
Scores on the team climate inventory, which assessed organizational culture type (group, developmental, rational, or hierarchical); leadership perceptions; and organizational factors, such as use of electronic medical records (EMRs), team composition, governance of the FHT, location, meetings, and time since FHT initiation. All analyses were adjusted for clustering of respondents within the FHT using a mixed random-intercepts model.
The response rate was 65.8% (413 of 628); 2 were excluded from analysis, for a total of 411 participants. At the time of survey completion, there was a median of 4 physicians, 11 other health professionals, and 4 management and clerical staff per FHT. The average team climate score was 3.8 out of a possible 5. In multivariable regression analysis, leadership score, group and developmental culture types, and use of more EMR capabilities were associated with higher team climate scores. Other organizational factors, such as number of sites and size of group, were not associated with the team climate score.
Culture, leadership, and EMR functionality, rather than organizational composition of the teams (eg, number of professionals on staff, practice size), were the most important factors in predicting climate in primary care teams.
PMCID: PMC3093607  PMID: 21571706
5.  Quality indicators for the prevention of cardiovascular disease in primary care 
Canadian Family Physician  2010;56(7):e255-e262.
To determine the feasibility and usefulness of collecting 9 previously described quality indicators of cardiovascular disease (CVD) prevention in primary care.
Retrospective chart audit.
Family health team in Hamilton, Ont, comprising approximately 30 000 patients and 25 physicians over 2 sites.
A random sample of community-dwelling men who were 40 to 80 years of age and women who were 50 to 80 years of age on January 1, 2003, and who had complete physical examinations in 2003.
The frequency with which quality indicators were collected during the complete physical examination, whether the collection of these indicators predicted subsequent collection of the same indicators, and physician or patient behavioural changes to reduce the risk of CVD.
Of the 237 patient charts reviewed, 142 were of men and 95 were of women. Collection of most of the quality indicators was high (> 50%). Results were adjusted for age, sex, and family health team site. Measurements to check for obesity were collected more frequently in women, while blood pressure measurements and follow-up when required were completed more frequently in men. The relationship between the collection of an indicator and the subsequent times the same indicator was collected was not significant for any of the variables except excess alcohol consumption, in that collection of the excess alcohol consumption indicator led to a significant increase in subsequent collection of that same indicator (P = .0091). Age significantly predicted the number of times cholesterol and blood pressure were repeatedly checked (P = .0074 and P = .0077, respectively). The collection of these indicators was significantly associated with behavioural changes related to CVD prevention on the part of the patient or physician, with collection of the alcohol consumption indicator being the most likely to encourage subsequent behavioural changes. The only indicator to not reach statistical significance for subsequent changes was the cholesterol indicator (P = .08).
The collection of previously described quality indicators for the primary prevention of CVD in Canada is feasible. Collection of the indicators does not generally predict short-term outcomes; however, collection of most indicators increased the odds of patient or physician behavioural changes for the primary prevention of CVD.
PMCID: PMC2922828  PMID: 20631261
6.  The nature of informational continuity of care in general practice 
The availability of patient information to practitioners forms the basis of informational continuity of care. Changes in family practice that now encourage multiphysician clinics have meant that informational continuity of care has become crucial because it is likely that a patient will not continuously see the same doctor. Therefore a review of the nature of informational continuity is useful.
To answer the question ‘How is informational continuity developed in general practice?’.
Design of study
A rigorous systematic review of relevant electronic databases.
Databases were searched for articles answering the research question. Articles focused on family medicine and informational continuity of care were included. Data from reviewed articles were independently extracted and reviewed by two researchers. Conceptual and evidence-based articles were included.
Initially, 193 articles were obtained from all five bibliographic databases; 57 were retained following title and abstract review. Of these, 34 articles were included in the final systematic review. Results show that informational continuity of care is developed using paper/electronic records and remembered information collectively, through a series of doctor–patient consultations over time. Obstacles to its development are practitioners not recording patient information and patients not disclosing important details.
These findings have implications for newer styles of primary care that may have a negative impact in the successful management of chronic illnesses in particular.
PMCID: PMC2576310  PMID: 19000395
continuity of care; information management; medical records; primary health care
7.  GPs' approach to insulin prescribing in older patients: a qualitative study 
Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people.
To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes.
Design of study
Qualitative individual interviews using a grounded theory approach.
Primary care.
A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin.
Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing.
GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.
PMCID: PMC2566521  PMID: 18682013
insulin; primary health care; qualitative research; type 2 diabetes mellitus
8.  Consent for use of personal information for health research: Do people with potentially stigmatizing health conditions and the general public differ in their opinions? 
BMC Medical Ethics  2009;10:10.
Stigma refers to a distinguishing personal trait that is perceived as or actually is physically, socially, or psychologically disadvantageous. Little is known about the opinion of those who have more or less stigmatizing health conditions regarding the need for consent for use of their personal information for health research.
We surveyed the opinions of people 18 years and older with seven health conditions. Participants were drawn from: physicians' offices and clinics in southern Ontario; and from a cross-Canada marketing panel of individuals with the target health conditions. For each of five research scenarios presented, respondents chose one of five consent choices: (1) no need for me to know; (2) notice with opt-out; (3) broad opt-in; (4) project-specific permission; and (5) this information should not be used. Consent choices were regressed onto: demographics; health condition; and attitude measures of privacy, disclosure concern, and the benefits of health research. We conducted focus groups to discuss possible reasons for observed consent choices.
We observed substantial variation in the control that people wish to have over use of their personal information for research. However, consent choice profiles were similar across health conditions, possibly due to sampling bias. Research involving profit or requiring linkage of health information with income, education, or occupation were associated with more restrictive consent choices. People were more willing to link their health information with biological samples than with information about their income, occupation, or education.
The heterogeneity in consent choices suggests individuals should be offered some choice in use of their information for different types of health research, even if limited to selectively opting-out. Some of the implementation challenges could be designed into the interoperable electronic health record. However, many questions remain, including how best to capture the opinions of those who are more privacy sensitive.
PMCID: PMC2724473  PMID: 19630941
9.  What are the roles involved in establishing and maintaining informational continuity of care within family practice? A systematic review 
BMC Family Practice  2008;9:65.
Central to establishing continuity of care is the development of a relationship between doctor and patient/caregiver. Transfer of information between these parties facilitates the development of continuity in general; and specifically informational continuity of care. We conducted a systematic review of published literature to gain a better understanding of the roles that different parties – specifically doctors, patients, family caregivers, and technology – play in establishing and maintaining informational continuity of care within family practice.
Relevant published articles were sought from five databases. Accepted articles were reviewed and appraised in a consistent way. Fifty-six articles were retained following title and abstract reviews. Of these, 28 were accepted for this review.
No articles focused explicitly on the roles involved in establishing or maintaining informational continuity of care within family practice. Most informational continuity of care literature focused on the transfer of information between settings and not at the first point of contact. Numerous roles were, however, were interpreted using the data extracted from reviewed articles. Doctors are responsible for record keeping, knowing patients' histories, recalling accumulated knowledge, and maintaining confidentiality. Patients are responsible for disclosing personal and health details, transferring information to other practitioners (including new family doctors), and establishing trust. Both are responsible for developing a relationship of trust. Technology is an important tool of informational continuity of care through holding important information, providing search functions, and providing a space for recorded information. There is a significant gap in our knowledge about the roles that family caregivers play.
The number of roles identified and the interrelationships between them indicates that establishing and maintaining informational continuity of care within family practice is a complex and multifaceted process. This synthesis of roles provided serves as an important resource for continuity of care researchers in general, for the development of continuity of care quality indicators, and for the practice of family medicine.
PMCID: PMC2626592  PMID: 19068124
10.  You’ve got mail 
Canadian Family Physician  2007;53(3):401.
PMCID: PMC1949063  PMID: 17872668
11.  Obesity registers 
PMCID: PMC1764554  PMID: 17200394
12.  GPs on the move 
PMCID: PMC1463192  PMID: 15720940
13.  How to diagnose diabetes 
PMCID: PMC550615  PMID: 15738472

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