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1.  Perspectives of People Living with HIV on Access to Health Care: Protocol for a Scoping Review 
JMIR Research Protocols  2016;5(2):e71.
Strategies to improve access to health care for people living with human immunodeficiency virus (PLHIV) have demonstrated limited success. Whereas previous approaches have been informed by the views of health providers and decision-makers, it is believed that incorporating patient perspectives into the design and evaluations of health care programs will lead to improved access to health care services.
We aim to map the literature on the perspectives of PLHIV concerning access to health care services, to identify gaps in evidence, and to produce an evidence-informed research action plan to guide the Living with HIV program of research.
This scoping review includes peer-reviewed and grey literature from 1946 to May 2014 using double data extraction. Variations of the search terms “HIV”, “patient satisfaction”, and “health services accessibility” are used to identify relevant literature. The search strategy is being developed in consultation with content experts, review methodologists, and a librarian, and validated using gold standard studies identified by those stakeholders. The inclusion criteria are (1) the study includes the perspectives of PLHIV, (2) study design includes qualitative, quantitative, or mixed methods, and (3) outcome measures are limited to patient satisfaction, their implied needs, beliefs, and desires in relation to access to health care. The papers are extracted by two independent reviewers, including quality assessment. Data is then collated, summarized, and thematically analyzed.
A total of 12,857 references were retrieved, of which 326 documents were identified as eligible in pre-screening, and 64 articles met the inclusion criteria (56% qualitative studies, 38% quantitative studies and 6% mixed-method studies). Only four studies were conducted in Canada. Data synthesis is in progress and full results are expected in June, 2016.
This scoping review will record and characterize the extensive body of literature on perspectives of PLHIV regarding access to health care. A literature repository will be developed to assist stakeholders, decision-makers, and PLHIV in developing and implementing patient-oriented health care programs.
PMCID: PMC4889870  PMID: 27193076
HIV; HIV Infections; Attitude to Health; Patient Satisfaction; Perspective; Health Services Accessibility; Health Services/Utilization; Access to Health Care
2.  Measures of Quality of Care for People with HIV: A Scoping Review of Performance Indicators for Primary Care 
PLoS ONE  2015;10(9):e0136757.
The healthcare of people with HIV is transitioning from specialty care to the primary healthcare (PHC) system. However, many of the performance indicators used to measure the quality of HIV care pre-date this transition. The goal of this work was to examine how existing HIV care performance indicators measure the comprehensive and longitudinal care offered in a PHC setting. A scoping review consisting of peer-reviewed and grey literature searches was performed. Two reviewers evaluated study eligibility and indicators in documents meeting inclusion criteria were extracted into a database. Indicators were matched to a PHC performance measurement framework to determine their applicability for evaluating quality of care in the PHC setting. The literature search identified 221 publications, of which 47 met inclusion criteria. 1184 indicators were extracted and removal of duplicates left 558 unique indicators. A majority of the 558 indicators fell under the ‘secondary prevention’ (12%) and ‘care of chronic conditions’ (33%) domains when indicators were matched to the PHC performance framework. Despite the imbalance, nearly all performance domains in the PHC framework were populated by at least one indicator with significant concentrations in domains such as patient-provider relationship, patient satisfaction, population and community characteristics, and access to care. Existing performance frameworks for the care of people with HIV provide a comprehensive set of indicators that align well with a PHC performance framework. Nonetheless, some important elements of care, such as patient-reported outcomes, are poorly covered by existing indicators. Advancing our understanding of how the experience of care for people with HIV is impacted by changes in health services delivery, specifically more care within the PHC system, will require performance indicators to capture this aspect of HIV care.
PMCID: PMC4586139  PMID: 26414994
3.  Impact of a chronic disease self-management program on healthcare utilization in eastern Ontario, Canada 
Preventive Medicine Reports  2015;2:586-590.
This study aims to examine patients' patterns of health care utilization before and after participation in a Chronic Disease Self-Management Program (CDSMP). We conducted a pre-post study using health care administrative data from 186 individuals in the Ottawa region who participated in our CDSMP between September 2009 and January 2011. We collected the number of general practitioner/specialist visits, planned/unplanned emergency department visits, and hospitalizations, measured 6 months and 1 year before and after participation in the CDSMP. Multivariate analysis was performed to identify associations between patient characteristics and pre-post CDSMP health care utilization. CDSMP participation showed no effect on number of physician visits, hospitalizations, or emergency department visits. Individuals with > 5 chronic conditions were more likely to visit a physician and the emergency department following the CDSMP than those with 1 chronic condition. Among individuals > 61 years of age, those with the marital status widowed were more likely to visit their physician and the emergency department following the CDSMP than married individuals. To conclude, the CDSMP appeared not to decrease health care utilization. Low baseline utilization rates, short-term follow-ups, and a relatively healthy patient population may have contributed to the program's low impact.
•We examine patients' health care use before and after a self-management program.•Patients complete six workshops teaching chronic disease self-management skills.•The program does not appear to decrease health care utilization.•Several factors (e.g. low baseline usage, high patient health) may reduce impact.
PMCID: PMC4721386  PMID: 26844122
Chronic disease; Self-management; Utilization; Emergency department visits; Physician visits
4.  Improving awareness, accountability, and access through health coaching 
Canadian Family Physician  2015;61(3):e158-e164.
To assess patients’ experiences with and perceptions of health coaching as part of their ongoing care.
A qualitative research design using semistructured interviews that were recorded and transcribed verbatim.
Ottawa, Ont.
Eleven patients (> 18 years of age) enrolled in a health coaching pilot program who were at risk of or diagnosed with type 2 diabetes.
Patients’ perspectives were assessed with semistructured interviews. Interviews were conducted with 11 patients at the end of the pilot program, using a stratified sampling approach to ensure maximum variation.
Main findings
All patients found the overall experience with the health coaching program to be positive. Patients believed the health coaching program was effective in increasing awareness of how diabetes affected their bodies and health, in building accountability for their health-related actions, and in improving access to care and other health resources.
Patients perceive one-on-one health coaching as an acceptable intervention in their ongoing care. Patients enrolled in the health coaching pilot program believed that there was an improvement in access to care, health literacy, and accountability, all factors considered to be precursors to behavioural change.
PMCID: PMC4369629  PMID: 25932483
6.  Health coaching in primary care: a feasibility model for diabetes care 
BMC Family Practice  2014;15:60.
Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes.
We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods.
All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches’ capacity to perform their role.
It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention.
PMCID: PMC4021256  PMID: 24708783
7.  Assessing methods for measurement of clinical outcomes and quality of care in primary care practices 
To evaluate the appropriateness of potential data sources for the population of performance indicators for primary care (PC) practices.
This project was a cross sectional study of 7 multidisciplinary primary care teams in Ontario, Canada. Practices were recruited and 5-7 physicians per practice agreed to participate in the study. Patients of participating physicians (20-30) were recruited sequentially as they presented to attend a visit. Data collection included patient, provider and practice surveys, chart abstraction and linkage to administrative data sets. Matched pairs analysis was used to examine the differences in the observed results for each indicator obtained using multiple data sources.
Seven teams, 41 physicians, 94 associated staff and 998 patients were recruited. The survey response rate was 81% for patients, 93% for physicians and 83% for associated staff. Chart audits were successfully completed on all but 1 patient and linkage to administrative data was successful for all subjects. There were significant differences noted between the data collection methods for many measures. No single method of data collection was best for all outcomes. For most measures of technical quality of care chart audit was the most accurate method of data collection. Patient surveys were more accurate for immunizations, chronic disease advice/information dispensed, some general health promotion items and possibly for medication use. Administrative data appears useful for indicators including chronic disease diagnosis and osteoporosis/ breast screening.
Multiple data collection methods are required for a comprehensive assessment of performance in primary care practices. The choice of which methods are best for any one particular study or quality improvement initiative requires careful consideration of the biases that each method might introduce into the results. In this study, both patients and providers were willing to participate in and consent to, the collection and linkage of information from multiple sources that would be required for such assessments.
PMCID: PMC3431283  PMID: 22824551
Performance measurement; Primary care; Quality of care; Evaluation
8.  The patient’s voice: an exploratory study of the impact of a group self-management support program 
BMC Family Practice  2012;13:65.
Given the potential value of self-management support programs for people with chronic diseases, it is vital to understand how they influence participants’ health attitudes and behaviours. The Stanford Chronic Disease Self-Management Program (CDSMP), the most well-known and widely studied such program, is funded in many provinces and jurisdictions throughout Canada. However, there is little published evidence on its impact in the Canadian health-care system. We studied participants’ reactions and perceived impacts of attending the Stanford program in one Ontario health region so we could assess its value to the health region. The study asked: What are participants’ reactions and perceived impacts of attending the Stanford CDSMP?
This mixed methods exploratory study held four focus groups approximately one year after participants attended a Stanford program workshop. At the beginning of each session, participants filled out a survey on the type and frequency of community and health resources used for their self-management. During the sessions, a moderator guided the discussion, asking about such things as long-term impact of the program on their lives and barriers to self-management of their chronic conditions.
Participants perceived diverse effects of the workshop: from having a profound impact on one area to affecting all aspects of their lives. A change in physical activity patterns was the most prominent behaviour change, noted by over half the participants. Other recurrent effects included an improved sense of social connection and better coping skills. Barriers to self-management were experienced by almost all participants with several dominant themes emerging including problems with the health system and patient-physician interaction. Participants reported a wide variety of resources used in their self-management, and in some cases, an increase in use was noted for some resources.
Self-management support is, at its core, a complex and patient-centred concept, so a diversity of outcomes to match the diversity of participants should be expected. As these interventions move into different target populations and communities, it is essential that we continue to explore through multiple research methods, the effects, and their meaning to participants, ensuring the optimal investment of resources for the very individuals these interventions aim to serve.
PMCID: PMC3431243  PMID: 22748018
Chronic disease; Self-management; Diabetes; Community health
9.  Pharmacist provision of primary health care: a modified Delphi validation of pharmacists' competencies 
BMC Family Practice  2012;13:27.
Pharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists' effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services.
Using a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada.
Ten key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains.
Expert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists' contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role.
PMCID: PMC3372430  PMID: 22455482
Primary health care; Pharmacy; Pharmacists; Competencies; Scope of practice
11.  Performance feedback: An exploratory study to examine the acceptability and impact for interdisciplinary primary care teams 
BMC Family Practice  2011;12:14.
This mixed methods study was designed to explore the acceptability and impact of feedback of team performance data to primary care interdisciplinary teams.
Seven interdisciplinary teams were offered a one-hour, facilitated performance feedback session presenting data from a comprehensive, previously-conducted evaluation, selecting highlights such as performance on chronic disease management, access, patient satisfaction and team function.
Several recurrent themes emerged from participants' surveys and two rounds of interviews within three months of the feedback session. Team performance measurement and feedback was welcomed across teams and disciplines. This feedback could build the team, the culture, and the capacity for quality improvement. However, existing performance indicators do not equally reflect the role of different disciplines within an interdisciplinary team. Finally, the effect of team performance feedback on intentions to improve performance was hindered by a poor understanding of how the team could use the data.
The findings further our understanding of how performance feedback may engage interdisciplinary team members in improving the quality of primary care and the unique challenges specific to these settings. There is a need to develop a shared sense of responsibility and agenda for quality improvement. Therefore, more efforts to develop flexible and interactive performance-reporting structures (that better reflect contributions from all team members) in which teams could specify the information and audience may assist in promoting quality improvement.
PMCID: PMC3078845  PMID: 21443806
12.  Barriers and facilitators to recruitment of physicians and practices for primary care health services research at one centre 
While some research has been conducted examining recruitment methods to engage physicians and practices in primary care research, further research is needed on recruitment methodology as it remains a recurrent challenge and plays a crucial role in primary care research. This paper reviews recruitment strategies, common challenges, and innovative practices from five recent primary care health services research studies in Ontario, Canada.
We used mixed qualitative and quantitative methods to gather data from investigators and/or project staff from five research teams. Team members were interviewed and asked to fill out a brief survey on recruitment methods, results, and challenges encountered during a recent or ongoing project involving primary care practices or physicians. Data analysis included qualitative analysis of interview notes and descriptive statistics generated for each study.
Recruitment rates varied markedly across the projects despite similar initial strategies. Common challenges and creative solutions were reported by many of the research teams, including building a sampling frame, developing front-office rapport, adapting recruitment strategies, promoting buy-in and interest in the research question, and training a staff recruiter.
Investigators must continue to find effective ways of reaching and involving diverse and representative samples of primary care providers and practices by building personal connections with, and buy-in from, potential participants. Flexible recruitment strategies and an understanding of the needs and interests of potential participants may also facilitate recruitment.
PMCID: PMC3017524  PMID: 21144048
15.  Riding the wave of primary care research 
Canadian Family Physician  2009;55(10):e35-e40.
Family medicine departments and primary health care research centres across the country are growing in size and complexity and therefore require increasingly sophisticated management strategies. Conducting effective and relevant research relies on a stable and efficient organization.
To focus on the needs of individuals, teams, and the organization in order to ensure the success of research projects.
In order to ensure the success of research projects, the C.T. Lamont Primary Health Care Research Centre (CTLC) in Ottawa, Ont, used the following strategies: ensuring organizational support (ie, protected time for research and sustained funding for some investigators); arranging financial and infrastructure support; building skills and confidence (eg, education sessions); organizing linkages and collaborations (eg, forums among staff members); creating appropriate dissemination (eg, newsletter, website); and providing continuity and sustainability.
In order to ensure progress in primary health care research, the CTLC created solutions that focused on the individual, team, and organizational levels. With its management strategies, the CTLC was successful in maintaining a high-functioning team and a well-organized research organization.
PMCID: PMC2762299  PMID: 19826140
16.  Health promotion activity in primary care: performance of models and associated factors 
Open Medicine  2009;3(3):149-164.
Lifestyle behaviours have significant health and economic consequences. Primary care providers play an important role in promoting healthy behaviours. We compared the performance of primary care models in delivering health promotion and identified practice factors associated with its delivery.
Surveys were conducted in 137 randomly selected primary care practices in 4 primary care models in Ontario, Canada: 35 community health centres, 35 fee-for-service practices, 35 family health networks and 32 health service organizations. A total of 4861 adult patients who were visiting their family practice participated in the study. Qualitative nested case studies were also conducted at 2 practices per model. A 7-item question was used to evaluate health promotion. The main outcome was whether at least 1 of the 7 health promotion items was discussed at the survey visit. Multilevel logistic regressions were used to compare the models and determine performance-related practice factors.
The rate of health promotion was significantly higher in community health centres than in the other models (the unadjusted difference ranged between 8% and 13%). This finding persisted after controlling for patient and family physician profiles. Factors independently positively associated with health promotion were as follows: reason for visit (for a general checkup: adjusted odds ratio [AOR] 3.34, 95% confidence interval [CI] 2.81–3.97; for care for a chronic disease: AOR 2.03, 95% CI 1.69–2.43), patients having and seeing their own provider (for those not: AOR 0.58, 95% CI 0.43–0.78), number of nurses in the practice (AOR 1.07, 95% CI 1.02–1.12), percentage of female family physicians (AOR 1.38, 95% CI 1.15–1.66), smaller physician panel size (AOR 0.92, 95% CI 0.85–1.01) and longer booking interval (AOR 1.03, 95% CI 1.01–1.04). Providers in interdisciplinary practices viewed health promotion as an integral part of primary care, whereas other providers emphasized the role of relational continuity in effective health promotion.
We have identified several attributes associated with health promotion delivery. These results may assist practice managers and policy-makers in modifying practice attributes to improve health promotion in primary care.
PMCID: PMC3090121  PMID: 21603049
17.  The Comparison of Models of Primary Care in Ontario (COMP-PC) study: methodology of a multifaceted cross-sectional practice-based study 
Open Medicine  2009;3(3):165-173.
Many industrialized nations have initiated reforms in the organization and delivery of primary care. In Ontario, Canada, salaried and capitation models have been introduced in an attempt to address the deficiencies of the traditional fee-for-service model. The Ontario setting therefore provides an opportunity to compare these funding models within a region that is largely homogeneous with respect to other factors that influence care delivery. We sought to compare the performance of the models across a broad array of dimensions and to understand the underlying practice factors associated with superior performance. We report on the methodology grounding this work.
Between 2004 and 2006 we conducted a cross-sectional mixed-methods study of the fee-for-service model, including family health groups, family health networks, community health centres and health service organizations. The study was guided by a conceptual framework for primary care organizations. Performance across a large number of primary care attributes was evaluated through surveys and chart abstractions. Nested case studies generated qualitative provider and patient data from 2 sites per model along with insights from key informants and policy-makers familiar with all models.
The study recruited 137 practices. We conducted 363 provider surveys and 5361 patient surveys, and we performed 4108 chart audits. We also conducted interviews with 40 family physicians, 6 nurse practitioners, 24 patients and 8 decision-makers. The practice recruitment rate was 45%; it was lowest in fee-for-service practices (23%) and in family health networks (37%). A comparison with all Ontario practices in these models using health administrative data demonstrated that our sample was adequately representative. The patient participation (82%) and survey scale completion (93%) rates were high.
This article details our approach to performing a comprehensive evaluation of primary care models and may be a useful resource for researchers interested in primary care evaluation.
PMCID: PMC3090123  PMID: 21603051
19.  Gauging to gain 
Canadian Family Physician  2008;54(9):1215-1217.
PMCID: PMC2553459  PMID: 18791081
20.  Professionalism for Medicine: Opportunities and Obligations*  
Physicians' dual roles-as healer and professional-are linked by codes of ethics governing behaviour and are empowered by science.Being part of a profession entails a societal contract. The profession is granted a monopoly over the use of a body of knowledge and the privilege of self-regulation and, in return, guarantees society professional competence, integrity and the provision of altruistic service.Societal attitudes to professionalism have changed from supportive to increasingly critical-with physicians being criticised for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence.Professional values are also threatened by many other factors. The most important are the changes in healthcare delivery in the developed world, with control shifting from the profession to the State and/or the corporate sector.For the ideal of professionalism to survive, physicians must understand it and its role in the social contract. They must meet the obligations necessary to sustain professionalism and ensure that healthcare systems support, rather than subvert, behaviour that is compatible with professionalism's values.
PMCID: PMC1888411  PMID: 15296199

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