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1.  Who gets a family physician through centralized waiting lists? 
BMC Family Practice  2015;16:10.
Background
North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians’ enrolment of orphan patients through centralized waiting lists, the Guichet d’accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians’ after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled.
Methods
A longitudinal quantitative analysis spanning a five-year period (2008–2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used.
Results
The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level.
Conclusion
Centralized waiting lists linked to financial incentives increased the number of family physicians’ patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.
doi:10.1186/s12875-014-0220-7
PMCID: PMC4328670  PMID: 25649074
Payment; Incentives; Centralized waiting lists; Registry; Enrolment; Vulnerable patients
2.  Evaluation of the implementation of centralized waiting lists for patients without a family physician and their effects across the province of Quebec 
Background
Most national and provincial commissions on healthcare services in Canada over the past decade have recommended that primary care services be strengthened in order to guarantee each citizen access to a family physician. Despite these recommendations, finding a family physician continues to be problematic. The issue of enrolment with a family physician is worrying in Canada, where nearly 21% of the country’s population reported not having a family physician in the last Commonwealth Fund survey.
To respond to this important need, centralized waiting lists have been implemented in four Canadian provinces to help ‘orphan,’ or unaffiliated, patients find a family physician. These organizational mechanisms are intended to better coordinate the demand for and supply of family physicians. The objectives of this study are: to assess the effects of centralized waiting lists for orphan patients (GACOs) implemented in the province of Quebec and to explain the variation among their effects by analyzing factors influencing implementation process.
Methods
This study is based on two complementary and sequential research strategies. The first (objective 1) is a quantitative longitudinal design to assess the effects of all the GACOs (n = 93) in Quebec using clinical-administrative data. The second (objective 2) involves using four case studies to explain variations in effects through in-depth analysis of the various factors contributing to the observed effects. The primary source of data will be key actors involved in the GACOs. We expect to conduct around 40 semi-structured interviews.
Discussion
This will be the first study in Canada to evaluate the implementation of this innovation. It will provide an exhaustive picture of the effects of GACO implementation in Quebec and to assess their potential for generalization elsewhere in Canada. At the theoretical level, this study will produce new knowledge on the factors having the greatest influence on the implementation of primary care innovations in professional environments.
doi:10.1186/s13012-014-0117-9
PMCID: PMC4159553  PMID: 25185703
Primary healthcare; Access; Continuity; Implementation study
4.  Conditions for production of interdisciplinary teamwork outcomes in oncology teams: protocol for a realist evaluation 
Background
Interdisciplinary teamwork (ITW) is designed to promote the active participation of several disciplines in delivering comprehensive cancer care to patients. ITW provides mechanisms to support continuous communication among care providers, optimize professionals’ participation in clinical decision-making within and across disciplines, and foster care coordination along the cancer trajectory. However, ITW mechanisms are not activated optimally by all teams, resulting in a gap between desired outcomes of ITW and actual outcomes observed. The aim of the present study is to identify the conditions underlying outcome production by ITW in local oncology teams.
Methods
This retrospective multiple case study will draw upon realist evaluation principles to explore associations among context, mechanisms and outcomes (CMO). The cases are nine interdisciplinary cancer teams that participated in a previous study evaluating ITW outcomes. Qualitative data sources will be used to construct a picture of CMO associations in each case. For data collection, reflexive focus groups will be held to capture patients’ and professionals’ perspectives on ITW, using the guiding question, ‘What works, for whom, and under what circumstances?’ Intra-case analysis will be used to trace associations between context, ITW mechanisms, and patient outcomes. Inter-case analysis will be used to compare the different cases’ CMO associations for a better understanding of the phenomenon under study.
Discussion
This multiple case study will use realist evaluation principles to draw lessons about how certain contexts are more or less likely to produce particular outcomes. The results will make it possible to target more specifically the actions required to optimize structures and to activate the best mechanisms to meet the needs of cancer patients. This project could also contribute significantly to the development of improved research methods for conducting realist evaluations of complex healthcare interventions. To our knowledge, this study is the first to use CMO associations to improved empirical and theoretical understanding of interdisciplinary teamwork in oncology, and its results could foster more effective implementation in clinical practice.
doi:10.1186/1748-5908-9-76
PMCID: PMC4074333  PMID: 24938443
Interdisciplinarity; Professional practices; Realist evaluation; Patient outcomes; Case study; Cancer
5.  Reforming healthcare systems on a locally integrated basis: is there a potential for increasing collaborations in primary healthcare? 
Background
Over the past decade, in the province of Quebec, Canada, the government has initiated two consecutive reforms. These have created a new type of primary healthcare – family medicine groups (FMGs) – and have established 95 geographically defined local health networks (LHNs) across the province. A key goal of these reforms was to improve collaboration among healthcare organizations. The objective of the paper is to analyze the impact of these reforms on the development of collaborations among primary healthcare practices and between these organisations and hospitals both within and outside administrative boundaries of the local health networks.
Methods
We surveyed 297 primary healthcare practices in 23 LHNs in Quebec’s two most populated regions (Montreal & Monteregie) in 2005 and 2010. We characterized collaborations by measuring primary healthcare practices’ formal or informal arrangements among themselves or with hospitals for different activities. These collaborations were measured based on the percentage of clinics that identified at least one collaborative activity with another organization within or outside of their local health network. We created measures of collaboration for different types of primary healthcare practices: first- and second-generation FMGs, network clinics, local community services centres (CLSCs) and private medical clinics. We compared their situations in 2005 and in 2010 to observe their evolution.
Results
Our results showed different patterns of evolution in inter-organizational collaboration among different types of primary healthcare practices. The local health network reform appears to have had an impact on territorializing collaborations firstly by significantly reducing collaborations outside LHNs areas for all types of primary healthcare practices, including new type of primary healthcare and CLSCs, and secondly by improving collaborations among healthcare organizations within LHNs areas for all organizations. This is with the exception of private medical clinics, where collaborations decreased both outside and within LHNs.
Conclusion
Health system reforms aimed at creating geographically based networks influenced primary healthcare practices’ both among themselves (horizontal collaborations) and with hospitals (vertical collaborations). There is evidence of increased collaborations within defined geographic areas, particularly among new type of primary healthcare.
doi:10.1186/1472-6963-13-262
PMCID: PMC3750424  PMID: 23835105
Primary care; Network; Inter-organization collaboration
6.  Constructing Taxonomies to Identify Distinctive Forms of Primary Healthcare Organizations 
ISRN Family Medicine  2013;2013:798347.
Background. Primary healthcare (PHC) renewal gives rise to important challenges for policy makers, managers, and researchers in most countries. Evaluating new emerging forms of organizations is therefore of prime importance in assessing the impact of these policies. This paper presents a set of methods related to the configurational approach and an organizational taxonomy derived from our analysis. Methods. In 2005, we carried out a study on PHC in two health and social services regions of Quebec that included urban, suburban, and rural areas. An organizational survey was conducted in 473 PHC practices. We used multidimensional nonparametric statistical methods, namely, multiple correspondence and principal component analyses, and an ascending hierarchical classification method to construct a taxonomy of organizations. Results. PHC organizations were classified into five distinct models: four professional and one community. Study findings indicate that the professional integrated coordination and the community model have great potential for organizational development since they are closest to the ideal type promoted by current reforms. Conclusion. Results showed that the configurational approach is useful to assess complex phenomena such as the organization of PHC. The analysis highlights the most promising organizational models. Our study enhances our understanding of organizational change in health services organizations.
doi:10.5402/2013/798347
PMCID: PMC4041222  PMID: 24959575
7.  Emerging organisational models of primary healthcare and unmet needs for care: insights from a population-based survey in Quebec province 
BMC Family Practice  2012;13:66.
Background
Reform of primary healthcare (PHC) organisations is underway in Canada. The capacity of various types of PHC organizations to respond to populations’ needs remains to be assessed. The main objective of this study was to evaluate the association of PHC affiliation with unmet needs for care.
Methods
Population-based survey of 9205 randomly selected adults in two regions of Quebec, Canada. Outcomes Self-reported unmet needs for care and identification of the usual source of PHC.
Results
Among eligible adults, 18 % reported unmet needs for care in the last six months. Reasons reported for unmet needs were: waiting times (59 % of cases); unavailability of usual doctor (42 %); impossibility to obtain an appointment (36 %); doctors not accepting new patients (31 %). Regression models showed that unmet needs were decreasing with age and was lower among males, the least educated, and unemployed or retired. Controlling for other factors, unmet needs were higher among the poor and those with worse health status. Having a family doctor was associated with fewer unmet needs. People reporting a usual source of care in the last two-years were more likely to report unmet need for care. There were no differences in unmet needs for care across types of PHC organisations when controlling for affiliation with a family physician.
Conclusion
Reform models of primary healthcare consistent with the medical home concept did not differ from other types of organisations in our study. Further research looking at primary healthcare reform models at other levels of implementation should be done.
doi:10.1186/1471-2296-13-66
PMCID: PMC3431245  PMID: 22748060
Primary care; Unmet needs for care; Primary healthcare organization; Vulnerability
8.  Management continuity in local health networks 
Introduction
Patients increasingly receive care from multiple providers in a variety of settings. They expect management continuity that crosses boundaries and bridges gaps in the healthcare system. To our knowledge, little research has been done to assess coordination across organizational and professional boundaries from the patients’ perspective. Our objective was to assess whether greater local health network integration is associated with management continuity as perceived by patients.
Method
We used the data from a research project on the development and validation of a generic and comprehensive continuity measurement instrument that can be applied to a variety of patient conditions and settings. We used the results of a cross-sectional survey conducted in 2009 with 256 patients in two local health networks in Quebec, Canada. We compared four aspects of management continuity between two contrasting network types (highly integrated vs. poorly integrated).
Results
The scores obtained in the highly integrated network are better than those of the poorly integrated network on all dimensions of management continuity (coordinator role, role clarity and coordination between clinics, and information gaps between providers) except for experience of care plan.
Conclusion
Some aspects of care coordination among professionals and organizations are noticed by patients and may be valid indicators to assess care coordination.
PMCID: PMC3429137  PMID: 22977427
management continuity; patient perspective; coordination of care
9.  Does Receiving Clinical Preventive Services Vary across Different Types of Primary Healthcare Organizations? Evidence from a Population-Based Survey 
Healthcare Policy  2010;6(2):67-84.
Objective:
To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS).
Method:
Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics.
Outcome measures:
Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS.
Results:
CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35—2.37) or mixed (OR 1.22; 95% CI 1.01—1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41—2.38) compared to a single visit.
Conclusion:
Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.
PMCID: PMC3016636  PMID: 22043224
10.  Evaluation of the impact of interdisciplinarity in cancer care 
Background
Teamwork is a key component of the health care renewal strategy emphasized in Quebec, elsewhere in Canada and in other countries to enhance the quality of oncology services. While this innovation would appear beneficial in theory, empirical evidences of its impact are limited. Current efforts in Quebec to encourage the development of local interdisciplinary teams in all hospitals offer a unique opportunity to assess the anticipated benefits. These teams working in hospital outpatient clinics are responsible for treatment, follow-up and patient support. The study objective is to assess the impact of interdisciplinarity on cancer patients and health professionals.
Methods/Design
This is a quasi-experimental study with three comparison groups distinguished by intensity of interdisciplinarity: strong, moderate and weak. The study will use a random sample of 12 local teams in Quebec, stratified by intensity of interdisciplinarity. The instrument to measure the intensity of the interdisciplinarity, developed in collaboration with experts, encompasses five dimensions referring to aspects of team structure and process. Self-administered questionnaires will be used to measure the impact of interdisciplinarity on patients (health care utilization, continuity of care and cancer services responsiveness) and on professionals (professional well-being, assessment of teamwork and perception of teamwork climate). Approximately 100 health professionals working on the selected teams and 2000 patients will be recruited. Statistical analyses will include descriptive statistics and comparative analysis of the impact observed according to the strata of interdisciplinarity. Fixed and random multivariate statistical models (multilevel analyses) will also be used.
Discussion
This study will pinpoint to what extent interdisciplinarity is linked to quality of care and meets the complex and varied needs of cancer patients. It will ascertain to what extent interdisciplinary teamwork facilitated the work of professionals. Such findings are important given the growing prevalence of cancer and the importance of attracting and retaining health professionals to work with cancer patients.
doi:10.1186/1472-6963-11-144
PMCID: PMC3129294  PMID: 21639897
11.  The Continuing Saga of Emergency Room Overcrowding: Are We Aiming at the Right Target? 
Healthcare Policy  2010;5(3):27-39.
Emergency room utilization in Canada is considerably higher than in other industrialized countries. Despite significant investments, recurrent emergency room crises persist. Focusing particularly on the situation in Quebec, this paper examines the evolution of Canada's and Quebec's healthcare systems over the past 40 years and identifies the key developments that resulted in today's problems and the challenges that must be addressed. In this historical overview, we argue that emergency room problems arise from past decisions that gave hospitals a predominant role in the healthcare system and partly modified their original mission, as well as from counterproductive funding modalities. Other decisions have also weakened primary care services, which are strongly focused on acute health problems and are poorly coordinated with the rest of the system. Symptomatic remedies have only eased the pressure on emergency rooms, but the real solution is more complex and must address the historical residues that are paralyzing our healthcare system.
PMCID: PMC2831731  PMID: 21286266
12.  At the interface of community and healthcare systems: a longitudinal cohort study on evolving health and the impact of primary healthcare from the patient's perspectiv 
Background
Massive efforts in Canada have been made to renew primary healthcare. However, although early evaluations of initiatives and research on certain aspects of the reform are promising, none have examined the link between patient assessments of care and health outcomes or the impacts at a population level. The goal of this project is to examine the effect of patient-centred and effective primary healthcare on the evolution of chronic illness burden and health functioning in a population, and in particularly vulnerable groups: the multi-morbid and the poor.
Methods/Design
A randomly selected cohort of 2000 adults aged 25 to 75 years will be recruited within the geographic boundaries of four local healthcare networks in Quebec. At recruitment, cohort members will report on socio-demographic information, functional health and healthcare use. Two weeks, 12 months and 24 months after recruitment, cohort participants will complete a self-administered questionnaire on current health and health behaviours in order to evaluate primary healthcare received in the previous year.
The dependent variables are calculated as change over time of functional health status, chronic illness burden, and health behaviours. Dimensions of patient-centred care and clinical processes are measured using sub-scales of validated instruments. We will use Poisson regression modelling to estimate the incidence rate of chronic illness burden scores and structural equation modelling to explore relationships between variables and to examine the impact of dimensions of patient-centred care and effective primary healthcare.
Discussion
Results will provide valuable information for primary healthcare clinicians on the course of chronic illness over time and the impact on health outcomes of accessible, patient-centred and effective care. A demonstration of impact will contribute to the promotion of continuous quality improvement activities at a clinical level. While considerable advances have been made in the management of specific chronic illnesses, this will make a unique contribution to effective care for persons with multiple morbidities. Furthermore, the cohort and data architecture will serve as a research platform for future projects.
doi:10.1186/1472-6963-10-258
PMCID: PMC2940881  PMID: 20815880
13.  Primary Care Organization and Outcomes of an Emergency Visit among Seniors 
Healthcare Policy  2009;5(1):e115-e131.
This study explored whether organizational characteristics of primary care services provided by area of residence in two Quebec regions are related to outcomes of an emergency department (ED) visit among seniors discharged home. Provincial administrative databases on a sample of seniors who made an ED visit and their 30-day outcomes were linked by area of residence to data from a survey of key informants from primary care clinics. Measures of organizational characteristics included three scales derived from principal components analysis and one theoretically derived global score that measured the degree of conformity to characteristics of ideal emerging primary care models. In multivariate analyses, adjusting for patient characteristics, patients living in areas in the lowest quartile for the global score had higher rates of return ED visits without hospitalization. Emerging primary care organizational models along the lines currently being pursued in Quebec may help to reduce the growing burden of ED care of seniors.
PMCID: PMC2732659  PMID: 20676243
14.  Interprofessional collaborative practice within cancer teams: Translating evidence into action. A mixed methods study protocol 
Background
A regional integrated cancer network has implemented a program (educational workshops, reflective and mentoring activities) designed to support the uptake of evidence-informed interprofessional collaborative practices (referred to in this text as EIPCP) within cancer teams. This research project, which relates to the Registered Nurses' Association of Ontario (RNAO) Best Practice Guidelines and other sources of research evidence, represents a unique opportunity to learn more about the factors and processes involved in the translation of evidence-based recommendations into professional practices. The planned study seeks to address context-specific challenges and the concerns of nurses and other stakeholders regarding the uptake of evidence-based recommendations to effectively promote and support interprofessional collaborative practices.
Aim
This study aims to examine the uptake of evidence-based recommendations from best practice guidelines intended to enhance interprofessional collaborative practices within cancer teams.
Design
The planned study constitutes a practical trial, defined as a trial designed to provide comprehensive information that is grounded in real-world healthcare dynamics. An exploratory mixed methods study design will be used. It will involve collecting quantitative data to assess professionals' knowledge and attitudes, as well as practice environment factors associated with effective uptake of evidence-based recommendations. Semi-structured interviews will be conducted concurrently with care providers to gather qualitative data for describing the processes involved in the translation of evidence into action from both the users' (n = 12) and providers' (n = 24) perspectives. The Graham et al. Ottawa Model of Research Use will serve to construct operational definitions of concepts, and to establish the initial coding labels to be used in the thematic analysis of the qualitative data. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interrelated contextual factors that enhance the uptake of EIPCP and changes in professional practices.
Discussion
The information obtained from the study will produce new knowledge on the interventions and sources of support most conducive to the uptake of evidence and building of capacity to sustain new interprofessional collaborative practice patterns. It will provide new information on strategies for overcoming barriers to evidence-informed interventions. The findings will also pinpoint critical determinants of 'what works and why' taking into account the interplay between evidence, operational, relational micro-processes of care, uniqueness of patients' needs and preferences, and the local context.
doi:10.1186/1748-5908-5-53
PMCID: PMC2912241  PMID: 20626858
15.  Features of Primary Healthcare Clinics Associated with Patients' Utilization of Emergency Rooms: Urban–Rural Differences 
Healthcare Policy  2007;3(2):72-85.
Objective:
A 2002 survey of primary healthcare sites found that 51% of rural and 33% of urban primary care patients reported using the hospital emergency room (ER) in the last 12 months. We did a secondary analysis to identify urban–rural differences in accessibility-related organizational features that predicted ER use.
Methods:
We collected information on clinic organization and physicians' practice profiles from 100 primary healthcare sites across Quebec and 2,725 of their regular patients, who reported on ER use. We used hierarchical logistic regression to identify organizational features that predict the probability of ER use by patients.
Results:
Patient confidence in rapid access at their clinic decreases ER use (OR=0.73). Rural sites offer fewer walk-in services or on-site medical procedures and less proximity to laboratory and diagnostic services, but paradoxically, rural patients are more confident that their own physician will see them for a sudden illness. Patients from clinics offering a larger range of medical procedures on site have lower ER use (OR=0.92 per procedure). Rural physicians tend to divide their time between hospital and primary care; doing in-patient care increases ER use (OR=1.64).
Discussion:
Decreased ER use is found in patients of clinics organized to enhance responsiveness to acute needs, especially in rural areas. Although the high rates of ER use in rural areas partly reflect problems with the accessibility of primary care clinics, in a resource-scarce context rural hospital ERs may cover both primary care urgent problems and emergencies.
PMCID: PMC2645171  PMID: 19305782
16.  Involving Decision-Makers in Producing Research Syntheses: The Case of the Research Collective on Primary Healthcare in Quebec 
Healthcare Policy  2007;2(4):e193-e209.
This paper reports on a research collective on primary healthcare (PHC) conducted in Quebec in 2004. Thirty ongoing or recently completed studies were synthesized through a process involving a high degree of exchange among researchers who conducted the original studies, investigators and decision-makers. The viewpoints expressed by decision-makers who participated in the process were analyzed in terms of convergence with and divergence from the researchers’ viewpoints. In four cases, there was convergence between the decision-makers’ and the researchers’ viewpoints, thus increasing the validity of the collective’s findings. The main divergence between the two groups’ viewpoints concerns the strategy adopted in Quebec to create local health and social services networks. Such divergence reflects the distinction made by Klein between scientific evidence and organizational and political evidence.
Our study results illustrate that decision-makers’ viewpoints can play an important interpretive and complementary role in producing research syntheses. Although integrating decision-makers’ viewpoints into syntheses has been regarded as a strategy for improving the use of research findings, our analysis shows that decision-makers’ view-points do not necessarily have to be integrated into syntheses but can, instead, be examined for convergence with or divergence from researchers’ viewpoints. This deliberative process can enrich discussions and lead to enlightened decision- and policy making.
PMCID: PMC2585463  PMID: 19305728
17.  Governance, Health Policy Implementation and the Added Value of Regionalization 
Healthcare Policy  2007;2(3):97-114.
Objectives:
In this paper we focus on governance and the added value of regionalization in the context of health policy implementation.
What are regional boards’ patterns of action in the governance process?
How do these patterns favour policy implementation?
Analytical framework:
To enhance our understanding of the role of regional boards in governance processes, we relied on four conceptual constructs that corresponded to models of collective action: political, technocratic, democratic and cognitive.
Alongside the four models, we analyzed the impact of governance on health policy implementation using Mazmanian and Sabatier’s general analytical framework, which identifies three types of variables that affect public policy implementation: (1) variables related to the complexity of the problem, (2) statutory variables that structure the implementation of the policy and (3) non-statutory variables related to the context.
Methods:
We conducted a qualitative, longitudinal case study of the regional implemention of the Program to Combat Cancer in Quebec.
Findings:
This research stresses the added value of a clinico-administrative governance of change, whereby regional boards, in synergy with clinical leaders, participate in the orientation of collective action. Analysis of the regional board’s patterns of action reveals the utility of combined technocratic, democratic, political and cognitive actions.
PMCID: PMC2585452  PMID: 19305724
18.  Continuity of primary care and emergency department utilization among elderly people 
Background
People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with emergency department use by elderly people in both urban and rural areas.
Methods
We conducted a cross-sectional study using information for a random sample of 95 173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an amergency department per 1000 days at risk [i.e., alive and not in hospital] during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care.
Results
After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio [RR] 1.45, 95% confidence interval [CI] 1.41–1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44–1.48, and 1.27, 95% CI 1.25–1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.
Interpretation
Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas.
doi:10.1503/cmaj.061615
PMCID: PMC2072991  PMID: 18025427
19.  The Research Collective: A Tool for Producing Timely, Context-linked Research Syntheses 
Healthcare Policy  2006;1(4):58-75.
This paper reports on a research collective in primary healthcare (PHC) conducted in Quebec in 2004. A lead team of investigators synthesized 30 ongoing or recently completed studies from project description forms filled out by the participating researchers.
The process of the collective is examined by addressing the three main challenges met in the course of its completion, namely, (a) the need to derive an analytical framework to regroup variables in a meaningful way, (b) the assessment of strength of evidence and (c) coping with a mix of quantitative and qualitative studies. Advantages of the collective over other forms of research synthesis include timeliness, low cost relative to the total cost of the studies it comprises and the information it generates and, finally, context linkage, which enhances relevance but which could limit transferability of the findings. Overall, the research collective appears to be a promising tool for research synthesis.
PMCID: PMC2585353  PMID: 19305681

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