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1.  Building access to specialist care through e-consultation 
Open Medicine  2013;7(1):e1-e8.
Background
Limited access to specialist care remains a major barrier to health care in Canada, affecting patients and primary care providers alike, in terms of both long wait times and inequitable availability. We developed an electronic consultation system, based on a secure web-based tool, as an alternative to face-to-face consultations, and ran a pilot study to evaluate its effectiveness and acceptability to practitioners.
Methods
In a pilot program conducted over 15 months starting in January 2010, the e-consultation system was tested with primary care providers and specialists in a large health region in Eastern Ontario, Canada. We collected utilization data from the electronic system itself (including quantitative data from satisfaction surveys) and qualitative information from focus groups and interviews with providers.
Results
Of 18 primary care providers in the pilot program, 13 participated in focus groups and 9 were interviewed; in addition, 10 of the 11 specialists in the program were interviewed. Results of our evaluation showed good uptake, high levels of satisfaction, improvement in the integration of referrals and consultations, and avoidance of unnecessary specialist visits. A total of 77 e-consultation requests were processed from 1 Jan. 2010 to 1 Apr. 2011. Less than 10% of the referrals required face-to-face follow-up. The most frequently noted benefits for patients (as perceived by providers) included improved access to specialist care and reduced wait times. Primary care providers valued the ability to assist with patient assessment and management by having access to a rapid response to clinical questions, clarifying the need for diagnostic tests or treatments, and confirming the need for a formal consultation. Specialists enjoyed the improved interaction with primary care providers, as well as having some control in the decision on which patients should be referred.
Interpretation
This low-cost referral system has potential for broader implementation, once payment models for physicians are adapted to cover e-consultation.
PMCID: PMC3654501  PMID: 23687533
2.  The patient’s voice: an exploratory study of the impact of a group self-management support program 
BMC Family Practice  2012;13:65.
Background
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?
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2296-13-65
PMCID: PMC3431243  PMID: 22748018
Chronic disease; Self-management; Diabetes; Community health
3.  Transition from specialist to primary diabetes care: A qualitative study of perspectives of primary care physicians 
BMC Family Practice  2009;10:39.
Background
The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP) perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center.
Methods
Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings.
Results
Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface, insufficient patient confidence or trust in PCP's ability to manage diabetes, poor motivation and "non-compliance" emerged as potential patient barriers to transition. Incongruence between PCP attitudes and expectations related to diabetes self-management and those of patients who had attended a multidisciplinary specialist center was also observed.
Conclusion
This study underlines the breadth of PCP concerns related to transition of diabetes care and the importance of this topic to them. While tools that promote timely information flow and care planning are cornerstones to successful transition, and may be sufficient for some practitioners, appropriately resourced decision support and education strategies should also be available to enhance PCP capacity and readiness to resume diabetes care after referral to a specialist center. Characteristics of the patient-care provider relationship that impact discharge were identified and are worthy of further research.
doi:10.1186/1471-2296-10-39
PMCID: PMC2704171  PMID: 19500397
4.  Just-in-Time Information Improved Decision-Making in Primary Care: A Randomized Controlled Trial 
PLoS ONE  2008;3(11):e3785.
Background
The “Just-in-time Information” (JIT) librarian consultation service was designed to provide rapid information to answer primary care clinical questions during patient hours. This study evaluated whether information provided by librarians to answer clinical questions positively impacted time, decision-making, cost savings and satisfaction.
Methods and Finding
A randomized controlled trial (RCT) was conducted between October 2005 and April 2006. A total of 1,889 questions were sent to the service by 88 participants. The object of the randomization was a clinical question. Each participant had clinical questions randomly allocated to both intervention (librarian information) and control (no librarian information) groups. Participants were trained to send clinical questions via a hand-held device. The impact of the information provided by the service (or not provided by the service), additional resources and time required for both groups was assessed using a survey sent 24 hours after a question was submitted. The average time for JIT librarians to respond to all questions was 13.68 minutes/question (95% CI, 13.38 to 13.98). The average time for participants to respond their control questions was 20.29 minutes/question (95% CI, 18.72 to 21.86). Using an impact assessment scale rating cognitive impact, participants rated 62.9% of information provided to intervention group questions as having a highly positive cognitive impact. They rated 14.8% of their own answers to control question as having a highly positive cognitive impact, 44.9% has having a negative cognitive impact, and 24.8% with no cognitive impact at all. In an exit survey measuring satisfaction, 86% (62/72 responses) of participants scored the service as having a positive impact on care and 72% (52/72) indicated that they would use the service frequently if it were continued.
Conclusions
In this study, providing timely information to clinical questions had a highly positive impact on decision-making and a high approval rating from participants. Using a librarian to respond to clinical questions may allow primary care professionals to have more time in their day, thus potentially increasing patient access to care. Such services may reduce costs through decreasing the need for referrals, further tests, and other courses of action.
Trial Registration
Controlled-Trials.com ISRCTN96823810
doi:10.1371/journal.pone.0003785
PMCID: PMC2583045  PMID: 19023446
5.  Integrating Public Health and Primary Care 
Healthcare Policy  2007;3(1):e160-e181.
Purpose:
Improved health and social outcomes would be possible with better coordination and collaboration between public health and primary care. The purpose of this study is to identify linkages between these health sectors with the aim of informing a forward-looking policy approach to integrate public health functions in primary care.
Methods:
We searched national and international journals and the grey literature for relevant papers and reports published from January 1999 to December 2003. The final set of documents provided broad coverage of the topic, with emphasis on national and international representation and a special focus on disease surveillance, health promotion, accident and illness prevention and chronic diseases.
Results:
Three main findings emerged from this study. First, there is a need to understand and clearly articulate the roles and functions of public health and primary care in Canada. Second, the main areas of overlap between these sectors are health surveillance, health promotion and prevention of disease and injury. Third, based on an international literature search, we identified 10 models that demonstrate how these sectors can be integrated; five of them were developed in Canada.
Conclusions:
National and international evidence and a variety of working models support the integration of public health functions in primary care. Canada has been a leader in developing models of integrated health systems that combine individualized approaches to influence personal health behaviour and community approaches to influence the health of the population. These integration models could be further developed through a focus on the common need of primary care and public health to address the health implications of the ever-present risk of emerging infectious diseases in Canada.
PMCID: PMC2645118  PMID: 19305749
6.  Framework for primary care organizations: the importance of a structural domain 
Purpose
Conceptual frameworks for primary care have evolved over the last 40 years, yet little attention has been paid to the environmental, structural and organizational factors that facilitate or moderate service delivery. Since primary care is now of more interest to policy makers, it is important that they have a comprehensive and balanced conceptual framework to facilitate their understanding and appreciation. We present a conceptual framework for primary care originally developed to guide the measurement of the performance of primary care organizations within the context of a large mixed-method evaluation of four types of models of primary care in Ontario, Canada.
Methods
The framework was developed following an iterative process that combined expert consultation and group meetings with a narrative review of existing frameworks, as well as trends in health management and organizational theory.
Results
Our conceptual framework for primary care has two domains: structural and performance. The structural domain describes the health care system, practice context and organization of the practice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care.
Conclusion
As primary care evolves through demonstration projects and reformed delivery models, it is important to evaluate its structural and organizational features as these are likely to have a significant impact on performance.
doi:10.1093/intqhc/mzm054
PMCID: PMC2533520  PMID: 18055502
conceptual framework; organizational theory; performance measurement; primary care; quality of health care
7.  Family physicians’ reactions to performance assessment feedback 
Canadian Family Physician  2006;52(12):1570.
OBJECTIVE
To explore and describe family physicians’ personal and professional responses to performance assessment feedback.
DESIGN
Qualitative study using one-on-one semistructured interviews after feedback on performance.
SETTING
Fee-for-service family practices in eastern Ontario.
PARTICIPANTS
Eight physicians out of 25 physicians in the control group of a previous randomized controlled trial who received performance assessment feedback were purposefully selected using maximum variation sampling to represent various levels of performance. Five female physicians (2 part-time and 3 full-time) and 3 male physicians (all full-time) were interviewed. These physicians had practised family medicine for an average of 18.5 years (range 9 to 32 years).
METHOD
Semistructured one-on-one interviews were conducted to determine what physicians thought and felt about their private feedback sessions and to solicit their opinions on performance assessment in general. Information was analyzed using an open coding style and a constant comparative method of analysis.
MAIN FINDINGS
Two major findings were central to the core elements of medical professionalism and perceived accountability. Physicians indicated that the private feedback they received was a valuable and necessary part of medical professionalism; however, they were reluctant to share this feedback with patients. Physicians described various layers of accountability from the most important inner layer, patients, to the least important outer layer, those funding the system.
CONCLUSION
Performance feedback was viewed as important to family physicians for maintaining medical professionalism and accountability.
PMCID: PMC1783757  PMID: 17279238
8.  Why do family physicians fail to detect renal impairment? 
Canadian Family Physician  2006;52(2):213.
OBJECTIVE
To investigate why many patients with renal impairment (30.7%) were not recognized by their family physicians despite an earlier educational intervention on detecting renal impairment; and to determine whether certain factors related to physicians, patients, or the intervention itself were associated with whether renal impairment was detected.
DESIGN
Qualitative approach using grounded theory.
SETTING
A Health Service Organization in Ottawa, Ont.
PARTICIPANTS
A purposeful sample of six family physicians.
METHODS
In semistructured interviews, participants were asked to describe the workup ordered and their decision-making processes for patients in whom they had recently detected renal impairment. They were also asked to evaluate the six components of an educational intervention designed to help them to detect renal impairment. Finally, one patient’s chart was reviewed (a chart containing a laboratory report noting an abnormal result for kidney function and having no indication that renal impairment had been recognized) to identify reasons for lack of detection.
RESULTS
Most physicians did not investigate every patient with renal impairment (glomerular filtration rate of <78 mL/min) in the same way because they took individual patient factors into consideration. Reasons for not detecting renal impairment were “managed differently” or “missed,” with the former being the most common. The educational intervention physicians remembered most often was chart rounds, and these were viewed as helpful. “Missed” cases were more often deliberately managed differently than unintentionally not detected.
CONCLUSION
Physicians used various approaches to detect and manage renal impairment despite interventions that recommended a consistent procedure.
PMCID: PMC1479723  PMID: 16926964

Results 1-8 (8)