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Objective: To determine whether neighbours who share the same family physicians have better cardiovascular and health care outcomes., Design: Retrospective cohort study using administrative health databases., Setting: Ontario., Participants: The study population included 2,690,482 adult patients cared for by 1710 family physicians., Interventions: Adult residents of Ontario were linked to their family physicians and the geographic distance between patients in the same panel or list was calculated. Using distance between patients within a panel to stratify physicians into quintiles of panel proximity, physicians and patients from close-proximity practices were compared with those from more-distant-proximity practices. Age- and sex-standardized incidence rates and hazard ratios from cause-specific hazards regression models were determined., Main Outcome Measures: The occurrence of a major cardiovascular event during a 5-year follow-up period (2008 to 2012)., Results: Patients of panels in the closest-proximity quintile lived an average of 3.9 km from the 10 closest patients in their panel compared with 12.4 km for the 10 closest patients of panels in the distant-proximity quintile. After adjusting for various patient and physician characteristics, patients in the most-distant-proximity practices had a 24% higher rate of cardiovascular events (adjusted hazard ratio=1.24 [95% CI 1.20 to 1.28], P <.001) than patients in the closest-proximity practices. Age- and sex-standardized all-cause mortality and total per patient health care costs were also lowest in the closest-proximity quintile. In sensitivity analyses restricted to large urban communities and to White long-term residents, results were similar., Conclusion: The better cardiovascular outcomes observed in close-proximity panels may be related to a previously unrecognized mechanism of social connectedness that extends the effectiveness of primary care practitioners., (Copyright © 2022 the College of Family Physicians of Canada.)

Objective: To investigate whether the fetal fibronectin assay would be useful for determining if a woman was close to a term delivery. If effective, this test would allow parturient women to stay in their communities longer., Design: This feasibility study used a prospective cohort design to examine the negative predictive value of the fetal fibronectin test at term., Setting: Iqaluit, NU., Participants: A total of 30 parturient women from rural and isolated communities in Nunavut., Intervention: Starting at 36 weeks' gestation, women were tested every 2 days, and after 39 weeks this increased to every day until labour., Main Outcome Measures: The negative predictive value of the fetal fibronectin test was assessed., Results: Women were no more likely to give birth at 7 or more days after their last negative fetal fibronectin test result relative to their likelihood of giving birth at 6 or fewer days after their last negative test result. Hence, the presence of fetal fibronectin in cervical secretion did not predict term delivery., Conclusion: This project indicated that the fetal fibronectin test did not have adequate sensitivity or specificity as a diagnostic measure to predict a delay of labour at term., (Copyright© the College of Family Physicians of Canada.)

Objective: To gain a more comprehensive understanding of patients' perceptions of access to their primary care practice and how these relate to patient characteristics., Design: Cross-sectional study., Setting: Ontario., Participants: Adult primary care patients in Ontario (N = 1698) completing the Quality and Costs of Primary Care (QUALICOPC) Patient Experiences Survey., Main Outcome Measures: Responses to 11 access-related survey items, analyzed both individually and as a Composite Access Score (CAS)., Results: The mean (SD) CAS was 1.78 (0.16) (the highest possible CAS was 2 and the lowest was 1). Most patients (68%) waited more than 1 day for their appointment. By far most (96%) stated that it was easy to obtain their appointment and that they obtained that appointment as soon as they wanted to (87%). There were no statistically significant relationships between CAS and sex, language fluency, income, education, frequency of emergency department use, or chronic disease status. A higher CAS was associated with being older and being born in Canada, better self-reported health, and increased frequency of visits to a doctor., Conclusion: Despite criticisms of access to primary care, this study found that Ontario patients belonging to primary care practices have favourable impressions of their access. There were few statistically significant relationships between patient characteristics and access, and these relationships appeared to be weak., (Copyright© the College of Family Physicians of Canada.)

Objective: To examine the barriers to and facilitators of practice facilitation experienced by participants in the Improving Delivery of Cardiovascular Care (IDOCC) project., Design: Case studies of practice facilitators' narrative reports., Setting: Eastern Ontario., Participants: Primary care practices that participated in the IDOCC project., Main Outcome Measures: Cases were identified by calculating sum scores in order to determine practices' performance relative to their peers. Two case exemplars were selected that scored within ± 1 SD of the total mean score, and a qualitative analysis of practice facilitators' narrative reports was conducted using a 5-factor implementation framework to identify barriers and facilitators. Narratives were divided into 3 phases: planning, implementation, and sustainability., Results: Barriers and facilitators fluctuated over the intervention's 3 phases. Site A reported more barriers (n = 47) than facilitators (n = 38), while site B reported a roughly equal number of barriers (n = 144) and facilitators (n = 136). In both sites, the most common barriers involved organizational and provider factors and the most common facilitators were associated with innovation and structural factors., Conclusion: Both practices encountered various barriers and facilitators throughout the IDOCC's 3 phases. The case studies reveal the complex interactions of these factors over time, and provide insight into the implementation of practice facilitation programs., (Copyright© the College of Family Physicians of Canada.)

Objective: To examine the use of computers in primary care practices., Design: The international Quality and Cost of Primary Care study was conducted in Canada in 2013 and 2014 using a descriptive cross-sectional survey method to collect data from practices across Canada. Participating practices filled out several surveys, one of them being the Family Physician Survey, from which this study collected its data., Setting: All 10 Canadian provinces., Participants: A total of 788 family physicians., Main Outcome Measures: A computer use scale measured the extent to which family physicians integrated computers into their practices, with higher scores indicating a greater integration of computer use in practice. Analyses included t tests and 2 tests comparing new and traditional models of primary care on measures of computer use and electronic health record (EHR) use, as well as descriptive statistics., Results: Nearly all (97.5%) physicians reported using a computer in their practices, with moderately high computer use scale scores (mean [SD] score of 5.97 [2.96] out of 9), and many (65.7%) reported using EHRs. Physicians with practices operating under new models of primary care reported incorporating computers into their practices to a greater extent (mean [SD] score of 6.55 [2.64]) than physicians operating under traditional models did (mean [SD] score of 5.33 [3.15]; t 726.60 = 5.84; P < .001; Cohen d = 0.42, 95% CI 0.808 to 1.627) and were more likely to report using EHRs (73.8% vs 56.7%; [Formula: see text]; P < .001; odds ratio = 2.15). Overall, there was a statistically significant variability in computer use across provinces., Conclusion: Most family physicians in Canada have incorporated computers into their practices for administrative and scholarly activities; however, EHRs have not been adopted consistently across the country. Physicians with practices operating under the new, more collaborative models of primary care use computers more comprehensively and are more likely to use EHRs than those in practices operating under traditional models of primary care., (Copyright© the College of Family Physicians of Canada.)

Objective: To examine access to primary care in new and traditional models using 2 dimensions of the concept of patient-centred access., Design: An international survey examining the quality and costs of primary health care (the QUALICOPC study) was conducted in 2013 in Canada. This study adopted a descriptive cross-sectional survey method using data from practices across Canada. Each participating practice filled out the Family Physician Survey and the Practice Survey, and patients in each participating practice were asked to complete the Patient Experiences Survey., Setting: All 10 Canadian provinces., Participants: A total of 759 practices and 7172 patients., Main Outcome Measures: Independent t tests were conducted to examine differences between new and traditional models of care in terms of availability and accommodation, and affordability of care., Results: Of the 759 practices, 407 were identified as having new models of care and 352 were identified as traditional. New models of care were distinct with respect to payment structure, opening hours, and having an interdisciplinary work force. Most participating practices were from large cities or suburban areas. There were few differences between new and traditional models of care regarding accessibility and accommodation in primary care. Patients under new models of care reported easier access to other physicians in the same practice, while patients from traditional models reported seeing their regular family physicians more frequently. There was no difference between the new and traditional models of care with regard to affordability of primary care. Patients attending clinics with new models of care reported that their physicians were more involved with them as a whole person than patients attending clinics based on traditional models did., Conclusion: Primary care access issues do not differ strongly between traditional and new models of care; however, patients in the new models of care believed that their physicians were more involved with them as people.

Objective: To describe the models of practice used by nurse practitioners (NPs) and FPs in community health centres (CHCs), and to examine the roles of NPs and FPs in these models., Design: Cross-sectional study using an organizational survey completed by managers of the CHC sites, as well as administrative data on patient sociodemographic characteristics and encounter activities., Setting: A total of 21 CHCs (13 main sites and 8 satellite sites) operating in eastern Ontario during the period from December 1, 2006, to November 30, 2008., Participants: A total of 44 849 patients, 53 full-time equivalent FPs, and 41 full-time equivalent NPs., Main Outcome Measures: Family physicians' and NPs' models of practice, the sociodemographic characteristics and medical profiles of patients who were treated in each model of practice, and FPs' and NPs' use of time., Results: Patients were attributed to 1 of 3 models of practice in CHCs based on the proportion of visits to FPs and NPs: FP care (53% of patients), NP care (29%), and shared care (18%). Patients who received care in the NP model of practice were younger and more likely to be female, be homeless, and not have postsecondary education.Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits. Patients who received care in the shared care model had intermediate profiles. Nurse practitioners performed more off-site care and walk-in visits. Family physicians and NPs spent a similar proportion of time performing various duties such as direct clinical care and administration tasks., Conclusion: Although NPs mainly cared for their own patient panels (in the NP care model), they did share some patients with FPs and provide some care to patients under the FP model of practice. Patients who were cared for by FPs and NPs had quite different characteristics.

Objective: To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care., Design: Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices., Setting: Three regions of Quebec., Participants: Health care professionals and staff of 5 PC practices., Methods: Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed., Main Findings: The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters., Conclusion: Irrespective of their models, PC practices' pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care., (Copyright© the College of Family Physicians of Canada.)

Problem Addressed: A key priority in primary health care research is determining how to ensure the advancement of new family physician clinician investigators (FP-CIs). However, there is little consensus on what expectations should be implemented for new investigators to ensure the successful and timely acquisition of independent salary support., Objective of Program: Support new FP-CIs to maximize early career research success., Program Description: This program description aims to summarize the administrative and financial support provided by the C.T. Lamont Primary Health Care Research Centre in Ottawa, Ont, to early career FP-CIs; delineate career expectations; and describe the results in terms of research productivity on the part of new FP-CIs., Conclusion: Family physician CI's achieved a high level of research productivity during their first 5 years, but most did not secure external salary support. It might be unrealistic to expect new FP-CIs to be self-financing by the end of 5 years. This is a career-development program, and supporting new career FP-CIs requires a long-term investment. This understanding is critical to fostering and strengthening sustainable primary care research programs.

Objective: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics., Design: Cross-sectional survey., Setting: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres)., Participants: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator., Main Outcome Measures: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care., Results: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access., Conclusion: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Objective: To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC., Design: Cross-sectional study., Setting: Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery., Participants: A total of 137 practices, 363 providers, and 5144 patients., Main Outcome Measures: Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations., Results: Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural., Conclusion: Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.

Objective: To compare the ability of users of 2 medical search engines, InfoClinique and the Trip database, to provide correct answers to clinical questions and to explore the perceived effects of the tools on the clinical decision-making process., Design: Randomized trial., Setting: Three family medicine units of the family medicine program of the Faculty of Medicine at Laval University in Quebec city, Que., Participants: Fifteen second-year family medicine residents., Intervention: Residents generated 30 structured questions about therapy or preventive treatment (2 questions per resident) based on clinical encounters. Using an Internet platform designed for the trial, each resident answered 20 of these questions (their own 2, plus 18 of the questions formulated by other residents, selected randomly) before and after searching for information with 1 of the 2 search engines. For each question, 5 residents were randomly assigned to begin their search with InfoClinique and 5 with the Trip database., Main Outcome Measures: The ability of residents to provide correct answers to clinical questions using the search engines, as determined by third-party evaluation. After answering each question, participants completed a questionnaire to assess their perception of the engine's effect on the decision-making process in clinical practice., Results: Of 300 possible pairs of answers (1 answer before and 1 after the initial search), 254 (85%) were produced by 14 residents. Of these, 132 (52%) and 122 (48%) pairs of answers concerned questions that had been assigned an initial search with InfoClinique and the Trip database, respectively. Both engines produced an important and similar absolute increase in the proportion of correct answers after searching (26% to 62% for InfoClinique, for an increase of 36%; 24% to 63% for the Trip database, for an increase of 39%; P = .68). For all 30 clinical questions, at least 1 resident produced the correct answer after searching with either search engine. The mean (SD) time of the initial search for each question was 23.5 (7.6) minutes with InfoClinique and 22.3 (7.8) minutes with the Trip database (P = .30). Participants' perceptions of each engine's effect on the decision-making process were very positive and similar for both search engines., Conclusion: Family medicine residents' ability to provide correct answers to clinical questions increased dramatically and similarly with the use of both InfoClinique and the Trip database. These tools have strong potential to increase the quality of medical care.

Objective: To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients., Design: We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management., Setting: Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont., Participants: A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes., Intervention: A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later., Main Outcome Measures: We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial., Results: At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50)., Conclusion: We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses., Trial Registration Number: NCT00238836 (ClinicalTrials.gov).

Objective: To test the accuracy of imputing a practice population's average socioeconomic characteristics (such as average education levels and average income) using census data centred on the location of the practice., Design: Comparison of census data with survey data collected in primary care offices., Setting: Ontario., Participants: A cross-sectional sample of patients from 116 urban practices., Main Outcome Measures: Patient data were compared with census data at different levels of aggregation using mean absolute relative error (ARE), median ARE, and Spearman rank correlations., Results: A total of 4413 patient surveys were collected. Differences between patient profiles and census data were large. Most mean AREs were clustered between 0.70 and 0.80, and median AREs were as high as 1.67. Correlations were low (ρ = 0.02) to moderate (ρ = 0.48). These results held across both levels of aggregation., Conclusion: The use of imputation techniques based on practice location is inadvisable, given the large differences that were observed.

Objective: To assess whether the model of service delivery affects the equity of the care provided across age groups., Design: Cross-sectional study., Setting: Ontario., Participants: One hundred thirty-seven practices, including traditional fee-for-service practices, salaried community health centres (CHCs), and capitation-based family health networks and health service organizations., Main Outcome Measures: To compare the quality of care across age groups using multilevel linear or logistic regressions. Health service delivery measures and health promotion were assessed through patient surveys (N = 5111), which were based on the Primary Care Assessment Tool, and prevention and chronic disease management were assessed, based on Canadian recommendations for care, through chart abstraction (N = 4108)., Results: Older individuals reported better health service delivery in all models. This age effect ranged from 1.9% to 5.7%, and was larger in the 2 capitation-based models. Individuals aged younger than 30 years attending CHCs had more features of disadvantage (ie, living below the poverty line and without high school education) and were more likely than older individuals to report discussing at least 1 health promotion subject at the index visit. These differences were deemed an appropriate response to greater needs in these younger individuals. The prevention score showed an age-sex interaction in all models, with adherence to recommended care dropping with age for women. These results are largely attributable to the fact that maneuvers recommended for younger women are considerably more likely to be performed than other maneuvers. Chronic disease management scores showed an inverted U relationship with age in fee-for-service practices, family health networks, and health service organizations but not in CHCs., Conclusion: The salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups. The thrust toward adopting capitation-based payment is unlikely to have an effect on age disparities.

Problem Addressed: A well documented gap remains between evidence and practice for clinical practice guidelines in cardiovascular disease (CVD) care., Objective of Program: As part of the Champlain CVD Prevention Strategy, practitioners in the Champlain District of Ontario launched a large quality-improvement initiative that focused on increasing the uptake in primary care practice settings of clinical guidelines for heart disease, stroke, diabetes, and CVD risk factors., Program Description: The Champlain Primary Care CVD Prevention and Management Guideline is a desktop resource for primary care clinicians working in the Champlain District. The guideline was developed by more than 45 local experts to summarize the latest evidence-based strategies for CVD prevention and management, as well as to increase awareness of local community-based programs and services., Conclusion: Evidence suggests that tailored strategies are important when implementing specific practice guidelines. This article describes the process of creating an integrated clinical guideline for improvement in the delivery of cardiovascular care.

Objective: To determine which of 4 organizational models of primary care in Ontario were more community oriented., Design: Cross-sectional investigation using practice and provider surveys derived from the Primary Care Assessment Tool, with nested qualitative case studies (2 practices per model)., Setting: Thirty-five fee-for-service family practices (including family health groups), 32 health service organizations, 35 family health networks, and 35 community health centres (CHCs) in Ontario., Participants: A total of 137 practices and 363 providers., Main Outcome Measures: Community orientation (CO) was assessed from the perspectives of the practices and the providers working in them. Practice CO scores reflect activities that practices use to reach out to their communities, assess the needs of their communities, and monitor or evaluate the effectiveness of their programs and services. The self-rated provider CO score reflects providers' participation in home visits and their perceptions of their own degree of CO., Results: At the practice level, CHCs had significantly higher CO scores than the other models did (P < .001 for most differences); in fact, the other models rarely reported meaningful levels of CO. Self-rated provider CO scores were also higher in CHCs, but were present in other models as well., Conclusion: Primary care providers in Ontario give themselves high ratings for CO; however, indicators of CO activity at the practice level were found to a significantly higher degree in CHCs than in the other models.

Unlabelled: BACKGROUND T o examine the methodology used to evaluate whether focusing the work of nurse practitioners and a pharmacist on frail and at-risk patients would improve the quality of care for such patients., Design: Evaluation of methodology of a randomized controlled trial including analysis of quantitative and qualitative data over time and analysis of cost-effectiveness., Setting: A single practice in a rural area near Ottawa, Ont., Participants: A total of 241 frail patients, aged 50 years and older, at risk of experiencing adverse health outcomes., Intervention: At-risk patients were randomly assigned to receive Anticipatory and Preventive Team Care (from their family physicians, 1 of 3 nurse practitioners, and a pharmacist) or usual care., Main Outcome Measures: The principal outcome for the study was the quality of care for chronic disease management. Secondary outcomes included other quality of care measures and evaluation of the program process and its cost-effectiveness. This article examines the effectiveness of the methodology used. Quantitative data from surveys, administrative databases, and medical records were supplemented with qualitative information from interviews, focus groups, work logs, and study notes., Conclusion: Three factors limit our ability to fully demonstrate the potential effects of this team structure. For reasons outside our control, the intervention duration was shorter than intended; the practice's physical layout did not facilitate interactions between the care providers; and contamination of the intervention effect into the control arm cannot be excluded. The study used a randomized design, relied on a multifaceted approach to evaluating its effects, and used several sources of data. TRIAL REGISTRATION NUMBER NCT00238836 (CONSORT).

Objective: To evaluate the cost-effectiveness of Anticipatory and Preventive Team Care (APTCare)., Design: Analysis of data drawn from a randomized controlled trial., Setting: A family health network in a rural area near Ottawa, Ont., Participants: Patients 50 years of age or older at risk of experiencing adverse health outcomes. Analysis of cost-effectiveness was performed for a subsample of participants with at least 1 of the chronic diseases used in the quality of care (QOC) measure (74 intervention and 78 control patients)., Interventions: At-risk patients were randomly assigned to receive usual care from their family physicians or APTCare from a collaborative team., Main Outcome Measures: Cost-effectiveness and the net benefit to society of the APTCare intervention., Results: Costs not directly associated with delivery of the intervention were similar in the 2 arms: $9121 and $9222 for the APTCare and control arms, respectively. Costs directly associated with the program were $3802 per patient for a total cost per patient of $12,923 and $9222, respectively (P=.033). A 1% improvement in QOC was estimated to cost $407 per patient. Analysis of the net benefit to society in absolute dollars found a breakeven threshold of $750 when statistical significance was required. This implies that society must place a value of at least $750 on a 1% improvement in QOC in order for the intervention to be socially worthwhile. By any of the metrics used, the APTCare intervention was not cost-effective, at least not in a population for which baseline QOC was high., Conclusion: Although our calculations suggest that the APTCare intervention was not cost-effective, our results need the following caveats. The costs of such a newly introduced intervention are bound to be higher than those for an established, up-and-running program. Furthermore, it is possible that some benefits of the secondary preventive measures were not captured in this limited 12- to 18-month study or were simply not measured. TRIAL REGISTRATION NUMBER NCT00238836 (CONSORT).

Objective: T o examine whether quality of care (QOC) improves when nurse practitioners and pharmacists work with family physicians in community practice and focus their work on patients who are 50 years of age and older and considered to be at risk of experiencing adverse health outcomes., Design: Randomized controlled trial., Setting: A family health network with 8 family physicians, 5 nurses, and 11 administrative personnel serving 10 000 patients in a rural area near Ottawa, Ont., Participants: Patients 50 years of age and older at risk of experiencing adverse health outcomes (N = 241)., Interventions: At-risk patients were randomly assigned to receive usual care from their family physicians or Anticipatory and Preventive Team Care (APTCare) from a collaborative team composed of their physicians, 1 of 3 nurse practitioners, and a pharmacist., Main Outcome Measures: Quality of care for chronic disease management (CDM) for diabetes, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease., Results: Controlling for baseline demographic characteristics, the APTCare approach improved CDM QOC by 9.2% (P < .001) compared with traditional care. The APTCare intervention also improved preventive care by 16.5% (P < .001). We did not observe significant differences in other secondary outcome measures (intermediate clinical outcomes, quality of life [Short-Form 36 and health-related quality of life scales], functional status [instrumental activities of daily living scale] and service usage)., Conclusion: Additional resources in the form of collaborative multidisciplinary care teams with intensive interventions in primary care can improve QOC for CDM in a population of older at-risk patients. The appropriateness of this intervention will depend on its cost-effectiveness. TRIAL REGISTRATION NUMBER NCT00238836 (CONSORT).

Problem Being Addressed: 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. OBJECTIVE OF THE PROGRAM To focus on the needs of individuals, teams, and the organization in order to ensure the success of research projects., Program Description: 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., Conclusion: 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.

Objective: To explore family physicians' perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices., Design: Qualitative design using focus groups followed by semistructured interviews., Setting: Seven physician-led group family practices in urban, suburban, and semirural Ontario communities., Participants: Twelve purposively selected family physicians participating in the IMPACT (Integrating family Medicine and Pharmacy to Advance primary Care Therapeutics) project., Methods: We conducted 4 exploratory focus groups to gather information on collaborative practice issues in order to construct our interview guide. We later interviewed 12 physicians 1 year into the integration process. Focus groups and interviews were audiotaped and transcribed verbatim. Four researchers used immersion and crystallization techniques to identify codes for the data and thematic editing to distil participants' perspectives on physician-pharmacist collaborative practice. FINDINGS The focus groups revealed concerns relating to operational efficiencies, medicolegal implications, effects on patient-physician relationships, and work satisfaction. The follow-up semistructured interviews revealed ongoing operational challenges, but several issues had resolved and clinical and practice-level benefits surfaced. Clinical benefits included having colleagues to provide reliable drug information, gaining fresh perspectives, and having increased security in prescribing. Practice-level benefits included group education, liaison with community pharmacies, and an enhanced sense of team. Persistent operational challenges included finding time to learn about pharmacists' role and skills and insufficient space in practices to accommodate both professionals., Conclusion: Physicians' perspectives on collaborative practice 12 months after pharmacists were integrated into their family practices were positive overall. Some ongoing operational challenges remained. Several of the early concerns about collaborative practice had been resolved as physicians discovered the benefits of working with pharmacists, such as increased security in prescribing.

Objective: To assess the extent to which advances in preventive care delivery, achieved in primary care practices through outreach facilitation, could be sustained over time after purposefully redirecting the focus of practice physicians and staff away from prevention and toward a new content area in need of improvement-chronic illness management., Design: Before-and-after study., Setting: Primary care networks and family health networks in Ontario., Participants: A volunteer sample of 30 primary care practices recruited from 99 eligible sites., Intervention: Outreach visits directed at modifying physician behaviour were delivered by trained nurse facilitators using practice-tailored systems strategies. For the first 12 months, the intervention focused on improving delivery of preventive care, after which facilitation of chronic illness management was introduced for another 3 to 9 months., Main Outcome Measures: Changes in practices' performance rates for selected preventive maneuvers (according to recommendations of the Canadian Task Force on Preventive Health Care) between baseline and follow-up, conducted 3 to 9 months after the end of the prevention intervention, measured from chart reviews for those maneuvers likely to be recorded and from telephoneinterviews with patients for lifestyle counseling., Results: Four of the 30 practices dropped out of the study. In the remaining practices, at the postintervention follow-up, there was an increase in the delivery of the appropriate grade A (19.3%, 95% confidence interval [CI] 10.4% to 28.3%) and B (9.3%, 95% CI 5.4% to 13.2%) maneuvers, accompanied by a reduction in inappropriate grade D maneuvers (-15.9%, 95% CI -22.1% to -9.6%), for an absolute improvement of 12% (P < .0001) in the overall preventive care performance, as determined by a chart audit. We found no changes in the provision of lifestyle counseling maneuvers measured from telephone interviews with patients (1.3%, 95% CI 1.0% to 3.7%)., Conclusion: The tailored, multifaceted intervention delivered by nurse facilitators was effective in producing significant improvements in preventive care performance that extended beyond the prevention intervention period.

Objective: To explore factors affecting collaboration between family physicians and psychologists., Design: Mailed French-language survey., Setting: Eastern Ontario., Participants: Family physicians practising in the area of the Réseau des services de santé en français de l'Est de l'Ontario., Main Outcome Measures: Physicians' knowledge and understanding of the qualifications of psychologists and the regulations governing their profession; beliefs regarding the effectiveness of psychological treatments; views on the integration of psychologists into primary care; and factors affecting referrals to psychologists., Results: Of 457 surveys sent, 118 were returned and analyzed (27% of surveys delivered). Most family physicians were well aware that there were evidence-based psychological interventions for mental health and personal difficulties, and some knew that psychological interventions could help with physical conditions. Physicians had some knowledge about the qualifications and training of psychologists. Many physicians reported being uncomfortable providing counseling themselves owing to time constraints, the perception that they were inadequately trained for such work, and personal preferences. The largest barrier to referring patients to psychologists was cost, since services were not covered by public health insurance. Some physicians were deterred from referring by previous experience of not receiving feedback on patients from psychologists. Increased access to clinical psychologists through collaborative care was considered a desirable goal for primary health care., Conclusions: Family physicians know that there are evidence-based psychological interventions for mental health issues. Psychologists need to communicate better about their credentials and what they can offer, and share their professional opinions and recommendations on referred patients. Physicians would welcome practice-based psychological services and integrated interdisciplinary collaboration as recommended by the Kirby and Romanow commissions, but such collaboration is hampered by the lack of public health insurance coverage.

Objective: To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals., Design: Single-arm study with historical controls., Setting: Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario., Participants: Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity., Interventions: Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone., Main Outcome Measures: Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and costs incurred by community home-care services for patients following discharge from hospital., Results: The outcomes of 43 hospital admissions were matched with those of 363 controls. Patients enrolled in the program stayed longer in hospital (coefficient 3.3 days, P < .001), used more community care services following discharge (coefficient $729, P = .007), and were more likely to be readmitted to hospital within 3 months of discharge (coefficient 17%, P = .012) than patients treated in hospital. Total substituted costs of home-based care were not significantly different from the costs of hospitalization (coefficient -$501, P = .11)., Conclusion: While estimated cost savings were not statistically significant, the limitations of our study suggest that we underestimated these savings. In particular, the economic inefficiencies of a small immature program and the inability to control for certain factors when selecting historical controls affected our results. Further research is needed to determine the economic effect of mature home-based programs.

Objective: To examine the feasibility and efficacy of integrating home health monitoring into a primary care setting., Design: A mixed method was used for this pilot study. It included in-depth interviews, focus groups, and surveys., Setting: A semirural family health network in eastern Ontario comprising 8 physicians and 5 nurses caring for approximately 10 000 patients., Participants: Purposeful sample of 22 patients chosen from the experimental group of 120 patients 50 years old or older in a larger randomized controlled trial (N = 240). These patients had chronic illnesses and were identified as being at risk based on objective criteria and physician assessment., Interventions: Between November 2004 and March 2006, 3 nurse practitioners and a pharmacist installed telehomecare units with 1 or more peripheral devices (eg, blood-pressure monitor, weight scale, glucometer) in patients' homes. The nurse practitioners incorporated individualized instructions for using the unit into each patient's care plan. Patients used the units every morning for collecting data, entering values into the system either manually or directly through supplied peripherals. The information was transferred to a secure server and was then uploaded to a secure Web-based application that allowed care providers to access and review it from any location with Internet access. The devices were monitored in the office on weekdays by the nurse practitioners., Main Outcome Measures: Acceptance and use of the units, patients' and care providers' satisfaction with the system, and patients' demographic and health characteristics., Results: All 22 patients, 12 men and 10 women with an average age of 73 years (range 60 to 88 years), agreed to participate. Most were retired, and a few were receiving community services. Common diagnoses included hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease. All patients had blood pressure monitors installed, 11 had wired weight scales,5 had glucometers, and 5 had pulse oximeters. The units were in place for 9 to 339 days. Three patients asked to have the systems removed early because they did not use them or found them inconvenient. The other patients and their informal caregivers found the technology user-friendly and useful. Health care providers were satisfied with the technology and found the equipment useful. They thought it might reduce the number of office visits patients made and help track long-term trends., Conclusion: These pilot results demonstrate that telehomecare monitoring in a collaborative care community family practice is feasible and well used, and might improve access to and quality of care.

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.

Objective: To describe Ottawa family physicians' perceptions of their preparedness to respond to outbreaks of infectious diseases or other public health emergencies and to assess their capacity and willingness to assist in the event of such emergencies., Design: Cross-sectional self-administered survey conducted between February 11 and March 10, 2004., Setting: The City of Ottawa, Ont, and the Department of Family Medicine at the University of Ottawa., Participants: Ottawa family physicians; respondents can be considered a self-selected sample., Main Outcome Measures: Self-reported office preparedness and physicians' capacity and willingness to respond to public health emergencies., Results: Response rate was 41%. Of 676 physicians contacted, 274 responded, and of those, 246 completed surveys. About 26% of respondents felt prepared for an outbreak of influenza not well covered by vaccine. About 18% felt prepared for serious respiratory epidemics, such as severe acute respiratory syndrome; about 50% felt unprepared. Most respondents (80%) thought they were not ready to respond to an earthquake. About 77% of physicians were willing to be contacted on an urgent basis in case of a public health emergency. Of these, 94% would assist in immunization clinics, 84% in antibiotic clinics, 58% in assessment centres, 52% in treatment centres, 41% with declaration of death, 26% with home care, and 23% with telephone counseling., Conclusion: Family physicians appear to be unprepared for, but willing to address, serious public health emergencies. It is essential to set up effective partnerships between primary care and public health services to support family physicians' capacity to respond to emergencies. This type of study, along with the creation of a register of available services and of a virtual network for sharing information, is an initial step in assessing primary care response.

Objective: To promote incorporation of new guidelines on control of respiratory infections into family physicians' practices., Sources of Information: The World Health Organization website on pandemic influenza, the Canadian Pandemic Influenza Plan, the Ontario guidelines on respiratory infection control, and research on implementing guidelines into family practice were reviewed. We also researched and calculated what the costs of implementing the guidelines would be., Main Message: Effective control of respiratory infections in physicians' offices can be achieved by displaying signs in the waiting room, having reception staff give masks to patients with cough and fever, instructing these patients to clean their hands with alcohol gel and to sit at least 1 m from others, inquiring about patients' or their close contacts' recent travel, using disinfectant wipes to clean possibly contaminated surfaces in waiting rooms and examining areas, and having staff and care providers wear masks and wash hands or use alcohol gel. The approximate annual cost of incorporating the guidelines is about 800 dollars per physician., Conclusion: Because the outbreak of an influenza pandemic is likely imminent, implementing standard guidelines for control of respiratory infections in primary care offices seems wise. Following these guidelines would help prevent patients and staff from contracting serious respiratory illnesses.

Objective: To determine the effectiveness of a short-term intervention to promote best practices for control of respiratory infections in primary care physicians' offices., Design: Before-after observational study., Setting: Family physicians' offices in Ottawa, Ont., Participants: General practitioners and office staff., Interventions: Four infection-control practices (use of masks, alcohol-based hand gel, and signs, and asking patients to sit at least 1 m apart in the waiting room) were observed, and 2 reported infection-control practices (disinfecting surfaces and use of hand-gel dispensers in examining rooms) were audited before the intervention and 6 weeks after the intervention., Main Outcome Measures: Percentage of patients asked to use masks and alcohol-based hand gel, number of relevant signs, and percentage of patients asked to sit at least 1 m away from other patients. Percentage of surfaces disinfected and percentage of physicians using hand-gel dispensers in examining rooms., Results: Of 242 practices invited, 53 agreed to participate (22% response rate), and within those practices, 143/151 (95%) physicians participated. Signs regarding respiratory infection control measures increased from 15.4% to 81.1% following the intervention (P < .001). At least 1 patient with cough and fever was given a mask in 17% of practices before the intervention; during the observation period after the intervention, at least 1 patient was given a mask in 66.7% of practices (P < .001). Patients were instructed to use alcohol-based hand gel in 24.5% of practices before the intervention and in 79.2% of practices after it (P < .001). Instruction to sit at least 1 m from others in the waiting area was given in 39.6% of practices before the intervention and in 52.8% of practices following the intervention (P < .001). Before the intervention, the percentage of practices using all 4 audited primary prevention measures was 3.8%; after the intervention, 52.8% of practices were using them (P < .001), demonstrating a 49% increase in adoption of best practices., Conclusion: A multifaceted intervention by public health nurses successfully promoted best practices for control of respiratory infections in primary care offices. Collaboration between public health services and primary care can promote best practices and warrants further study and development in areas of common interest.

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.