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Introduction: Canadian emergency departments (ED) are struggling to provide timely emergency care. Very few studies have assessed attempts to improve ED patient flow in the rural context. We assessed the impact of SurgeCon, an ED patient-management protocol, on total patient visits, patients who left without being seen (LWBS), length of stay for departed patients (LOSDep), and physician initial assessment time (PIA) in a rural community hospital ED.Methods: We implemented a set of commonly used methods for increasing ED efficiency with an innovative approach over 45 months. Our intervention involved seven parts comprised of an external review, Lean training, fast track implementation, patient-centeredness approach, door-to-doctor approach, performance reporting, and an action-based surge capacity protocol. We measured key performance indicators including total patient visits (count), PIA (minutes), LWBS (percentage), and LOSDep (minutes) before and after the SurgeCon intervention. We also performed an interrupted time series (ITS) analysis.Results: During the study period, 80,709 people visited the ED. PIA decreased from 104.3 (±9.9) minutes to 42.2 (±8.1) minutes, LOSDep decreased from 199.4 (±16.8) minutes to 134.4(±14.5) minutes, and LWBS decreased from 12.1% (±2.2) to 4.6% (±1.7) despite a 25.7% increase in patient volume between pre-intervention and post-intervention stages. The ITS analysis revealed a significant level change in PIA – 19.8 minutes (p

Context: Cancer and chronic disease prevention and screening (CCDPS) guidelines are not consistently applied in primary care. Furthermore, while most patients have multiple risks and conditions, guidelines are focused on a specific disease or organ system. The BETTER program (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) involves an evidence-based intervention provided by an allied health professional within a primary care practice who acquires advanced skills in CCDPS and takes on the role of Prevention Practitioner (PP). Using the BETTER toolkit, created through a rigorous process of knowledge synthesis and harmonization of recommendations, the PP meets with patients for a personalized prevention visit. Objective: To describe the: 1) evidence review process used to identify high-quality clinical practice guidelines (CPGs), 2) harmonization of primary prevention and screening recommendations, and 3) identification, development, and refinement of resources and tools for inclusion in the BETTER toolkit. The BETTER toolkit will be used to inform CCDPS in rural, remote, and urban primary care settings across Canada. Methods: In 2017, the BETTER Program conducted a literature review of evidence-based CPGs published between 2010 and 2016. For this update, high-quality international, Canadian, and Provincial CPGs published between 2016 and 2021, focusing on primary prevention and screening of cancer and chronic disease, and applicable to patients 40-69 years of age were identified. A Clinical Working Group consisting of decision-makers, researchers, clinicians, and a patient representative across Canada was split up into 3 topic review teams. A total of 19 CCDPS topics within scope for BETTER were identified. Topic teams reviewed the literature and synthesized guidelines based on evidence for their topic and updated the toolkits to inform the PP role. Results: Development of an updated care map that considers family history and risk factor assessment that is tailored to the patient and adaptable to diverse practice settings. Conclusions: Synthesized and evidence-based integrated care plans can be used to assess patients' CCDPS risk and preferences in diverse populations in Canada. The updated toolkit will facilitate the application of recommendations for the primary prevention of cancer and chronic disease in patients 40-69 years of age., Presenters Donna Manca, MD, MCLSC, Denise Campbell-Scherer, MD, PhD, Carolina Fernandes, MA, MSc, Eva Grunfeld, MD, PhD, FCFP, Kris Aubrey-Bassler, MD, FCFP, MSc, Aisha Lofters, MD, Katherine Latko, CDE, RD, [...]

Background: The original 'BETTER' (Building on Existing Tools To Improve Chronic Disease Prevention and Screening in Primary Care) approach consisted of a prevention-focused visit between participants aged 40–65 years and a "Prevention Practitioner" (PP), who empowered the participant to set achievable prevention and screening goals for cancers and chronic diseases. BETTER was successfully adapted for economically deprived communities (BETTER HEALTH) in Canada. Our objective was to conduct a review of guidelines in preparation for adapting the 'BETTER HEALTH' approach for younger adults aged 18–39 years living with lower income, a group known to have earlier mortality due to a higher prevalence of preventable chronic diseases than their peers with higher income. Methods: We searched multiple electronic databases and grey literature for clinical practice guidelines on prevention/screening and included those that met the following criteria: published in English from 2008–2020 in Canada or any of the following countries (Australia, Ireland, New Zealand, Scotland, United States and England); and addressed prevention or screening. We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and extracted data (publication details, recommendations, and Quality/Level of evidence as reported by authors) from sources with overall scores of 5 or higher. Final recommendations were compiled after harmonization with input from diverse stakeholders (co-investigators, PPs, and the Community Advisory Committee). Results: We included a total of 85 guidelines, and developed a final list of 42 recommendations for 18–39 year-olds across 21 topics. Specific recommendations fell under the following topics: cancers, cardiovascular disease, diabetes, obesity, lifestyle (alcohol; healthy nutrition/physical activity); healthy relationships and healthy sexuality, immunization, oral health, social determinants of health, and substance use. Conclusion: We identified evidence-based guidelines on individual-level prevention/screening actions for adults 18–39 years old and relevant for those living with lower income which will directly inform development and implementation of the BETTER LIFE intervention. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. Methods: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40–69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. Results: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40–69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. Conclusions: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care. [ABSTRACT FROM AUTHOR]

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial demonstrated the effectiveness of an approach to chronic disease prevention and screening (CDPS) through a new skilled role of a 'prevention practitioner'(PP). The PP has appointments with patients 40-65 years of age that focus on primary prevention activities and screening of cancer (breast, colorectal, cervical), diabetes and cardiovascular disease and associated lifestyle factors. There are numerous and occasionally conflicting evidence-based guidelines for CDPS, and the majority of these guidelines are focused on specific diseases or conditions; however, primary care providers often attend to patients with multiple conditions. To ensure that high-level evidence guidelines were used, existing clinical practice guidelines and tools were reviewed and integrated into blended BETTER tool kits. Building on the results of the BETTER trial, the BETTER tools were updated for implementation of the BETTER 2 program into participating urban, rural and remote communities across Canada.MethodsA clinical working group consisting of PPs, clinicians and researchers with support from the Centre for Effective Practice reviewed the literature to update, revise and adapt the integrated evidence algorithms and tool kits used in the BETTER trial. These resources are nuanced, based on individual patient risk, values and preferences and are designed to facilitate decision-making between providers across the target diseases and lifestyle factors included in the BETTER 2 program. Using the updated BETTER 2 toolkit, clinicians 1) determine which CDPS actions patients are eligible to receive and 2) develop individualized 'prevention prescriptions' with patients through shared decision-making and motivational interviewing.ResultsThe tools identify the patients' risks and eligible primary CDPS activities: the patient survey captures the patient's health history; the prevention visit form and integrated CDPS care map identify eligible CDPS activities and facilitate decisions when certain conditions are met; and the 'bubble diagram' and 'prevention prescription' promote shared decision-making.ConclusionThe integrated clinical decision-making tools of BETTER 2 provide resources for clinicians and policymakers that address patients' complex care needs beyond single disease approaches and can be adapted to facilitate CDPS in the urban, rural and remote clinical setting.Trial registrationThe registration number of the original RCT BETTER trial was ISRCTN07170460 .

PURPOSE Case management (CM) is a promising intervention for frequent users of health care services. Our research question was how and under what circumstances does CM in primary care work to improve outcomes among frequent users with chronic conditions? METHODS We conducted a realist synthesis, searching MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) for articles meeting the following criteria: (1) population: adult frequent users with chronic disease, (2) intervention: CM in a primary care setting with a postintervention evaluation, and (3) primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Academic and gray literature were evaluated for relevance and robustness. Independent reviewers extracted data to identify context, mechanism, and outcome (CMO) configurations. Analysis of CMO configurations allowed for the modification of an initial program theory toward a refined program theory. RESULTS Of the 9,295 records retrieved, 21 peer-reviewed articles and an additional 89 documents were retained. We evaluated 19 CM interventions and identified 11 CMO configurations. The development of a trusting relationship fostering patient and clinician engagement in the CM intervention was recurrent in many CMO configurations. CONCLUSION Our refined program theory proposes that in the context of easy access to an experienced and trusted case manager who provides comprehensive care while maintaining positive interactions with patients, the development of this relationship fosters the engagement of both individuals and yields positive outcomes when the following mechanisms are triggered: patients and clinicians feel supported, respected, accepted, engaged, and committed; and patients feel less anxious, more secure, and empowered to self-manage., INTRODUCTION Frequent users of health care services are a small proportion of the population who account for a disproportionate number of visits to emergency departments, thereby placing a heavy strain [...]

Case management (CM) is an intervention for improving integrated care for patients with complex care needs. The implementation of this complex intervention often raises opportunities for change and collective leadership has the potential to optimize the implementation. However, the application of collective leadership in real-world is not often described in the literature. This commentary highlights challenges faced during the implantation of a CM intervention in primary care for people with complex care needs, including stakeholders' buy-in and providers' willingness to change their practice, selection of the best person for the case manager position and staff turnover. Based on lessons learned from PriCARE research program, this paper encourages researchers to adopt collective leadership strategies for the implementation of complex interventions, including promoting a collaborative approach, fostering stakeholders' engagement in a trusting and fair environment, providing a high level of communication, and enhancing collective leadership attitudes and skills. The learnings from the PriCARE program may help guide researchers for implementing complex healthcare interventions. [ABSTRACT FROM AUTHOR]

Introduction: Although a large portion of the Canadian population lives in rural areas, there remains a deficit in the number of family physicians serving these populations. We explored the factors that influence a family physician's decision to work in rural/ remote communities in order to identify strategies that may aid in the recruitment and retention of family physicians to such communities. Methods: Qualitative study using a participatory research approach. Interview questions were developed based on a literature search of factors influencing family physicians' decisions to practise in a rural/remote location. Semistructured interviews were conducted with rural physicians from across Canada to identify influential factors, and subsequent thematic analysis was performed. Responses to the interview questions were categorized into 3 main themes: factors influencing physicians to work in rural locations, factors influencing physicians to leave or avoid rural practice, and strategies for improving recruitment and retention. Results: Seventeen interviews were conducted; saturation was achieved after 12. A wide scope of practice and rural training exposure were important factors in encouraging physicians to practise in rural/remote areas. The biggest challenges were issues relating to family and spousal support, ability to attend continuing professional educational opportunities and ability to connect with specialists and tertiary care centres. Conclusion: Effective strategies are required to increase family physician recruitment to rural communities. Our results provide several strategies for addressing low rates of recruitment and retention of family physicians in rural/remote communities, including, but not limited to, providing opportunities for professional development and having a supportive work environment. Introduction : Bien qu'une partie importante de la population canadienne vive en milieu rural, il y a un nombre insuffisant de medecins de famille pour servir cette population. Nous avons tente de determiner les facteurs qui incitent les medecins de famille a travailler en region rurale et eloignee afin de proposer des strategies susceptibles de favoriser le recrutement et le maintien en poste de medecins de famille dans ces localites. Methodes : Nous avons procede a une etude qualitative a l'aide dune approche de recherche participative. Les questions d'entrevue ont ete elaborees a la suite dune recherche documentaire sur les facteurs qui incitent les medecins de famille a exercer en milieu rural et eloigne. Des entretiens semi-structures ont ete menes aupres de medecins de regions rurales partout au Canada afin de cerner les facteurs d'influence et soumettre ensuite ces derniers a des analyses thematiques. Les reponses aux questions d'entrevue ont ete divisees en 3 themes principaux : facteurs qui incitent les medecins a travailler en milieu rural; facteurs qui incitent les medecins a quitter la pratique en milieu rural ou a l'eviter; et strategies d'amelioration du recrutement et du maintien en poste. Resultats : Dix-sept entretiens ont ete realises et la saturation a ete atteinte apres 12 entretiens. Le vaste champ de pratique et l'exposition a la formation rurale etaient des facteurs importants de la decision des medecins d'exercer en region rurale et eloignee. Les principales difficultes etaient liees au soutien de la famille et du conjoint ou de la conjointe, a la capacite de participer a la formation continue, et a la capacite de contact avec des specialistes et des centres de soins tertiaires. Conclusion : Nous avons besoin de strategies efficaces pour accroitre le recrutement de medecins de famille dans les localites rurales. Nos resultats offrent plusieurs strategies pour s'attaquer aux faibles taux de recrutement et de maintien en poste, notamment le fait de beneficier d'occasions de formation continue et de milieux de travail favorables qui offrent du soutien., INTRODUCTION Considering that over a third of Canadas population lives in rural areas, (1) it is assumed that the proportion of family physicians in these areas reflect the same statistic. [...]