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Introduction: Family Medicine Groups, implemented in Quebec in 2002, are interprofessional primary care teams designed to improve timely access to high-quality primary care. This study investigates whether Family Medicine Groups increased rates of guideline-recommended screenings for 3 chronic diseases: colorectal cancer (colonoscopy/sigmoidoscopy), breast cancer (mammography), and osteoporosis (bone mineral density testing)., Methods: Using population-based administrative health data from the provincial insurer (2000-2010), the authors examined elderly and chronically ill patients who registered with a general practitioner in the first 15 months of the Family Medicine Group policy. Propensity score weighting and a difference-in-differences model estimated differential change in biennial screening rates among Family Medicine Group and non-Family Medicine Group patients over 5 years of follow-up (analysis, 2016-2018)., Results: Rates of mammography, colonoscopy/sigmoidoscopy, and bone mineral density testing increased after patient registration with a general practitioner, similarly for both Family Medicine Group and non-Family Medicine Group patients. Colonoscopy/sigmoidoscopy rates increased by 9.7% and 10.4% for Family Medicine Group and non-Family Medicine Group patients, mammography rates by 5.3% and 3.4%, and bone mineral density testing by 4.2% and 7.1%. Difference-in-differences estimates showed no detectable effect of Family Medicine Groups on disease screening rates: -0.06 percentage points (95% CI= -0.32, 0.20) for colonoscopy/sigmoidoscopy, 1.01 percentage points (95% CI= -0.25, 2.27) for mammography, and -0.32 (95% CI= -0.71, -0.07) for bone mineral density testing., Conclusions: This study found no evidence that Family Medicine Groups affected screening rates for these 3 chronic diseases. Limitations in the implementation of the Family Medicine Group policy in its early years may have contributed to this lack of impact. Interprofessional primary care teams may need to include elements other than organizational changes to increase disease prevention efforts., (Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the mechanisms associated with success and failure of chronic disease prevention and management (CDPM) programs, as well as their key contexts., Design: Realist synthesis., Setting: Six primary care CDPM programs funded between 2011 and 2013 in Quebec., Participants: Patients, health providers, program leaders, and other stakeholders involved in CDPM programs., Methods: A collaborative research process was implemented, involving representatives from the executive and advisory committees: researchers, health care providers, decision makers, and patients and families. Leaders were asked to provide all documents related to their programs to the research team. The documents were selected depending on their relevance and rigour. The thematic analysis of each program consisted of identifying the outcomes and mechanisms, as well as the specific contexts associated with these outcomes. Results for each program were validated by its leader before synthesizing the results of all programs together., Main Findings: A total of 108 documents (eg, grant applications, scientific reports) were collected from the programs. Positive and negative outcomes were observed at the patient, health care provider, and health care system levels. Four main mechanism categories were associated with outcomes: patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners. The main contextual factors that influenced the successes of these mechanisms were related to patients (multimorbidity, involvement of family caregivers), to health care providers (professional training, culture of interprofessional collaboration, mobilization of family physician), and to health care organizations (coordination between services, history of collaboration between partners, funding)., Conclusion: This study confirms the essential role of patient-centred interdisciplinary care; self-management support and a motivational approach; professional support; and care coordination and relationships with partners when caring for patients with chronic diseases. It constitutes a relevant contribution for stakeholders involved in primary care transformation and should be used to inform the sustainability and scaling up of CDPM programs., (Copyright© the College of Family Physicians of Canada.)

Warfarin is primarily metabolized by cytochrome 2C9, encoded by gene CYP2C9. Here, we investigated whether variants in nuclear receptor genes which regulate the expression of CYP2C9 are associated with warfarin response. We used data from 906 warfarin users from the Quebec Warfarin Cohort (QWC) and tested the association of warfarin dose requirement at 3 months following the initiation of therapy in nine nuclear receptor genes: NR1I3, NR1I2, NR3C1, ESR1, GATA4, RXRA, VDR, CEBPA, and HNF4A. Three correlated SNPs in the VDR gene (rs4760658, rs11168292, and rs11168293) were associated with dose requirements of warfarin (P = 2.68 × 10 -5 , P = 5.81 × 10 -4 , and P = 5.94 × 10 -4 , respectively). Required doses of warfarin were the highest for homozygotes of the minor allele at the VDR variants (P < 0.0026). Variants in the VDR gene were associated with the variability in response to warfarin, emphasizing the possible clinical relevance of nuclear receptor gene variants on the inter-individual variability in drug metabolism.

Introduction: In 2011, the Agence de la santé et des services sociaux de Montréal (ASSSM), in partnership with the region's Centres de santé et de services sociaux (CSSS), coordinated the implementation of a program on cardiometabolic risk based on the Chronic Care Model. The program, intended for patients suffering from diabetes or hypertension, involved a series of individual follow-up appointments, group classes and exercise sessions. Our study assesses the impact on patient health outcomes of variations in the implementation of some aspects of the program among the six CSSSs taking part in the study., Methods: The evaluation was carried out using a quasi-experimental "before and after" design. Implementation variables were constructed based on data collected during the implementation analysis regarding resources, compliance with the clinical process set out in the regional program, the program experience and internal coordination within the care team. Differences in differences using propensity scores were calculated for HbA1c results, achieving the blood pressure (BP) target, and two lifestyle targets (exercise level and carbohydrate distribution) at the 6- and 12-month follow-ups, based on greater or lesser patient exposure to the implementation of various aspects of the program under study., Results: The results focus on 1185 patients for whom we had data at the 6-month follow- up and the 992 patients from the 12-month follow-up. The difference in differences analysis shows no clear association between the extent of implementation of the various aspects of the program under study and patient health outcomes., Conclusion: The program produces effects on selected health indicators independent of variations in program implementation among the CSSSs taking part in the study. The results suggest that the effects of this type of program are more highly dependent on the delivery of interventions to patients than on the organizational aspects of its implementation., Competing Interests: The authors have no conflicts of interest to declare.

Size of primary health care (PHC) practices is often used as a proxy for various organizational characteristics related to provision of care. The objective of this article is to identify some of these organizational characteristics and to determine the extent to which they mediate the relationship between size of PHC practice and patients' experience of care, preventive services, and unmet needs. In 2010, we conducted population and organization surveys in 2 regions of the province of Quebec. We carried out multilevel linear and logistic regression analyses, adjusting for respondents' individual characteristics. Size of PHC practice was associated with organizational characteristics and resources, patients' experience of care, unmet needs, and preventive services. Overall, the larger the size of a practice, the higher the accessibility, but the lower the continuity. However, these associations faded away when organizational variables were introduced in the analysis model. This result supports the hypothesized mediating effect of organizational characteristics on relationships between practice size and patients' experience of care, preventive services, and unmet needs. Our results indicate that size does not add much information to organizational characteristics. Using size as a proxy for organizational characteristics can even be misleading because its relationships with different outcomes are highly variable., (© The Author(s) 2016.)

Background: Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation., Methods: The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis., Results and Discussion: Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event., Conclusion: The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

Aim: To assess the extent to which new forms of PHC organization - Family medicine groups (FMG) and Network clinics (NC) - established in Quebec since 2003, are associated with a better experience of care than other forms of PHC organization, for patients with chronic diseases., Methods: Two surveys were conducted in 2010 in two regions of Quebec: the first among 9,180 residents and the second among 606 PHC organizations. Indices of experience of care were constructed concerning accessibility, continuity, comprehensiveness and perceived outcomes. Five categories of chronic diseases were selected. Descriptive analyses and multilevel regression analyses were conducted to compare the different forms of PHC organization., Results: Individuals with chronic diseases tend to report a better experience of care than those without chronic diseases for all dimensions except for accessibility. FMGs compare to group practices on all dimensions and NCs are associated with a poorer experience of care on most dimensions., Conclusion: Experience of care associated with FMGs and NCs is not superior to that associated with group practices.

Background: Healthcare reforms initiated in the early 2000s in Québec involved the implementation of new modes of primary healthcare (PHC) delivery and the creation of Health and Social Services Centers (HSSCs) to support it. The objective of this article is to assess and explain the degree of PHC organizational change achieved following these reforms., Methods: We conducted two surveys of PHC organizations, in 2005 and 2010, in two regions of the province of Québec, Canada. From the responses to these surveys, we derived a measure of organizational change based on an index of conformity to an ideal type (ICIT). One set of explanatory variables was contextual, related to coercive, normative and mimetic influences; the other consisted of organizational variables that measured receptivity towards new PHC models. Multilevel analyses were performed to examine the relationships between ICIT change in the post-reform period and the explanatory variables., Results: Positive results were attained, as expressed by increase in the ICIT score in the post-reform period, mainly due to implementation of new types of PHC organizations (Family Medicine Groups and Network Clinics). Organizational receptivity was the main explanatory variable mediating the effect of coercive and mimetic influences. Normative influence was not a significant factor in explaining changes., Conclusion: Changes were modest at the system level but important with regard to new forms of PHC organizations. The top-down decreed reform was a determining factor in initiating change whereas local coercive and normative influences did not play a major role. The exemplar role played by certain PHC organizations through mimetic influence was more important. Receptivity of individual organizations was both a necessary condition and a mediating factor in influencing change. This supports the view that a combination of top-down and bottom-up strategy is best suited for achieving substantial changes in PHC local organization.

Background: The goal of this project is to evaluate the implementation of an integrated and interdisciplinary program for prevention and management of cardiometabolic risk (PCMR). The intervention is based on the Chronic Care Model. The study will evaluate the implementation of the PCMR in 6 of the 12 health and social services centres (CSSS) in Montréal, and the effects of the PCMR on patients and the practice of their primary care physicians up to 40 months following implementation, as well as the sustainability of the program. Objectives are: 1-to evaluate the effects of the PCMR and their persistence on patients registered in the program and the practice of their primary care physicians, by implementation site and degree of exposure to the program; 2-to assess the degree of implementation of PCMR in each CSSS territory and identify related contextual factors; 3-to establish the relationships between the effects observed, the degree of PCMR implementation and the related contextual factors; 4-to assess the impact of the PCMR on strengthening local services networks., Methods/design: The evaluation will use a mixed design that includes two complementary research strategies. The first strategy is similar to a quasi-experimental "before-after" design, based on a quantitative approach; it will look at the program's effects and their variations among the six territories. The effects analysis will use data from a clinical database and from questionnaires completed by participating patients and physicians. Over 3000 patients will be recruited. The second strategy corresponds to a multiple case study approach, where each of the six CSSS constitutes a case. With this strategy, qualitative methods will set out the context of implementation using data from semi-structured interviews with program managers. The quantitative data will be analyzed using linear or multilevel models complemented with an interpretive approach to qualitative data analysis., Discussion: Our study will identify contextual factors associated with the effectiveness, successful implementation and sustainability of such a program. The contextual information will enable us to extrapolate our results to other contexts with similar conditions., Trial Registration: ClinicalTrials.gov: NCT01326130.

Background: Visiting friends and relatives (VFRs), especially young VFRs, are increasingly recognized in the industrialized world as a high-risk group of travelers., Methods: We performed a descriptive, cross-sectional design study of cases of malaria, hepatitis A, and typhoid reported to the Quebec registry of notifiable diseases between January 2004 and December 2007, occurring in VFRs and non-VFRs travelers., Results: VFRs account for 52.9% of malaria cases, 56.9% of hepatitis A cases, and 94.4% of typhoid cases reported in Quebec travelers. Almost all (91.6%) of the malaria cases among VFRs were acquired in Africa, particularly in sub-Saharan Africa. An important proportion of malaria cases among VFRs (86.4%) were due to Plasmodium falciparum. The vast majority (76.6%) of typhoid fever cases among VFRs were reported by travelers who had visited the Indian subcontinent. Among VFRs, 40% of total cases were under 20 y of age, compared to less than 6% among non-VFRs. Those under 20 years of age also accounted for 16.9% of malaria cases, 50% of typhoid cases, and 65.2% of hepatitis A cases among VFRs., Conclusion: Our study clearly shows that VFR children should be a primary target group for pre-travel preventive measures., (© 2011 International Society of Travel Medicine.)

Background: The Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care., Objectives: In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The goal of the present research project is to track the evolution of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance., Methods/design: This study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC., Discussion: The results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.

Objectives: Present a picture of physicians' preventive clinical practices (PCP) at a university medical centre, and identify the obstacles that hinder their implementation., Method: Self-administered questionnaire survey addressed to 367 general practitioners and specialists working at the Centre hospitalier de l'Université de Montréal (CHUM) in 2006., Results: Respondents claim to be recommending PCP (often or very often) in approximately 60-82% of cases. Women physicians report a larger integration for screening and vaccination (p < 0.05). General physicians claim to apply or recommend PCP more frequently than specialists (p < 0.05), except for anti-tobacco counseling. Lack of time (82%) and deficiencies in continuity of treatment (75%) are considered by the majority of respondents as major obstacles to the realization of PCP. Most participants (99%) consider delivering preventive services to be part of their role and 98% claim to be motivated to integrate PCP into their practice. However, almost half of physicians do not apply preventive recommendations to their own life and at least two thirds of them doubt the efficacy of counseling., Conclusion: Despite observed encouraging results, actions must be taken to improve the integration of PCP to general and specialized health care and to bring physicians around to adopting healthy lifestyle habits themselves.

We describe an autosomal-dominant locus for Restless Legs Syndrome (RLS) in a French-Canadian (FC) pedigree. Genome-wide microsatellite scan and linkage analysis were used in this study. The locus maps to chromosome 16p12.1 and spans 1.18 Mega bases. The maximum multipoint LOD scores are of 3.5 over the total of 10 markers. Evidence for the same locus was also found in a smaller FC pedigree sime095. The analysis of the sequence of 8 annotated genes within the region did not reveal any pathogenic mutations. Copy number variation and karyotype analyses did not reveal any chromosomal abnormality in the region. Further analyses of the region are necessary to find the genetic cause of RLS in this family.

Analysis of epidemiological data on health problems related to international travel helps put into perspective preventive interventions for travelers. To document the epidemiological context of travel health interventions in Québec, we reviewed surveillance data for three infectious diseases. The analysis included data collected in the notifiable diseases surveillance system for hepatitis A, typhoid, and malaria cases reported from 2000 to 2002. Additional data were obtained from the provincial hepatitis risk factor database as well as from regional public health departments. More than 40% of cases of hepatitis A for which risk factor information is available are associated with international travel; 20% of these cases were contracted in Mexico and 22% in the West Indies. The risk of acquiring hepatitis A seems to be higher among travelers under 35 years of age; also, given the number of Quebecers traveling to all regions of the world, this risk is proportionally higher in Africa. Data gathered for typhoid indicate that the risk to travelers from Québec is proportionately higher for Quebecers traveling to the Indian subcontinent and whose purpose is to visit family and friends, and for those who stay abroad for 4 weeks or longer. The risk of malaria is greater in Africa (where contracted cases are mostly caused by Plasmodium falciparum). Over half of malaria cases involve individuals traveling abroad for business (including volunteerism), and almost 75% contracted the disease during a stay of a month or more. Nearly half of the cases had not taken chemoprophylaxis. Available data have limitations for infectious disease surveillance among Québec travelers: imprecise number of cases (underdiagnosis and underreporting), imprecise denominators (number of travelers), and lack of data on the characteristics of trips taken. However, despite its limitations, this profile of infectious diseases among travelers from Québec provides interesting data for preventive intervention.

To continuously improve its assistance to Québec travel health providers, the Québec Advisory Committee on Travel Health conducted an exploratory and descriptive survey of dedicated travel clinics in Québec (Canada). During autumn 2003, a cross-sectional descriptive survey was carried out among the 97 travel health clinics listed in Québec. Data were collected using a self-administered questionnaire sent by mail. The response rate was 94%. More than three quarters of travel clinics in Québec are located in community health centers; the others are in private clinics and in hospitals. Although 80% of the clinics are located outside the most densely inhabited regions of Québec, they carry out less than 30% of the total number of pretravel consultations. Almost 60% of the clinics have fewer than 500 consultations a year. Overall, more than 114,000 travel health consultations are performed annually in Québec travel health clinics. Preventive services to travelers, including the most commonly used vaccines for travelers, are available in all regions of Québec, except in the northernmost region. Smaller clinics offer fewer services to travelers in terms of antimalarial prescriptions, less common vaccines, and post-travel consultations. The main sources of information for travel health practitioners are guidelines provided by public health authorities. Data obtained provide an up-to-date portrait of the services available in travel clinics in Québec that should assist public health authorities adapt their interventions to the needs and realities of these clinics.

Objectives: Travel agents are in a key position to encourage travelers to seek consultation in travel clinics. Since the beginning of the year 2000, a newsletter specifically designed to sensitize travel agents to travel health has been published by the public health authorities and distributed to all travel agencies in Quebec. This study was undertaken to evaluate the utilization and appreciation of the newsletter by travel agents and its impact on preventive practices., Methods: During the autumn of 2001, a cross-sectional descriptive survey was carried out among travel agencies in Quebec. Data were collected using a self-administered questionnaire sent by fax with a postal follow-up., Results: A total of 252 of the 950 travel agencies contacted (27%) answered our questionnaire. In all, 78% of respondents said their agency receives the newsletter. Among these agencies, the majority of respondents considered that the subjects discussed in the newsletter are interesting (often or in general: 96%), that the subjects and preventive recommendations for travel destinations are useful in the travel agent's practice (often or in general: 89%), and generally presented in an adequate way (96%). According to the respondents, the newsletter encouraged them, often or very often, to inform travelers about travel-related health problems (70%) or to recommend a consultation in a travel clinic (63%). The impact of the newsletter on the recommendation to consult was greater among agents having more than 10 years' experience (odds ratio [OR] 3.2). When asked about the best way to send them the newsletter, only 31% identified bulk mailing, which was the current mode of distribution., Conclusion: Satisfaction rate with the newsletter appears to be high among respondents who receive it. However, the low response rate to the survey may indicate that as a whole, the travel agents' interest in the newsletter is mitigated. Despite the limitations of this study, the results will allow us to modify some aspects of the publication, especially regarding its distribution.

Background: Many travelers from Québec visit tourist destinations, thereby becoming at risk of infectious diseases. Within a study of predictors of utilization of travel health consultation by travelers, knowledge about transmission and perception of risk and severity of some infectious diseases was measured., Methods: A cross-sectional survey was conducted during winter 1999 on travelers 16 years of age and over going to Mexico and the Dominican Republic. A 34-item self-administered bilingual questionnaire was distributed to travelers during seven flights departing from Montréal Airport., Results: The questionnaires were completed by 1,724 passengers (response rate: 75%). The majority (81%) of the 1,416 travelers from the province of Québec considered themselves at greater risk of diarrhea abroad. Risk perception was less important for hepatitis A and B (44% and 41%, respectively). Most travelers considered diarrhea as slightly or not severe, and hepatitis as severe illnesses. A majority had adequate knowledge about transmission of diarrhea but knowledge concerning hepatitis was less accurate. In the multivariate analysis, the most important associations were noted between perception of risk of diarrhea and knowledge about transmission of diarrhea (odds ratio [OR] 3.2); and between perception of risk of hepatitis and perception of severity of hepatitis (hepatitis A: OR 3.9; hepatitis B: OR 5.9). Consultation in a travel clinic before departure was associated with perception of higher risk of hepatitis A and of infectious diseases in general (OR 2.1)., Conclusion: Despite its limitations, this study indicates that travelers from Québec, going to sun destinations, seem to underestimate their risk of hepatitis related to travel. Knowledge about transmission of hepatitis seems poor. Education of travelers about risks and modes of transmission of infectious diseases should be reinforced. Travel health consultation before departure or for a previous trip appeared to be associated with higher risk perception.

Background: Among the factors influencing travelers to seek preventive health advice before departure, the travel agent's recommendation plays an important role. The objective of our study was to document the practices and needs of travel agents in Québec (Canada) in relation to the prevention of health problems among travelers., Methods: In June 2000, a cross-sectional descriptive survey was carried out among travel agents from all travel agencies in Québec. One agent per agency was asked to answer our questions. Data were collected using a 32-item telephone questionnaire., Results: Altogether, 708 travel agents from the 948 agencies contacted answered our questionnaire (participation rate: 75%). Most respondents (81%) believed that the travel agent has a role to play in the prevention of health problems among travelers, especially to recommend that travelers consult a travel clinic before departure. Although over 80% of the agents interviewed mentioned recommending a visit to a travel clinic before an organized tour to Thailand or a backpacking trip in Mexico, less than half said they make the same recommendation for a stay in a seaside resort in Mexico. The majority of respondents were acquainted with the services offered in travel health clinics, and these clinics were the source of travel health information most often mentioned by travel agents. However, nearly 60% of the agents questioned had never personally consulted a travel clinic. When asked about the best way to receive information about travelers' health, more than 40% of respondents favoured receiving information newsletters from public health departments regularly whereas 28% preferred the Internet., Conclusion: Despite the limits of this study, our results should help the public health network better target its interventions aimed to inform travel agents on prevention of health problems among travelers.