Publications by authors named "Bridget L Ryan"

52 Publications

Systematic review on the instruments used for measuring the association of the level of multimorbidity and clinically important outcomes.

BMJ Open 2021 May 5;11(5):e041219. Epub 2021 May 5.

Centre for Studies in Family Medicine, Department of Family Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada.

Objectives: There are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes.

Methods: We conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment.

Results: Ninety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases.

Conclusions: We listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.
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http://dx.doi.org/10.1136/bmjopen-2020-041219DOI Listing
May 2021

Primary Care Informatics Response to Covid-19 Pandemic: Adaptation, Progress, and Lessons from Four Countries with High ICT Development.

Yearb Med Inform 2021 Apr 21. Epub 2021 Apr 21.

Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.

Objective: Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned.

Methods: IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives.

Results: All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits.

Conclusions: Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted.
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http://dx.doi.org/10.1055/s-0041-1726489DOI Listing
April 2021

Patient-centred innovation for multimorbidity care: a mixed-methods, randomised trial and qualitative study of the patients' experience.

Br J Gen Pract 2021 Apr 26;71(705):e320-e330. Epub 2021 Mar 26.

Department of Family Medicine.

Background: Patient-centred interventions to help patients with multimorbidity have had mixed results.

Aim: To assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.

Design And Setting: Mixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.

Method: Patients aged 18-80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients' experiences of the intervention.

Results: A total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.

Conclusion: Overall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference's recommendations.
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http://dx.doi.org/10.3399/bjgp21X714293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997674PMC
April 2021

Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial.

Ann Fam Med 2021 Mar-Apr;19(2):126-134

Purpose: To measure the effectiveness of a 4-month interdisciplinary multifaceted intervention based on a change in care delivery for patients with multimorbidity in primary care practices.

Methods: A pragmatic randomized controlled trial with a mixed-methods design in patients aged 18 to 80 years with 3 or more chronic conditions from 7 family medicine groups (FMGs) in Quebec, Canada. Health care professionals (nurses, nutritionists, kinesiologists) from the FMGs were trained to deliver the patient-centered intervention based on a motivational approach and self-management support. Primary outcomes: self-management (Health Education Impact Questionnaire); and self-efficacy.

Secondary Outcomes: health status, quality of life, and health behaviors. Quantitative analyses used multi-level mixed effects and generalized linear mixed models controlling for clustering within FMGs. We also conducted in-depth interviews with patients, family members, and health care professionals.

Results: The trial randomized 284 patients (144 in intervention group, 140 in control group). The groups were comparable. After 4 months, the intervention showed a neutral effect for the primary outcomes. There was significant improvement in 2 health behaviors (healthy eating with odds ratios [OR] 4.36; = .006, and physical activity with OR 3.43; = .023). The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results.

Conclusions: Quantitatively, this intervention showed a neutral effect on the primary outcomes and substantial improvement in 2 health behaviors as secondary outcomes. Qualitatively, the intervention was evaluated as positive. The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.
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http://dx.doi.org/10.1370/afm.2650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939717PMC
December 2019

The risk of physical multimorbidity in people with psychotic disorders: A systematic review and meta-analysis.

J Psychosom Res 2021 01 24;140:110315. Epub 2020 Nov 24.

Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, Canada; Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, Canada. Electronic address:

Background: The occurrence of multiple co-occurring chronic health conditions, known as multimorbidity, is associated with decreases in quality of life for patients and poses unique challenges for healthcare systems. Since people with psychotic disorders have an excess of physical health conditions compared to the general population, they may also be at a higher risk for multimorbidity. We conducted a systematic review and meta-analysis to quantify the prevalence and excess risk of multimorbidity among people with psychotic disorders, relative to those without psychosis.

Methods: We searched the MEDLINE, EMBASE, and PsycINFO databases, and conducted forward and backward citation tracing of included studies. Studies published after 1990 were included if they reported the prevalence of multiple chronic physical health conditions among people with psychotic disorders. Data on the prevalence and relative risk of multimorbidity were meta-analyzed using random effects models.

Results: Fourteen studies met the inclusion criteria, and eight were included in the meta-analysis. Each study used a different operational definition of multimorbidity, both for the number and types of chronic conditions, which resulted in a wide range in prevalence estimates (16% to 91%). People with psychotic disorders had an increased risk of multimorbidity (RR = 1.69, 95%CI = 1.37,2.08), relative to those without psychosis.

Conclusions: People with psychotic disorders are more likely to experience multimorbidity than those without psychotic disorders. Clinicians treating people with psychosis should closely monitor for a range of physical health conditions. Future research examining multimorbidity among people with psychiatric illness should employ consistent definitions to better enable cross-study comparisons.
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http://dx.doi.org/10.1016/j.jpsychores.2020.110315DOI Listing
January 2021

Advancing cross-national planning and partnership: Proceedings from the International Multimorbidity Symposium 2019.

J Comorb 2020 Jan-Dec;10:2235042X20953313. Epub 2020 Sep 24.

Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada     .

The International Multimorbidity Symposium was held in November 2019 at Western University to achieve three main objectives: to discuss progress and findings from various jurisdictions; to facilitate collaboration through group discussion to identify strategies to move multimorbidity research forward; and to create concrete plans to ensure advances in multimorbidity research and knowledge can be achieved through cross-national partnership. This event included keynote presentations, elevator pitch presentations and breakout sessions and there was a total of 35 attendees from eight countries, representing diverse disciplines and training levels. The overall themes arising from the event were: the importance of integrating the study and management of multimorbidity from both the primary care and public health perspectives; meaningful engagement and collaboration with patients and caregivers to understand key dimensions of multimorbidity; the considerable benefit of collaborative international partnerships; and the need to spread and scale innovations for health care systems that can better respond to the complex needs of patients and caregivers who are living with multimorbidity. Finally, it was well-acknowledged among the attendees that expanding the collaboration and discussion among international colleagues via in-person and virtual events will be important to move multimorbidity research forward.
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http://dx.doi.org/10.1177/2235042X20953313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525218PMC
September 2020

Patterns of Primary Care Use Prior to a First Diagnosis of Nonaffective Psychotic Disorder in Ontario, Canada: Modèles d'utilisation des soins de première ligne avant un premier diagnostic de trouble psychotique non affectif en Ontario, Canada.

Can J Psychiatry 2021 Apr 5;66(4):406-417. Epub 2020 Oct 5.

Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.

Background: Many people experience early signs and symptoms before the onset of psychotic disorder, suggesting that there may be help-seeking prior to first diagnosis. The family physician has been found to play a key role in pathways to care. This study examined patterns of primary care use preceding a first diagnosis of psychotic disorder.

Methods: We used health administrative data from Ontario (Canada) to construct a population-based retrospective cohort. We investigated patterns of primary care use, including frequency and timing of contacts, in the 6 years prior to a first diagnosis of psychosis, relative to a general population comparison group matched on age, sex, geographic area, and index date. We used latent class growth modeling to identify distinct trajectories of primary care service use, and associated factors, preceding the first diagnosis.

Results: People with early psychosis contacted primary care over twice as frequently in the 6 years preceding first diagnosis (RR = 2.22; 95% CI, = 2.19 to 2.25), relative to the general population, with a sharp increase in contacts 10 months prior to diagnosis. They had higher contact frequency across nearly all diagnostic codes, including mental health, physical health, and preventative health. We identified 3 distinct service use trajectories: low-, medium-, and high-increasing usage.

Discussion: We found elevated patterns of primary care service use prior to first diagnosis of psychotic disorder, suggesting that initiatives to support family physicians in their role on the pathway to care are warranted. Earlier intervention has implications for improved social, educational, and professional development in young people with first-episode psychosis.
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http://dx.doi.org/10.1177/0706743720961732DOI Listing
April 2021

Interprofessional team-based geriatric education and training: A review of interventions in Canada.

Gerontol Geriatr Educ 2021 Apr-Jun;42(2):178-195. Epub 2020 Aug 13.

Health and Rehabilitation Sciences Program, Faculty of Health Sciences, Western University, London, Canada.

Given world-wide rises in the number of older adults, interprofessional education and training in geriatrics must be promoted across the learning spectrum, both for students and for health care professionals. This review examined interprofessional team-based education and training interventions in Canada focusing on the team component. A total of 10 studies (1997-2017) were eligible for analyzes. Studies offered health care providers opportunities to enhance their knowledge of geriatric competencies, as well as their ability to work in interprofessional geriatric teams. Although several interventions did not include team-based learning content explicitly, team-building opportunities, as well as assignments related to working on teams yielded positive impacts on learners. Results showed improved geriatric competencies as well as team functioning. Geriatric health care teams add significant value to the Canadian health care system. Consequently, opportunities to improve health care providers' geriatric knowledge and their ability to work in teams should be encouraged.
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http://dx.doi.org/10.1080/02701960.2020.1805320DOI Listing
August 2020

Beyond the Sick Role: The Many Roles of Adults With Type 1 and Type 2 Diabetes in the Management of Hypoglycemia-The InHypo-DM Study, Canada.

Can J Diabetes 2020 Oct 9;44(7):657-662. Epub 2020 Apr 9.

Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Objectives: Hypoglycemia is a common adverse event for people with type 1 and type 2 diabetes mellitus. In this article, we explore the specific roles that individuals assume to prevent or treat hypoglycemia.

Methods: A descriptive qualitative study from the UnderstandINg the impact of HYPOglycemia on Diabetes Management Study (InHypo-DM) research program. A purposive sample of people with type 1 and type 2 diabetes were recruited for semistructured interviews. There were 16 participants (women and men), who were, on average, 53 years old. Average time since diagnosis was 15 (type 1) and 21 (type 2) years; all patients had at least 1 hypoglycemic event in the past year. Individual and team analysis of interviews were conducted to identify overarching themes.

Results: Participants articulated 4 roles in preventing or treating hypoglycemia. The first role was being a manager by assuming ownership and accountability for their own glycemic control. The second role, being a technician, used both subjective and objective information and employed specific strategies to respond to hypoglycemic events. The third role, educator, extended beyond self-management to increase others' awareness of hypoglycemia. The fourth role, advocate, involved championing one's own needs during a hypoglycemic event. These 4 roles were, in turn, influenced by the contexts of work, social settings, exercise and travel.

Conclusions: These findings demonstrate that strategies that individuals use to avoid or reduce the severity of a hypoglycemic event extend beyond merely making impromptu decisions during events. Instead, these 4 roles of manager, technician, educator and advocate, embedded in specific contexts, enhanced their mastery in managing hypoglycemia in daily life.
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http://dx.doi.org/10.1016/j.jcjd.2020.03.011DOI Listing
October 2020

The revised Patient Perception of Patient-Centeredness Questionnaire: Exploring the factor structure in French-speaking patients with multimorbidity.

Health Expect 2020 08 27;23(4):904-909. Epub 2020 Apr 27.

Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada.

Background: The Patient Perception of Patient-Centeredness (PPPC) questionnaire was revised, and there is a need for the questionnaire to be tested in diverse primary care populations.

Objectives: This study aimed to examine the factor structure of the Revised PPPC questionnaire (PPPC-R) in French-speaking patients with multimorbidity.

Design: Secondary analysis from baseline data of the French arm of Patient-Centered Innovations for Persons with Multimorbidity Study (PACEinMM Study).

Setting And Participants: Participants were adult patients with multimorbidity attending primary health-care settings.

Outcome Measures: Exploratory factor analyses were applied to examine the factor structure of the PPPC-R. Cronbach's alpha values were calculated to assess the internal consistency of the whole questionnaire and of each factor explored.

Results: There were 301 participants, mean age 61.0, 53.2% female. The PPPC-R showed very good internal consistency, with three factors: Patient-Centered Clinical Method (PCCM) Component 1-Exploring the health, disease and illness experience + PCCM Component 4-Enhancing the patient-clinician relationship (Factor 1); PCCM Component 2-Understanding the whole person (Factor 2); and PCCM Component 3-Finding common ground (Factor 3). There was a good internal consistency within each factor (Cronbach's α = 0.87 for 8 items in Factor 1, 0.77 for 5 items in Factor 2 and 0.87 for 5 items in Factor 3).

Discussion And Conclusions: The French PPPC-R factor structure was in accordance with the underpinning conceptual model and presented with three factors. Further assessment of its validity and reproducibility are needed to allow its use as a measure of patient's perception of patient-centeredness.
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http://dx.doi.org/10.1111/hex.13068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495072PMC
August 2020

Healthcare teams and patient-related terminology: a review of concepts and uses.

Scand J Caring Sci 2021 Mar 1;35(1):55-66. Epub 2020 Apr 1.

Health and Rehabilitation Sciences Program, Faculty of Health Sciences, Western University, London, ON, Canada.

Background: Discussions concerning health care teams and patient-related terminology remain an ongoing debate. Terms such as interdisciplinary, multidisciplinary and transdisciplinary, as well as interprofessional are ambiguously defined and frequently used, rightly or wrongly, interchangeably. Also, clarification on the terminology regarding patients is rarely explicitly addressed in the health care team's literature, potentially resulting in confusion among health professional students, novice researchers, and practitioners.

Methods: A structured literature review was conducted. Electronic searches were performed from August 2018 to September 2019 on the following databases: CINHAL, Scopus, Science Direct, PubMed, Nursing and Allied Health and JSTOR. The following terms were used: 'terminology', 'team(s)', 'nursing', 'health', 'medical', 'education', 'interprofessional', 'interdisciplinary', 'multidisciplinary', 'transdisciplinary', 'collaboration', 'patient', 'client', 'customer', 'user' and 'person'.

Results: Small but significant nuances in the use of language and its implications for patient care can be made visible for health professional education and clinical practice. Healthcare is necessarily interdisciplinary and therefore we are obligated, and privileged, to think more critically about the use of terminology to ensure we are supporting high-quality evidence and knowledge application.

Conclusion: To avoid confusion and lack of consistency in the peer-review literature, authors should be encouraged to offer brief definitions and the rationale for the use of a particular term or group of term. In addition, a deeper understanding of the values that each patient-related term represents for particular disciplines or health care professions is essential to achieve a more comprehensive conceptual rigour.
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http://dx.doi.org/10.1111/scs.12843DOI Listing
March 2021

Moving from space to place: Reimagining the challenges of physical space in primary health care teams in Ontario.

Can Fam Physician 2019 09;65(9):e405-e410

Research Associate and Senior Manager in the Centre for Studies in Family Medicine at Western University.

Objective: To extend our understanding of how primary health care team members characterize the effects of location on team functioning.

Design: Qualitative study using grounded theory methodology, with in-depth analysis of data concerning the role of physical space in teamwork.

Setting: Family health teams in Ontario.

Participants: A total of 110 team members from 20 family health teams in Ontario.

Methods: Individual semistructured interviews were conducted. Interviews were audiorecorded and transcribed verbatim. Individual and group coding followed grounded theory processes of open, axial, and selective coding. Immersion in interview and field note data facilitated crystallization.

Main Findings: Across sites, regardless of their physical space, team members commented spontaneously about the role of space in team functioning. An overarching theme of a "sense of place" developed from data analysis. A sense of place could be established through co-location (being in the same physical space), the allocation of team members' working spaces, coming together, and having a shared vision. Physical space often operated as a key facilitator or considerable barrier to creating a sense of place; however, some teams with suboptimal physical space functioned as highly integrated teams, creating a sense of place through various means.

Conclusion: Many interprofessional health care teams cannot physically change less-than-optimal spaces. However, teams can thrive and create a sense of place through various means, some of which relate to actual physical space, and some of which relate to promoting common activities and a shared vision-factors that are effective for team building in general. When there are economic limitations, as well as structural constraints, then it is essential that creating a sense of place be a priority. Future research should consider this lens as a means for expanding the discussion and possible solutions around traditional space issues.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6741796PMC
September 2019

Living With Hypoglycemia: An Exploration of Patients' Emotions: Qualitative Findings From the InHypo-DM Study, Canada.

Diabetes Spectr 2019 Aug;32(3):270-276

Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.

Hypoglycemia is one of the most common adverse events for people living with type 1 or type 2 diabetes. To gain a deeper understanding of patients' emotions regarding hypoglycemia, we conducted a descriptive qualitative study. Purposive sampling was used to recruit participants for a 30- to 45-minute semi-structured interview. The 16 participants included both women and men with either type 1 or type 2 diabetes, with a mean age of 53 years and mean time since diagnosis of 21 years. All participants had experienced more than one hypoglycemia event in the past year, ranging from nonsevere to severe. Data collection and analysis occurred in an iterative manner. Individual and team analyses of interviews were conducted to identify overarching themes and sub-themes. Thematic analysis revealed the unique interconnection among the emotions experienced by participants, including fear, anxiety, frustration, confidence, and hope. Time, experience, and reflection helped to build participants' confidence in their ability to manage a hypoglycemia event. Patients' emotions regarding hypoglycemia provide valuable insights into life with diabetes. Although hypoglycemia continues to evoke feelings of fear and anxiety, the role of hope may temper these emotions. Understanding the complex interplay of emotions concerning hypoglycemia can guide health care providers in improving clinical practice and promoting patient-centered interventions. Ultimately, health care providers can build patients' hypoglycemia-related confidence by using a strengths-based approach.
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http://dx.doi.org/10.2337/ds18-0074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695265PMC
August 2019

Measuring Patients' Perceptions of Health Care Encounters: Examining the Factor Structure of the Revised Patient Perception of Patient-Centeredness (PPPC-R) Questionnaire.

J Patient Cent Res Rev 2019 29;6(3):192-202. Epub 2019 Jul 29.

Western University, London, Canada.

Purpose: Given the ongoing desire to make health care more patient-centered and growing evidence supporting the provision of patient-centered care, it is important to have valid tools for measuring patient-centered care. The patient-centered clinical method (PCCM) is a conceptual framework for providing patient-centered care. A revision to the PCCM framework led to a corresponding need to enhance the Patient Perception of Patient-Centeredness (PPPC) questionnaire. The original PPPC was aligned with the components of the PCCM conceptual framework and developed to measure patient-centeredness from the patient's perspective. The purpose of this study was to examine the factor structure of a revised version of the PPPC (ie, PPPC-R).

Methods: Eleven new items were added to the original 14 items. The modified questionnaire was administered to patients in primary health care teams in Ontario, Canada. The confirmatory factor analysis was conducted on a subset of 381 patients who had seen a family physician.

Results: The initial proposed 4-factor model first tested with a confirmatory factor analysis (CFA) did not fit adequately. Exploratory factor analysis was therefore used as a second step to modify the model and to identify weak items. A 3-factor exploratory model with 18 of the original 25 items was converted into a final hypothetical CFA model that had a good fit (χ=176.795, P<0.01; CFI=0.991; RMSEA=0.030). The third factor contained only 2 items and so is interpreted with caution.

Conclusions: The validity of the PPPC-R is supported by some congruence between the conceptual framework (the PCCM) and the statistical analysis (CFA), but there is not a 1:1 correspondence. The components of the PCCM represent conceptually what is important when teaching, researching, and providing patient-centered care, whereas the PPPC-R represents patient-centered care as it is experienced by the patient.
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http://dx.doi.org/10.17294/2330-0698.1696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6675140PMC
July 2019

Do four or more antenatal care visits increase skilled birth attendant use and institutional delivery in Bangladesh? A propensity-score matched analysis.

BMC Public Health 2019 May 16;19(1):583. Epub 2019 May 16.

Department of Epidemiology and Biostatistics, Western University, 1151 Richmond Street, London, ON, Canada.

Background: With Bangladesh's adoption of the third Sustainable Development Goal to reduce maternal mortality, the impetus for Bangladesh to continue to improve uptake of maternal healthcare is strong.

Methods: Using a propensity-score matched analysis, the present study utilized data from the 2014 Bangladesh Demographic Health survey to examine the impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery.

Results: The results revealed a significant and positive impact of four or more antenatal care visits on skilled birth attendant use and institutional delivery after matching treated and untreated mothers on included socio-demographic characteristics.

Conclusions: Implementation of policies to provide at least four antenatal care visits may serve as an effective strategy to increase SBA use and institutional delivery in Bangladesh, which could contribute to the reduction of maternal mortality.
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http://dx.doi.org/10.1186/s12889-019-6945-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521440PMC
May 2019

Identifying musculoskeletal conditions in electronic medical records: a prevalence and validation study using the Deliver Primary Healthcare Information (DELPHI) database.

BMC Musculoskelet Disord 2019 May 3;20(1):187. Epub 2019 May 3.

Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada.

Background: Musculoskeletal (MSK) conditions are a common presentation in primary care. This study sought to determine the prevalence of MSK conditions in primary care in Ontario and to validate the extent to which health administrative date billing codes accurately represent MSK diagnoses.

Methods: De-identified electronic medical records (EMR) from the DELPHI database in southwestern Ontario, which contains 2493 patients (55.6% female, mean age 50.3 years (SD = 22.2)) and 21,964 encounters (July 1, 2006-June 30, 2010) were used for the analyses. Outcomes included: validation measures of agreement between International Classification of Diseases (ICD-9) diagnostic codes (health administrative data) and International Classification of Primary Care (ICPC) diagnoses defined as the reference standard, time to first ICD-9 code, prevalence, and healthcare utilization.

Results: There were 2940 true positive MSK encounters with primary care practitioners for 998 patients. Performance of the ICD-9 diagnostic codes included sensitivity = 76.5%, specificity = 95.2%, PPV = 94.6%, and NPV = 78.7%, compared to the ICPC reference standard. The majority of 998 patients were coded with both an ICPC and ICD-9 MSK code at their first or second encounter (67.4%). However, 23.5% of patients with the ICPC reference standard MSK were never coded with ICD-9. Four-year prevalence of MSK was 52.3% and varied by age (4.5% 0-17 years, 20.1% 18-44, 42.7% 45-64, and 32.7% 65+). Patients at MSK encounters had a higher number of: investigations (17.9% compared to 9.1%, p < .0001); referrals (17.6% compared to 14.3%, p < .0001); and prescriptions for opioids (17.2% compared to 5.3%, p < .0001).

Conclusions: This study determined the prevalence of musculoskeletal conditions in primary care in Ontario using a reference standard definition. The study highlighted the value of using primary care ICPC codes to validate a definition for musculoskeletal conditions. Health administrative data can be used to ascertain the presence of musculoskeletal conditions; however, ICD-9 codes may underrepresent the prevalence of MSK conditions.
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http://dx.doi.org/10.1186/s12891-019-2568-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6499985PMC
May 2019

Primary care of adults with severe and profound intellectual and developmental disabilities: Family physicians' perspectives on patient-physician relationships.

Can Fam Physician 2019 Apr;65(Suppl 1):S59-S65

Research Manager in the Primary Healthcare Research Unit at Memorial University.

Objective: To explore family physicians' perspectives on the development of the patient-physician relationship with adult patients living with severe or profound intellectual and developmental disabilities (IDD).

Design: Constructivist grounded theory.

Setting: St John's, NL, and across Canada.

Participants: Fifteen family physicians currently caring for patients with severe or profound IDD.

Methods: Data were collected via in-depth, semistructured interviews conducted in-person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data.

Main Findings: From the perspective of family physicians, the core process in the development of the patient-physician relationship was acceptance. This acceptance was bidirectional. With respect to family physicians accepting patients, family physicians had to accept that their patients with severe and profound IDD were as equally deserving of their respect as any other patient-as unique individuals with their own goals and potential. With respect to patients accepting their family physicians, family physicians had to seek out signs of acceptance from their patients to fully appreciate and develop a trusting relationship. This bidirectional process of acceptance required family physicians to adapt the way they practised (eg, by spending more time with the patient and finding alternate forms of communication). It also required family physicians to define their role (eg, building trust and being an advocate) in a relationship that had the patient as the primary focus but simultaneously acknowledged the important involvement of the caregiver.

Conclusion: For family physicians, the process of acceptance seems to underpin the development of the patient-physician relationship with adult patients with severe or profound IDD. Findings highlight the need for family physicians to adapt the way they deliver care to these patients and define their role in these complex relationships. Ultimately, this study highlights family physicians' acceptance of their patients' humanity regardless of the nature of the relationship that was created between them.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501711PMC
April 2019

Clinical care gaps and solutions in diabetes and advanced chronic kidney disease: a patient-oriented qualitative research study.

CMAJ Open 2019 Apr-Jun;7(2):E258-E263. Epub 2019 Apr 23.

Division of Endocrinology and Metabolism, Department of Medicine (Clemens), Department of Epidemiology and Biostatistics (Clemens, Ryan) and Centre for Studies in Family Medicine (Ryan, Reichert), Western University; St. Joseph's Health Care London (Clemens), London, Ont.; ICES (Clemens, Getchell), London, Ont.; Children's Hospital (Robinson), London Health Sciences Centre; patient partner (O'Donnell), St. Joseph's Health Care London, London, Ont.

Background: Patients with diabetes and advanced chronic kidney disease face a high health care burden. As part of a patient-oriented research initiative to identify ways to better support patients' diabetes care, we explored their health care experience and solutions for patient-centred diabetes care.

Methods: We engaged 2 patients with advanced kidney disease and diabetes to join our multidisciplinary team as full research partners. They were involved in our design and conduct of the study, the analysis of the results and knowledge translation. We conducted qualitative interviews (1:1 semistructured interviews and focus groups) with patients with a history of both diabetes (type 1 or 2) and advanced kidney disease including those using dialysis. We identified overarching themes using individual and team analysis and conducted interviews until data saturation was reached.

Results: Twelve participants were interviewed between October 2017 and February 2018. Six people were interviewed in 2 separate focus groups (consisting of 4 and 2 participants) and 6 participated in 1:1 interviews with our team. Participants described being burdened by medical appointments, strict conflicting diets, costly diabetes therapies and fragmented, siloed health care. They indicated that self-management support, education and coordinated diabetes care might better support their diabetes care.

Interpretation: Patients with complex medical comorbidities face many challenges traversing a health care system organized around single diseases. Researchers and policy-makers should study and develop patient-centred diabetes care strategies to better support these high-risk patients.
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http://dx.doi.org/10.9778/cmajo.20180177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6498446PMC
April 2019

Social Vulnerability in Patients with Multimorbidity: A Cross-Sectional Analysis.

Int J Environ Res Public Health 2019 04 8;16(7). Epub 2019 Apr 8.

Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC G7H 5H6, Canada.

Background: Social aspects play an important role in individual health and should be taken into consideration in the long-term care for people with multimorbidity.

Purposes: To describe social vulnerability, to examine its correlation with the number of chronic conditions, and to investigate which chronic conditions were significantly associated with the most socially vulnerable state in patients with multimorbidity.

Methods: Cross-sectional analysis from the baseline data of the Patient-Centred Innovations for Persons with Multimorbidity (PACEinMM) Study. Participants were patients attending primary healthcare settings in Quebec, Canada. A social vulnerability index was applied to identify social vulnerability level. The index value ranges from 0 to 1 (1 as the most vulnerable). Spearman's rank correlation coefficient was calculated for the correlation between the social vulnerability index and the number of chronic conditions. Logistic regression was applied to investigate which chronic conditions were independently associated with the most socially vulnerable state.

Results: There were 301 participants, mean age 61.0 ± 10.5, 53.2% female. The mean number of chronic health conditions was 5.01 ± 1.82, with the most common being hyperlipidemia (78.1%), hypertension (69.4%), and obesity (54.2%). The social vulnerability index had a median value of 0.13 (range 0.00⁻0.78). There was a positive correlation between the social vulnerability index and the number of chronic conditions (r = 0.24, < 0.001). Obesity, depression/anxiety, and cardiovascular diseases were significantly associated with the most socially vulnerable patients with multimorbidity.

Conclusions: There was a significant correlation between social vulnerability and the total number of chronic conditions, with depression/anxiety, obesity, and cardiovascular diseases being the most related to social vulnerability.
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http://dx.doi.org/10.3390/ijerph16071244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6480630PMC
April 2019

Nonconventional diabetes-related care strategies for patients with chronic kidney disease: A scoping review of the literature.

J Comorb 2019 Jan-Dec;9:2235042X19831918. Epub 2019 Mar 1.

St Joseph's Health Care, London, Ontario, Canada.

Background: Patients with diabetes and chronic kidney disease (CKD) are at high risk of diabetes-related complications. Diabetes care can support these individuals, but outpatient clinic appointments can be difficult to attend, given their already high burden of multimorbidity.

Methods: We systematically searched the medical and grey literature for studies that evaluated the effect of nonconventional diabetes care strategies on diabetes-related outcomes in adults with stages 2-5 CKD or using dialysis (end of search December 30, 2017). We included both randomized-controlled trials and observational studies. Study selection and data extraction were completed by two independent reviewers. Diabetes-related outcomes included glycemic, blood pressure, and lipid control, along with microvascular complications, macrovascular complications, and death.

Results: After screening 2177 relevant citations, we identified 34 studies which met inclusion. The majority were observational studies. Studies were frequently small, single-centered, and excluded patients with more advanced CKD. Nonconventional diabetes care strategies included community-based care, unique self-management and education programs, nurse-led care clinics, dialysis-based diabetes programs, telemedicine, and interdisciplinary care clinics. Programs were most often developed by study investigators. Although there were limitations to several of the included studies, programs were described to have modest effects on physiologic outcomes, and in some cases, diabetes-related complications and death.

Conclusions: Nonconventional diabetes-related care might be helpful to patients with CKD. Prior to developing and implementing programs, however, it will be important to study them more rigorously, understand their acceptability to patients, and evaluate their costs and feasibility in a real-world setting.
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http://dx.doi.org/10.1177/2235042X19831918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416990PMC
March 2019

Building research culture and capacity in academic family medicine departments: Insights from a simulation workshop.

Can Fam Physician 2019 01;65(1):e38-e44

Professor in and Chair of the Department of Family Medicine at Western University.

Objective: To use data from a workshop in which various representatives from departments of family medicine (DFMs) aimed to identify strategies to increase research activity, particularly among clinical faculty members.

Design: Descriptive qualitative study using data from a workshop in which participants role-played (ie, as clinician-teachers, department chairs, and mentors) and, while in the role-playing scenario, were asked to imagine strategies that would encourage the clinical faculty members to engage in research.

Setting: The 2014 North American Primary Care Research Group Annual Meeting in New York City, NY.

Participants: Thirty-two workshop participants who belonged to DFMs and other academic primary care organizations: 18 from Canada, 11 from the United States, 2 from Australia, and 1 from the Netherlands.

Methods: Facilitators recorded the strategies at the workshop. Strategies were organized into themes and vetted by facilitators to ensure that they adequately represented the data. Finalized themes were compared and integrated across scenarios.

Main Findings: Participants enthusiastically and productively engaged in the role-playing scenarios. The themes that emerged from the workshop discussions indicated that in order to increase clinician-teacher engagement in research, the following factors needed to be attended to: gaining confidence in conducting research; finding research topics that have personal relevance; presenting clarity of expectations; fostering collaborative relationships; using a tailored approach; providing resources, structures, and processes; and having leadership and vision. Finally, it was important to recognize these efforts in the context of the existing research environment of the DFM and the various responsibilities of clinician-teachers.

Conclusion: The analysis of data arising from this simulation workshop elucidated practical strategies for building and sustaining research in DFMs. There is a clear indication that one size does not fit all with respect to strategies for building a research culture in a DFM; the authors' recommendations guide departments to tailor strategies to their unique context.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347319PMC
January 2019

The "Patient-centered coordination by a care team" questionnaire achieves satisfactory validity and reliability.

J Interprof Care 2019 Sep-Oct;33(5):558-569. Epub 2018 Dec 17.

Département de Médecine de Famille et de Médecine d'Urgence, Université de Sherbrooke , Sherbrooke , Quebec , Canada.

Increasing prevalence of chronic conditions and multimorbidity challenges health care systems and calls for patient-centered coordination of care. Implementation and evaluation of health policies focusing on the development of patient-centered coordination of care needs valid instruments measuring this dimension of care. The aim of this validation study was to assess the psychometric properties of the French version of the 14-item Patient-Centered Coordination by a Care Team (PCCCT) questionnaire in a primary care setting. PCCCT provides a total score from 0 (worst coordination) to 42 (best coordination). 165 adult patients consulting in primary care with one or more chronic condition(s) completed questionnaires (including PCCCT) at recruitment. After three weeks, participants completed PCCCT again, either by mail (group A) or during a telephone interview (group B). At recruitment, the mean (SD) PCCCT score was 33.3 (7.7). Exploratory factor analysis revealed a 2-dimension structure, 8 items relating to patient involvement and 6 items relating to coordination (factors loadings ranging from 0.34 to 0.88). PCCCT score correlated significantly with subscales of Haggerty's continuity questionnaire, Spearman correlation coefficients (95% confidence interval) ranging from 0.40 (0.22-0.57) to 0.52 (0.38-0.63). Internal consistency was excellent: Cronbach alpha 0.90 (0.79-0.92). Reliability was good, with an intraclass correlation coefficient of 0.68 (0.55-0.78) for test-retest reliability (group A) and of 0.65 (0.46-0.79) for reliability between the self-administered and the interviewer-administered versions of the questionnaire (group B,). The PCCCT questionnaire presents satisfactory validity and reliability; it can be used for the evaluation of health organizations involving team work in primary care.
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http://dx.doi.org/10.1080/13561820.2018.1554633DOI Listing
February 2020

Understanding the role of the family physician in early psychosis intervention.

BJPsych Open 2018 Nov 30;4(6):447-453. Epub 2018 Oct 30.

Project Coordinator, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, Canada.

Background: The family physician is key to facilitating access to psychiatric treatment for young people with first-episode psychosis, and this involvement can reduce aversive events in pathways to care. Those who seek help from primary care tend to have longer intervals to psychiatric care, and some people receive ongoing psychiatric treatment from the family physician.

Aims: Our objective is to understand the role of the family physician in help-seeking, recognition and ongoing management of first-episode psychosis.

Method: We will use a mixed-methods approach, incorporating health administrative data, electronic medical records (EMRs) and qualitative methodologies to study the role of the family physician at three points on the pathway to care. First, help-seeking: we will use health administrative data to examine access to a family physician and patterns of primary care use preceding the first diagnosis of psychosis; second, recognition: we will identify first-onset cases of psychosis in health administrative data, and look back at linked EMRs from primary care to define a risk profile for undetected cases; and third, management: we will examine service provision to identified patients through EMR data, including patterns of contacts, prescriptions and referrals to specialised care. We will then conduct qualitative interviews and focus groups with key stakeholders to better understand the trends observed in the quantitative data.

Discussion: These findings will provide an in-depth description of first-episode psychosis in primary care, informing strategies to build linkages between family physicians and psychiatric services to improve transitions of care during the crucial early stages of psychosis.

Declaration Of Interest: None.
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http://dx.doi.org/10.1192/bjo.2018.67DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235978PMC
November 2018

Beyond the grey tsunami: a cross-sectional population-based study of multimorbidity in Ontario.

Can J Public Health 2018 12 18;109(5-6):845-854. Epub 2018 Jul 18.

Centre for Studies in Family Medicine, Department of Family Medicine; Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.

Objectives: To determine volumes and rates of multimorbidity in Ontario by age group, sex, material deprivation, and geography.

Methods: A cross-sectional population-based study was completed using linked provincial health administrative databases. Ontario residents were classified as having multimorbidity (3+ chronic conditions) or not, based on the presence of 17 chronic conditions. The volumes (number of residents) of multimorbidity were determined by age categories in addition to crude and age-sex standardized rates.

Results: Among the 2013 Ontario population, 15.2% had multimorbidity. Multimorbidity rates increased across successively older age groups with lowest rates observed in youngest (0-17 years, 0.2%) and highest rates in the oldest (80+ years, 73.5%). The rate of multimorbidity increased gradually from ages 0 to 44 years, with a substantial and graded increase in the rates as the population aged. The top five chronic conditions, of the 17 examined, among those with multimorbidity were mood disorders, hypertensive disorders, asthma, arthritis, and diabetes.

Conclusion: Much of the common rhetoric around multimorbidity concerns the aging 'grey tsunami'. This study demonstrated that the volume of multimorbidity is derived from adults beginning as young as age 35 years old. A focus only on the old underestimates the absolute burden of multimorbidity on the health care system. It can mask the association of material deprivation and geography with multimorbidity which can turn our attention away from two critical issues: (1) potential inequality in health and health care in Ontario and (2) preventing younger and middle-aged people from moving into the multimorbidity category.
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http://dx.doi.org/10.17269/s41997-018-0103-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964436PMC
December 2018

Processes that influence the evolution of family health teams.

Can Fam Physician 2018 06;64(6):e283-e289

Assistant Professor in the Centre for Studies in Family Medicine in the Department of Family Medicine and the Department of Epidemiology and Biostatistics at the Schulich School of Medicine and Dentistry at Western University.

Objective: To identify the processes that influence the evolution of family health teams (FHTs).

Design: Qualitative study using grounded theory methodology.

Setting: Family health teams in Ontario.

Participants: A total of 110 team members from 20 FHT sites in Ontario.

Methods: Individual semistructured interviews were conducted and data were analyzed using initial coding, focused coding, and a constant comparison analysis.

Main Findings: The analysis illuminated the complex and diverse nature of the FHTs' evolutionary trajectories, which were influenced by 7 discrete but interrelated processes: sharing a common philosophy about teamwork; having effective leadership; respecting each other's scopes of practice; sharing the physical environment; including team activities; supporting conflict resolution; and managing change. The status of each site's evolution was categorized as evolving, progressing, or stalled.

Conclusion: The concept of evolution by its very definition does not imply stasis, and as the data revealed, change is always on the horizon. This study revealed 7 processes that influenced team evolution, and these processes were observed to be either optimally applied or noticeably limited in their execution, irrespective of team composition or configuration. These processes can be extrapolated to other primary health care teams to facilitate team evolution.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999255PMC
June 2018

Real-world crude incidence of hypoglycemia in adults with diabetes: Results of the InHypo-DM Study, Canada.

BMJ Open Diabetes Res Care 2018 24;6(1):e000503. Epub 2018 Apr 24.

Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Objective: Very few real-world studies have been conducted to assess the incidence of diabetes-related hypoglycemia. Moreover, there is a paucity of studies that have investigated hypoglycemia among people taking secretagogues as a monotherapy or in combination with insulin. Accordingly, our research team developed and validated the InHypo-DM Person with Diabetes Mellitus Questionnaire (InHypo-DMPQ) with the aim of capturing the real-world incidence of self-reported, symptomatic hypoglycemia. The questionnaire was administered online to a national sample of Canadians (≥18 years old) with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) treated with insulin and/or insulin secretagogues.

Research Design And Methods: Self-report data obtained from the InHypo-DMPQ were descriptively analyzed to ascertain the crude incidence proportions and annualized incidence densities (rates) of 30-day retrospective non-severe and 1-year retrospective severe hypoglycemia, including daytime and nocturnal events.

Results: A total of 552 people (T2DM: 83%; T1DM: 17%) completed the questionnaire. Over half (65.2%) of the total respondents reported experiencing at least one event (non-severe or severe) at an annualized crude incidence density of 35.1 events per person-year. The incidence proportion and rate of non-severe events were higher among people with T1DM versus T2DM (77% and 55.7 events per person-year vs 54% and 28.0 events per person-year). Severe hypoglycemia was reported by 41.8% of all respondents, at an average rate of 2.5 events per person-year.

Conclusions: The results of the InHypo-DMPQ, the largest real-world investigation of hypoglycemia epidemiology in Canada, suggest that the incidence of hypoglycemia among adults with diabetes taking insulin and/or insulin secretagogues is higher than previously thought.
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http://dx.doi.org/10.1136/bmjdrc-2017-000503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5922478PMC
April 2018

Patient-centred primary care of adults with severe and profound intellectual and developmental disabilities: Patient-caregiver-physician relationship.

Can Fam Physician 2018 04;64(Suppl 2):S63-S69

Research Manager in the Primary Healthcare Research Unit at Memorial University.

Objective: To explore the process of the development of the patient-physician relationship in adult patients with severe or profound intellectual and developmental disabilities (IDD), from the perspective of the patients' caregivers.

Design: Constructivist grounded theory.

Setting: St John's, NL.

Participants: Thirteen primary caregivers (5 males, 8 females) of 1 or more adults with severe or profound IDD.

Methods: Data were collected via in-depth, semistructured interviews conducted in person or by telephone. Interviews were audiorecorded and transcribed verbatim. Field notes were documented immediately by the interviewer and discussed with the research team. Memos in the form of reflective notes served as additional sources of data.

Main Findings: From the perspective of the caregivers, the core process in the development of the patient-physician relationship was protection. This process began as a result of the caregiver's recognition of the patient's vulnerability and moved through a number of stages before resulting in the development of a dynamic triangular interaction between the patient, caregiver, and family physician. First, the caregiver provides extreme nurturing to the patient, which results in the development of a strong bond between them. The patient and caregiver approached the family physician together as one unit, and then decided together on whether or not to open the patient-caregiver bond to the physician. The resultant dynamic triangular interaction formed the starting point from which 1 of 4 different relationship-development trajectories began. Which trajectory was taken and, therefore, the character of the relationships that developed was determined by how the caregiver and patient experienced their interaction with the family physician.

Conclusion: Findings highlight the process of protection and the centrality of the patient-caregiver bond within the development of a triadic relationship involving the patient with IDD, the caregiver, and the family physician. How a physician approaches this bond can influence the trajectory of the resulting relationship.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5906777PMC
April 2018

Patients' perceptions of access to primary care: Analysis of the QUALICOPC Patient Experiences Survey.

Can Fam Physician 2018 03;64(3):212-220

Associate Professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto in Ontario, Research Scientist at the Toronto Rehabilitation Institute, and Adjunct Scientist at the Institute for Clinical Evaluative Sciences.

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.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851400PMC
March 2018

Towards optimal electronic medical record use: perspectives of advanced users.

Fam Pract 2018 09;35(5):607-611

Centre for Studies in Family Medicine, Department of Family Medicine, Department of Epidemiology & Biostatistics, Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Canada.

Background: While primary health care electronic medical record (EMR) adoption has increased in Canada, the use of advanced EMR features is limited. Realizing the potential benefits of primary health care EMR use is dependent not only on EMR acquisition, but also on its comprehensive use and integration into practice; yet, little is known about the advanced use of EMRs in primary health care.

Objective: To explore the views of advanced primary health care EMR users practising in a team-based environment.

Methods: A descriptive qualitative approach was used to explore the views of primary health care practitioners who were identified as advanced EMR users. Twelve individual semi-structured interviews were held with primary health care practitioners in Southwestern Ontario, Canada. Field notes were created after each interview. Interviews were audio recorded and transcribed verbatim. Researchers independently coded the transcripts and then met to discuss the results of the coding. We used a thematic approach to data analysis.

Results: Three themes emerged from the data analysis: advanced EMR users as individuals with signature characteristics, advanced EMR users as visionaries and advanced EMR users as agents of change. In any one participant, these elements could overlap, illuminating the important interplay between these themes. Taken together, these themes defined advanced use among this group of primary health care practitioners.

Conclusions: To realize the potential benefits of EMR use in improved patient care and outcomes, we need to understand how to support EMR use. This study provides a necessary building block in furthering this understanding.
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http://dx.doi.org/10.1093/fampra/cmy002DOI Listing
September 2018

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data.

J Innov Health Inform 2017 Nov 17;24(4):888. Epub 2017 Nov 17.

Western University.

Background:   A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. OBJECTIVE:  To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. METHOD: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location.  Proportion of variance in referral rates attributable to the patient and practice levels. RESULTS:  On average, males had 0.26, and females 0.31 referrals in a 12-month period.  Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p<.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. CONCLUSIONS:  Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time.
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http://dx.doi.org/10.14236/jhi.v24i4.888DOI Listing
November 2017