This special conference proceedings issue of the McGill Journal of Medicine features the top 16 abstracts from the 4th Annual Family Medicine Research day jointly hosted by the Family Medicine Graduate Student Society and the Research Division of the Department of Family Medicine held on May 30, 2018 at Thomson House. This day celebrated the work of graduate students, medical students, residents and research assistants whose research centers on primary care and family medicine in Canada and internationally. We give special thanks to the abstract review committee, oral presentation judges, administrative staff, faculty donors, and funding we received from the Faculty of Medicine and PGSS, without whom this event would not have been possible.
Background: The objective was to describe trends in primary care continuity and acute hospital use in community-dwelling persons with dementia in Quebec from 2000 to 2015. Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. Primary care continuity, reflecting the degree to which patient primary care visits are concentrated among physicians, could be an important determinant of avoidable acute hospital use in dementia. To date, there are no descriptive trends in primary care continuity and acute hospital use for patients with dementia.
Methods: We conducted repeated, cross-sectional one-year cohort studies from 2000 to 2015. The population was community-dwelling persons (65 years of age or older) with dementia. Our outcomes were continuity of care in primary care (Bice-Boxerman index two-year prior diagnosis) and the rate of total and potentially avoidable acute hospital use (emergency department visits and hospital admissions). We gathered data from the Quebec provincial health administrative database in order to describe trends in the outcomes from 2000 to 2015. Rates will be standardized for differences in the distribution of age and sex over time.
Results: Primary care in Quebec has been reformed over the last decade, which may have increased primary care continuity, possibly leading to a decrease in acute hospital use. This study will be the first description of primary care continuity and avoidable acute hospital use over time for patients with dementia.
Conclusion: Describing primary care continuity and avoidable acute hospital use for patients with dementia is essential to ultimately inform healthcare policies aiming to reduce avoidable acute hospital use in this population..
Background: Potentially avoidable acute care transfers (PAACTs) for conditions that are potentially manageable in long-term care facilities (LTCFs) expose residents to additional risk. As such, LTCF family physicians and other frontline staff are increasingly being directed to reduce these transfers. To help develop local initiatives, we aim to 1) quantify PAACTs, adverse events, and information exchange during transfers; 2) identify associations between these variables; and 3) understand the contextual factors influencing transfer patterns from the perspectives of LTCF frontline staff.
Methods: This sequential explanatory mixed methods study will involve a retrospective cohort of full-time residents who experienced hospital transfers within a 24-month period at six publicly-funded LTCFs. We will abstract chart data to assess PAACT rates (using published ambulatory care sensitive diagnosis definitions), hospitalization rates following transfers, adverse outcome rates, and clinical information exchange between LTCFs and hospitals. Associations between outcomes (PAACTs and adverse events), information exchange, and resident/institution-level variables will be analyzed using multivariate statistical models. A second qualitative phase will include focus group discussions with 6-8 purposely selected frontline staff members within each facility. Semi-structured discussions, following a presentation of quantitative results, will be thematically analyzed to identify PAACT-related contextual factors and potential improvement strategies.
Results: We expect that transfer patterns and the factors associated therein will vary across the 6 LTCFs, and that our qualitative findings will provide an in-depth understanding of this phenomenon.
Conclusion: Our results will inform LTCF initiatives aimed at reducing PAACTs to improve care for this vulnerable population.
Background: Treatment resistant depression (TRD) in Canadian primary care is overrepresented by overweight and obese patients. Altered response to antidepressant (AD) treatment and obesogenic effects of certain ADs may contribute to high prevalence of TRD in this population. It is important to evaluate how primary care providers prescribe ADs known to cause weight changes.
Methods: We used a national primary care practice database to evaluate frequency of AD prescription to patients of different weight groups, with a focus on ADs known to modulate weight. The study sample was extracted from the national Canadian Primary Care Sentinel Surveillance Network (CPCSSN) for 2014-2016. 48,525 patients aged 18-65 with a history of depression were included. Measures were AD group, AD type, and body mass index. Data were analyzed with descriptive statistics and 95% Confidence Intervals (95% CI) were calculated by Newcomb-Wilson method.
Results: Compared to normal weight patients, 1.1% (95%CI: [0.11, 2.07]) more underweight patients received mirtazapine, a norepinephrine and specific serotonergic AD with a side effect of weight gain). In contrast, another obesogenic AD, amitriptyline, was prescribed to 1.3% (95%CI [0.85, 1.67]) more obese and 0.8% (95%CI [0.40, 1.17]) more overweight patients. Buproprion, a norepinephrine-dopamine reuptake inhibitor with a side effect of weight loss was prescribed to 1.4% more (95%CI [0.89,2.9]) obese and 0.9% more (95%CI [CI 0.34, 1.41]) overweight than to normal weight patients.
Conclusion: Our results suggest that prescribers account for weight-modulating impact of mirtazapine and bupropion but not for amitriptyline. In the next step, we will examine causal associations between AD prescription, body weight, and health outcomes using longitudinal analysis.
Background: Brazil has an expanding primary care system, with more than 60% of the population covered by community health workers (CHWs) and family health teams (FHTs). With the rising burden of non-communicable diseases (NCDs) and shortage of physicians and nurses, this study aims to explore the current knowledge, attitudes, and practices (KAP) regarding NCDs among CHWs in São Paulo and how they can effectively contribute to the management of NCDs as members of FHTs.
Methods: A sequential explanatory mixed-methods design will be used. Phase 1 is a cross-sectional KAP survey regarding NCDs, developed based on previously validated questionnaires, that will be sent electronically to all eligible CHWs. Survey responses will be analysed using descriptive statistics. Phase 2 will be a qualitative descriptive study using semi-structured focus groups with CHWs, nurses, and physicians working in FHTs. Phase 2 will aim to explain specific Phase 1 results and to further explore CHWs’ training and barriers/facilitators to sharing NCD management-related tasks. Focus group transcripts will undergo a thematic analysis.
Results: Knowledge and practice gaps regarding NCDs, with potential differences between FHTs, and education and experience levels are expected to be found. Barriers and facilitators specific to team dynamics, to the population served, and to material resources might further explain possible differences.
Conclusion: It is important to understand CHWs’ current knowledge and engagement in NCD management in order to optimize their training and clinical activities to better answer the complex health needs of an ageing, sicker population.
Background: Cultural safety is an approach to medical training that encourages practitioners to work in a culturally congruent way, acknowledging the validity of their patients’ worldviews. Lack of cultural safety is linked to ethnic health disparities and ineffective health services. Colombian medical schools currently provide no cultural safety training. This study reports the most significant change in the way medical students view traditional medicine after participating in a pilot cultural safety training program in Cota, Colombia.
Methods: We performed a qualitative descriptive study using an inductive thematic analysis for a five-month training program. Thirteen senior medical students completed the program, which included: 1) theoretical training on cultural safety and participatory research and 2) a community-based intervention, co-designed by traditional medicine users, cultural safety experts, and the medical students, with the aim of strengthening traditional medicine in Cota. Our evaluation utilized the Most Significant Change narrative approach, which allowed participants to communicate the changes most meaningful to them. We transcribed and analyzed student responses and discussed these in a debriefing session.
Results: Medical students described four significant changes: 1) greater respect for traditional medicine users to provide better healthcare; 2) recognition of traditional medicine as part of their cultural heritage and identity; 3) wanting to deepen their knowledge about traditional medicine; and 4) possibly incorporating traditional medicine in healthcare.
Conclusion: Medical students reported more positive perceptions of traditional medicine after participating in this community-based training program. Medical educators should consider the potential benefits of cultural safety training in multicultural settings.
Background: Men and women with dementia may have differential health system experiences due to variable patterns of longevity, availability of informal caregivers, and sex-specific manifestations of dementia. The introduction of new primary care models in Ontario emphasizing patient enrolment and team-based care since 2002 may have led to improved health system performance for men and women with dementia; however, provincial-level information is lacking. This study examines changes in health system performance since 2002 and whether they are similar between men and women.
Methods: We conducted a population-based, repeated, cross-sectional study of community-dwelling adults aged 65 years-of-age and older newly diagnosed with dementia in each year between 2002 and 2014. Patients were followed for one year. Thirty indicators of primary care performance were measured using health administrative data from the Institute for Clinical Evaluative Sciences. Proportions or averages for each indicator in each year were represented graphically, stratified by sex.
Results: The number of incident cases increased in men from 7,773 in 2002 to 10,070 in 2014 and in women from 12,096 to 14,172. Non-urgent emergency department visits decreased from 52% to 30% in men and from 55% to 28% in women. The proportion of avoidable hospitalizations decreased slightly by 1-2% over time in both sexes. Changes over time in home care visits, long-term care, and visits to primary care/specialists were similar for both sexes. Results on other indicators are forthcoming.
Conclusion: This study is among the first to track health system performance and to contrast sex differences in newly-diagnosed persons with dementia in Ontario. Few sex differences over time were observed. While some indicators improved overall, the relationship between the introduction of new primary care models and these changes should be further explored.
Background: Case management (CM) is a collaborative process involving assessment, planning, facilitation, care coordination, evaluation, and advocacy for patients. Despite the established benefits of CM for the care of vulnerable and chronically ill patients, implementation of CM remains challenging in Québec. Our objectives are: 1) understand how healthcare professionals view the structural transition towards collaborative health interventions like CM; 2) highlight potential barriers, successes, and limitations to establishing and sustaining CM usage according to Family Medicine Group (FMG) professionals; and, 3) identify strategies that will lead to better sustained CM into FMGs.
Methods: We are conducting a multi-centered qualitative case study in FMGs across Québec. Cases will be selected to represent maximum variability in terms of the degree to which CM has been implemented into FMGs and the clientele that FMGs service (Alzheimer’s patients vs. frequent healthcare users). Clinicians within each FMG will be engaged with focus groups, semi-structured interviews, and participant observation. A Document analysis will be performed, and a thematic analysis with be conducted.
Results: This research is intended to not only identify professional perceptions of CM, but to outline strategies for improving the uptake and sustainability of CM in FMGs. This may result in improved care for chronically ill patients and reduced overall strain on the Québec and Canadian health system.
Conclusion: Our qualitative case study will use the perceptions of FMG healthcare professionals to understand how to improve CM function and sustainability in FMGs, improving health outcomes for complex-care patients.
Background: Community health workers (CHWs) are key actors who provide health services to underserved populations. They require appropriate training since they often represent the sole port of entry to health care for marginalized communities. Community health interventions sometimes fail in the long-term because cultural factors of the CHWs are not considered. Therefore, more information is needed on the integration of culturally competent strategies for the sustainability of these training programs. This study aims to describe and understand the culturally competent strategies used in a training program for indigenous CHWs in resource-poor environments, and the responses to those efforts.
Methods: This is a qualitative case study (a methodology that studies the case within its context) of the McGill University Training and Education for Andean Community Health (TEACH) project. This study examines if and how cultural differences were reconciled in the training process delivered by Canadian health professionals to fifteen Ecuadorian indigenous women to become CHWs. Participants’ semi-structured interviews, teacher’s reports, and educational material from the case will be analyzed with thematic analysis to identify the cultural competent strategies used.
Results: We will identify the most effective culturally competent and educational engagement strategies used in the TEACH project for teaching CHWs in a cross-cultural context and analyze how these are implemented.
Conclusion: This study will identify culturally competent strategies for educational engagement important for health services in underserved communities. The results can inform improvement actions for the program and the implementation of future similar training programs of health actors in communities with different cultures.
Background: Having a primary care (PC) provider and a consistent relationship with that provider is vital in attaining proper asthma care management and education, two strategies shown to prevent emergency department (ED) visits for asthma in children. In Quebec, children are mainly followed by PC physicians in family medicine groups (FMGs), in non-FMGs (traditional primary care models), or by pediatricians. We sought to determine whether PC models are associated with differing rates of ED visits and hospitalizations of Quebec children with asthma and whether outcomes differ by levels of care continuity (high, medium, low).
Methods: We are conducting a population-based retrospective cohort study using provincial health administrative data from 2010-2013 for children with asthma aged 2-16 years old (N=38,791). The main exposure is the PC model (FMGs, family physicians not part of FMGs, or pediatricians). Covariates will include age, gender, co-morbidities, continuity of care (COC) index (high, medium, low), rurality, SES, previous healthcare utilization. The primary outcome is rate of ED visits and the secondary outcome is rate of hospital admissions. We will use multivariate Poisson and logistic regression analyses to test associations between exposure and outcomes.
Results: We aim to increase knowledge as well as inform policy and practice on primary care services in the management of asthma for children.
Conclusion: This study will describe the impact of primary care on outcomes for children with asthma in Quebec.
Background: Clinical teachers (physicians whose activities involve teaching) can improve their skills as instructors of future clinicians through faculty development programs. Despite the growing literature on professional identity, little is known about how clinical teachers construct and balance their identities as clinicians, teachers, and as students of faculty development. There is limited data on the influence that these processes may have on clinical practice. The purpose of this research is to examine the experiences of clinical teachers enrolled in a blended learning program on faculty development and understand how they relate it to their identities as physicians and teachers.
Methods: Interpretative phenomenological analysis (IPA) which explores in detail how people conceptualize their personal and social world, and how they respond to a specific phenomenon (in this case professional identity) adopting an insider’s perspective. Participants will be 5 to 10 purposively-sampled teachers in family medicine attending an international blended learning program on faculty development. In order to have a deeper understanding of their experience, two rounds of in-depth semi-structured interviews will be conducted with each participant and analyzed using latent thematic analysis.
Results: This investigation will shed light on how clinical teachers enrolled in a faculty development program make sense of their multiple professional identities over time, and reveal the advantages and challenges of simultaneously being a physician, educator, and student.
Conclusion: Examining the experiences of clinical teachers participating in faculty development programs can help to understand the construction and balance of their multiple professional identities and, moreover, improve these programs for a better quality of clinical practice and medical training.
Background: Healthcare systems are facing an increasing number of vulnerable elderly patients who require complex services and care. This population is mainly managed by family physicians. Transitions in care from hospitals to nursing homes for this population are especially threatening. In response to these challenges, transitional care (TC) interventions are being widely implemented at hospital discharge to increase quality of care, patient outcomes, and optimize use of services. The objectives were to determine the impact of TC interventions on health-related outcomes (all-cause mortality and quality of life), service use outcomes (emergency department visits, readmissions, and readmission days), and quality of care indicators (medication errors and advanced directives) among patients aged 65 and over discharged from hospital to nursing homes.
Methods: A systematic review of TC interventions from hospital to nursing homes in a population of older patients is being conducted. Medline, CINHAL, EMBASE, Cochrane Central, and Social Work Abstracts (2007-2016) were searched for randomized controlled studies and quasi-experimental studies in English or French. Study selection (title/abstract and full-text), data extraction, and quality appraisal was conducted by two independent reviewers. Relative risks and mean differences are currently being calculated using a random-effect model.
Results: From 5406 references, 11 studies were included and are currently being analyzed. The selected outcomes will provide useful insight on the impact and applicability of TC for a vulnerable older population.
Conclusion: This review will allow the research team to make recommendations for the care of hospitalised older patients and will guide future work on the development and implementation of transitional care interventions.
Background: Despite advances in HIV treatment and care, women living with HIV continue to experience persistent barriers to care and gaps in screenings and co-morbidity management. Strengthening care delivery for women living with HIV necessitates an understanding of who provides care, and where care is sought, to allow for more appropriate care interventions based on various typologies of care.
Methods: We created care typologies drawing on data from the baseline questionnaire of the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (N=1422). The analysis is restricted to 1236 participants who accessed care in the last year, and who provided self-reported data on their HIV-care provider and their site of HIV care. Descriptive statistics and four care typologies are presented.
Results: Participants lived in British Columbia (27.9%), Ontario (46.7%), and Quebec (25.4%), and varied in age from 16-30 years (8.3%), 30-40 years (29.1%), 40-50 years (32.9%), and >50 years (29.9%). Women identified as Indigenous (20.8%), African/Caribbean/Black (29.0%), and White (42.5%). Four care typologies were created: 1) 5.2% of women accessed care from a family doctor in HIV clinics; 2) 11.7% from a family doctor in non-HIV clinics; 3) 64% from a specialist in an HIV clinic; and 4) 18.9% from a specialist in non-HIV clinics.
Conclusion: Women living with HIV access care from a variety of HIV-care providers and care settings. Further work will investigate whether these care typologies are associated with differing gaps in HIV and women’s health care in order to design targeted interventions to improve care for women living with HIV.
Background: In northern regions including James Bay, Quebec, secondary and tertiary care services are limited; thus, primary care plays a crucial role in health service delivery. In 2014, the Cree Board of Health and Social Services for James Bay (CBHSSJB) supported an initiative in all nine James Bay Cree communities to stimulate local prioritization for health change. While many healthcare challenges identified were specific to youth (under 35 years old), youth perspectives in these reports are limited. We sought to understand how Cree youth perceived their engagement in health and health planning across James Bay.
Methods: As part of a CBHSSJB-McGill partnership, this qualitative descriptive study used a community-based participatory research approach. Ten Cree youth participated in two focus groups, and five Cree youth coordinators participated in key informant interviews. Thematic analysis was conducted and inductive codes were grouped into thematic categories.
Results: Cree participants characterized youth engagement in the following incremental capacities: participation in community and recreational activities; membership in local and regional youth councils; and decision-making as planners of health-related initiatives. Cree youth recommended using social media, youth assemblies, and youth as planners to further strengthen youth engagement and youth health in the region.
Conclusion: Our findings revealed an interconnectedness between youth health and youth engagement. James Bay Cree youth described how they needed to be engaged to be healthy, and to be healthy in order to be engaged. They contributed novel and practical insights to engage Indigenous youth in health planning across Canada.
Background: Little is known about physicians’ thoughts on the growing body of evidence nuancing the benefits and harms of mammography screening. This study aims to explore physicians’ perspectives on clinical research regarding mammography screening for average-risk women, and how physicians relate this research to clinical practice.
Methods: We conducted a cross-sectional survey using a validated questionnaire with closed and open-ended questions. Physician ratings were extracted from assessments of four research synopses (Patient Oriented Evidence that MattersTM: POEMs) on mammography screening. Quantitative data were evaluated with descriptive statistics and qualitative data were summarized thematically. Connections were assessed between both data sources.
Results: 1243 to 1351 physicians rated each POEM. Across all POEMs, the highest physician endorsement for using the information with patients was using it in a discussion with a patient. Three themes emerged from 310 qualitative comments across all POEMs: 1) perspectives on POEM information, 2) applying this information in practice, and 3) confronting clinical and cultural realities. Physicians held diverse perspectives on the value of the POEMs. Some physicians continued to support screening; others condemned harms such as overdiagnosis. Although physicians noted the POEMs’ potential to improve patient counseling, challenges remained, including the difficulty of explaining overdiagnosis, and lacking sufficient time to hold balanced discussions. Physicians advocated for the personalization of screening decision-making and patient-centered approaches to respect each patient’s values and preferences.
Conclusion: Important divergences exist in physicians’ assessments of clinical research on mammography screening and their use of this research in practice. Further research should explore how physicians may implement shared decision-making for mammography screening.
Background: The use of non-invasive cardiovascular imaging tests for diagnosing coronary artery disease (CAD) has risen dramatically over the last decade. However, national guidelines in diagnostic cardiology reported a lack of attention devoted to users’ satisfaction, and repeatedly documented the importance of patient-oriented research to guide clinical decision-making. In this context, this study aims to contribute to the understanding of patient and physician preference in relation to the choice of cardiovascular imaging tests.
Methods: A discrete choice experiment (DCE) questionnaire on a convenience sample from the Royal Victoria cardiology clinic was used to systematically elicit patient and physician preference toward diagnostic imaging tests. A hierarchical Bayesian procedure was used to estimate preference associated with tests’ attributes: cost, risks and side effects, type of procedures, diagnostic accuracy, type of scanner, and duration. High positive zero-centered utility values indicated high preference.
Results: 148 cardiac patients and 63 physicians completed the DCE. Risks and side effects had the greatest impact on patients’ preference (Χ2=157.7, p<0.01). Patients assigned notably high utility to tests with milder side effects (+97.9), while avoiding exposure to ionizing radiation (-36.7) and risks associated with the use of pharmacological agents inducing direct coronary arteriolar vasodilation (-61.3). Physicians attributed more importance to cost (Χ2=30.6, p<0.01) and diagnostic accuracy (Χ2=25.6, p<0.01).
Conclusion: Patients’ preference was most determined by the risks and side effects associated with cardiovascular imaging tests, while physicians preferred less costly and more accurate alternatives. In aiming for the best possible care, the clinical implementation of safer, more accurate and cost-effective imaging tests for diagnosing CAD may improve users’ satisfaction and health outcomes.
Background: Timely and efficient access to clinical information presents an ongoing challenge to long-term care (LTC) family physicians. The objectives of this project are two-fold: 1) evaluate the extent to which clinical information is both needed and efficiently available to Canadian LTC family physicians, and 2) describe how identified clinical information gaps may impede the delivery of high quality medical care in this setting.
Methods: A two-phase explanatory, sequential mixed methods design will be applied. Phase I will consist of an online survey that will be sent to a random sample of 800 LTC facilities across Canada asking physicians to assess how clinical information is used, disseminated, required, and efficiently available for the purposes of clinical decision-making. In Phase II, semi-structured interviews with purposefully selected survey participants will be conducted to assess the barriers and facilitators associated with efficient access to clinical information.
Results: We will report the extent to which identified clinical information gaps vary by facility-level (e.g. province, accreditation status) and respondent-level (e.g. patient load, years of experience) characteristics. Integration of results from both phases will provide an in-depth explanation of how clinical information is used, and whether information gaps are perceived to affect the ability to provide quality care in this setting.
Conclusion: Our results are expected to provide novel findings that will be useful to LTC family physicians in their quest to provide quality, collaborative, person-centered care to a vulnerable population often experiencing acute changes in their health status.