Primary Care In Canada Research Articles

Perspectives from primary health care providers on their roles for supporting adolescents and young adults transitioning from pediatric services

BackgroundTransitioning from pediatric care to adult-oriented care at age 18 (the age of transfer in most countries and jurisdictions) is a complex process for adolescents and young adults affected by chronic physical health and/or mental health conditions. The role of primary health care (PHC) providers for this population is poorly understood. Perspectives from these providers, such as family physicians and other members of the primary care team, have not been explored in depth.MethodsA total of 18 participants (e.g., family physicians, social workers, nurses) were recruited from 6 Primary Care Networks in Calgary, Alberta, Canada. Semi-structured individual interviews were conducted, and transcribed verbatim. A qualitative description approach was used to analyze the data, and included thematic analysis.ResultsFive distinct, yet overlapping, roles of primary health care providers for adolescents and young adults transitioning to adult care resulted from our analysis: (1) being the “common thread” (continuous accessible care); (2) caring for the “whole patient” (comprehensive care); (3) “knowing families” (family-partnered care); (4) “empowering” adolescents and young adults to develop “personal responsibility” (developmentally-appropriate care); and (5) “quarterbacking” care (coordination of specialist and/or community-based care). Participants identified potential benefits of these roles for adolescents and young adults transitioning to adult care, and barriers in practice (e.g., lack of time, having minimal involvement in pediatric care).ConclusionsInput from family physicians, who follow their patients across the lifespan and provide the majority of primary care in Canada, are critical for informing and refining recommended transition practices. Our findings provide insights, from PHC providers themselves, to bolster the rationale for primary care involvement during transitions from pediatric specialty and community-based care for AYAs. Solutions to overcome barriers for integrating primary care and specialty care for adolescents and young adults need to be identified, and tested, with input from key stakeholders.

Validating a case definition for adult asthma in primary care electronic medical records

Although asthma is one of the most common chronic conditions affecting Canadians, its epidemiologic characteristics and burden in primary care contexts are poorly understood. The aim of this study was to develop and validate a case definition to identify adults with asthma who consult family physicians and to estimate the prevalence of asthma in that setting in Canada. This validation study utilized a database of electronic medical records (EMRs) from the Southern Alberta Primary Care Research Network, a node of the Canadian Primary Care Sentinel Surveillance Network (SAPCReN-CPCSSN). The population included patients over age 17y of any gender and health status who had visited an SAPCReN-CPCSSN primary care provider during the period December 1, 2014−December 31, 2016. The validation of the case definition involved comparing a case-finding algorithm to caseness determined by an expert physician review of the records of 1000 patient in the CPCSSN database. The case definition, which included the ICD-9 code 493 and asthma-related text words, had 83.33% sensitivity (95% CI: 63.61–93.88%), 99.28% specificity (95% CI: 98.51–99.67%), a positive predictive value of 74.07% (95% CI: 55.03–87.14%), and a negative predictive value of 99.59% (95% CI: 98.93–99.86%). The prevalence of adult asthma in CPCSSN primary care practices in southern Alberta was 4.20% (95% CI: 4.09–4.31). The strong validation metrics suggest that this case definition is valid for both clinical and research purposes. The validated case definition may be used to improve patient care and improve understanding of the prevalence and burden of asthma in primary care in Canada.

Prevalence and Demographics of CKD in Canadian Primary Care Practices: A Cross-sectional Study

IntroductionSurveillance systems enable optimal care delivery and appropriate resource allocation, yet Canada lacks a dedicated surveillance system for chronic kidney disease (CKD). Using data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a national chronic disease surveillance system, this study describes the geographic, sociodemographic, and clinical variations in CKD prevalence in the Canadian primary care context.MethodsThis cross-sectional study included 559,745 adults in primary care in 5 provinces across Canada from 2010 through 2015. Data were analyzed by geographic (urban or rural residence), sociodemographic (age, sex, deprivation index), and clinical (medications prescribed, comorbid conditions) factors, using data from CPCSSN and the Canadian Deprivation Index. CKD stage 3 or higher was defined as 2 estimated glomerular filtration rate (eGFR) values of <60 ml/min per 1.73 m2 more than 90 days apart as of January 1, 2015.ResultsPrevalence of CKD was 71.9 per 1000 individuals and varied by geography, with the highest prevalence in rural settings compared with urban settings (86.2 vs. 68.4 per 1000). CKD was highly prevalent among individuals with 3 or more other chronic diseases (281.7 per 1000). Period prevalence of CKD indicated a slight decline over the study duration, from 53.4 per 1000 in 2010 to 46.5 per 1000 in 2014.ConclusionThis is the first study to estimate the prevalence of CKD in primary care in Canada at a national level. Results may facilitate further research, prioritization of care, and quality improvement activities to identify gaps and improvement in CKD care.

The integration challenge in Canadian regionalization.

In the 1990s, regionalization was introduced in Canada through administrative delegation in order to achieve a number of reform objectives, but among the most important was to improve the integration of services across diverse health sectors. Despite the failure of regionalization in fulfilling its promise of integration, regionalization still provides a foundation for achieving system-wide integration. For this to occur, however, regional and provincial health authorities need to be given the effective accountability for primary care. Given that primary healthcare physicians provide the majority of primary care in Canada, the funding for primary care physicians should be returned from provincial ministries of health to regional (or provincial) authorities in order to allow them the opportunity to become responsible for coordinating health services for their patient populations across the continuum of care, and to contract providers with the necessary incentives and penalties.

Reflections of the quality of primary care in Canada and Israel

Rachel Podell and her colleagues at the National Program for Quality Indicators in Community Healthcare in Israel have provided a clear and engaging description of thequality of primary care provided to the elderly in Israel. They examine changes overtime, variation across sub-groups, and comparisons with other countries. Over a 13year timeframe, most of the included process measures improved substantially, withfairly minor differences between demographic groups and largely favourablecomparisons with other countries.In the Podell et al article, there are few direct comparisons of primary care available between Canada and Israel, but we know from other studies that Canadian primary care compares relatively unfavourably with ten other developed countries in a number of measures. These include timely access to care, after-hours care, electronic medical record use and audit and feedback for quality improvement. More concerning is that few of these measures have improved in Canada over a number of years, despite a major policy focus on primary care, investments in payment reforms and the formation of groups and inter-professional teams.Differences in performance trajectories could relate to the major structural differences in primary care between Canada and Israel. While Canada has universal health insurance coverage for necessary physician and hospital services, most physicians practice privately, are paid mainly through fee-for-service and have few accountabilities to the health care system. Many Canadians lack a regular source of primary care and there is little or no competition between primary care practices or groups, as most of them have full practices, and are not accepting new patients. No Canadian province has completely implemented electronic medical records in primary care. Canada also lacks the organizational, administrative and support structures of Israel's health maintenance organizations.Canada and other countries can learn from the advances in data, measurement, feedback, and organization of care that are now applied routinely to ongoing quality improvement in Israel, with impressive results. The Israeli experience suggests that future developments designed to improve care and outcomes should include measurement infrastructure, formal reporting, accountability mechanisms, and management systems to address gaps and inequities in care.

Severe, eosinophilic asthma in primary care in Canada: a longitudinal study of the clinical burden and economic impact based on linked electronic medical record data

BackgroundStratification of patients with severe asthma by blood eosinophil counts predicts responders to anti-interleukin (IL)-5 (mepolizumab and reslizumab) and anti-IL-5 receptor α (benralizumab) therapies. This study characterized patients with severe asthma who could qualify for these biologics in a primary care setting.MethodsWe retrospectively selected patients from July 1, 2010, to June 30, 2014, using a linked electronic medical records (EMR) database (IMS Evidence 360 EMR Canada) for > 950,000 patients in primary care in Ontario, Canada. Patients aged ≥ 12 years with ≥ 2 documented asthma diagnoses were identified as having severe asthma based on prescriptions for high-dosage inhaled corticosteroids (ICS) plus either a leukotriene receptor antagonist, long-acting β2-agonist (LABA), or theophylline filled on the same day. Patients’ asthma was considered severe also if they received a prescription for ICS with oral corticosteroids (OCS) or an additional prescription for omalizumab. Patient characteristics, asthma-related medications, and blood eosinophil counts were captured using observed care patterns for the year prior to ICS/LABA and/or OCS prescription. Health care resource use (HCRU) and costs were captured throughout the 1-year follow-up period.ResultsWe identified 212 patients who met the criteria for severe asthma. These patients required an average of 6.5 physician visits during the 1-year follow-up period (95% confidence interval 5.7–7.3), and 20 (9%) were referred to respiratory specialists. Overall, 56 patients (26%) with severe asthma had complete blood counts, of whom 23 (41%) had blood eosinophil counts ≥ 300 cells/μL and might be considered for anti-eosinophil therapies. Patients with severe asthma and blood eosinophil counts ≥ 300 cells/μL had more respiratory specialist referrals (17% vs. 12%) than patients with blood eosinophils < 300 cells/μL.ConclusionsOur data suggest that during 2010–2014, Ontario primary care patients with severe asthma and high blood eosinophil counts had greater HRCU than those with lower counts. Approximately 41% of patients with severe asthma could qualify for anti-eosinophil drugs based on blood eosinophil counts. However, the eosinophilic status of most patients was unknown. It is appropriate to increase awareness of the use of blood eosinophil counts to identify patients who could be considered for anti-eosinophil therapies.

Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach.

The detection and management of chronic kidney disease lies within primary care; however, performance measures applicable in the Canadian context are lacking. We sought to develop a set of primary care quality indicators for chronic kidney disease in the Canadian setting and to assess the current state of the disease's detection and management in primary care. We used a modified Delphi panel approach, involving 20 panel members from across Canada (10 family physicians, 7 nephrologists, 1 patient, 1 primary care nurse and 1 pharmacist). Indicators identified from peer-reviewed and grey literature sources were subjected to 3 rounds of voting to develop a set of quality indicators for the detection and management of chronic kidney disease in the primary care setting. The final indicators were applied to primary care electronic medical records in the Electronic Medical Record Administrative data Linked Database (EMRALD) to assess the current state of primary care detection and management of chronic kidney disease in Ontario. Seventeen indicators made up the final list, with 1 under the category Prevalence, Incidence and Mortality; 4 under Screening, Diagnosis and Risk Factors; 11 under Management; and 1 under Referral to a Specialist. In a sample of 139 993 adult patients not on dialysis, 6848 (4.9%) had stage 3 or higher chronic kidney disease, with the average age of patients being 76.1 years (standard deviation [SD] 11.0); 62.9% of patients were female. Diagnosis and screening for chronic kidney disease were poorly performed. Only 27.1% of patients with stage 3 or higher disease had their diagnosis documented in their cumulative patient profile. Albumin-creatinine ratio testing was only performed for 16.3% of patients with a low estimated glomerular filtration rate (eGFR) and for 28.5% of patients with risk factors for chronic kidney disease. Family physicians performed relatively better with the management of chronic kidney disease, with 90.4% of patients with stage 3 or higher disease having an eGFR performed in the previous 18 months and 83.1% having a blood pressure recorded in the previous 9 months. We propose a set of measurable indicators to evaluate the quality of the management of chronic kidney disease in primary care. These indicators may be used to identify opportunities to improve current practice in Canada.

Improving Obesity Prevention and Management in Primary Care in Canada.

Obesity is a major risk factor for chronic diseases with significant morbidity, mortality and health care cost. There is concern due to the dramatic increase in overweight and obesity in Canada in the last 20years. The causes of obesity are multifactorial, with underestimation by patients and healthcare providers of the long-term nature of the condition, and its complexity. Solutions related to prevention and management will require multifaceted strategies involving education, health policy, public health and health systems across the care continuum. We believe that to support such strategies we need to have a strong primary care workforce equipped with appropriate knowledge, skills and attitudes to support persons at risk for, or with, obesity. To achieve this end, significant skills building is required to improve primary care obesity prevention and management efforts. This review will first examine the current state, and then will outline how we can improve.

How does the Nurse Practitioner as the Most Responsible Provider Affect Care in Seniors Age 65 and Older Admitted to Hospitals in Ontario, Canada?

Background: Evidence for Nurse Practitioners (NP) hospital based roles positively impacting patient care exists. Enabling changes have authorized a broader scope of practice. There is limited understanding of the NP role from the Most Responsible Provider (MRP) lens during care across the hospital trajectory focusing on admission, treatment and discharge. Aim: To identify how the NP as the Most Responsible Provider affects care in seniors over the age 65 admitted to Ontario Hospitals. Methods: A comprehensive literature search methodology was utilized to identify studies. Electronic databases searched CINAHL, Embase, MEDLINE, PubMed, Evidence Based Medicine, Cochrane, Google Scholar and Digital dissertations. Studies describing NP models of care anchored in assuming MRP roles with a focus on caring for seniors were targeted. Results: Seventeen studies met inclusion criteria: three randomized controlled trials, three systematic literature reviews, two mixed methods, two descriptive surveys, one cross-sectional, one pilot, one retrospective and four descriptive case studies. Conclusion: A critical research opportunity exists to fully explore Nurse Practitioner role contributions as the Most Responsible Provider for hospitalized seniors. What we know already: Information on the NP in the MRP role exists in pockets of primary care in Canada and the United States. NP hospital roles have only been evaluated in the context of consultation and shared care with physicians and teams. What we can learn: Enabling, empowering and embracing NP maximal scope of practice contributions as the MRP can be valuable across the continuum of hospital experiences. Bridging and synergizing NP care to meet complex senior care is a timely, safe and innovative care solution.

A microsimulation cost–utility analysis of alcohol screening and brief intervention to reduce heavy alcohol consumption in Canada

Screening and brief intervention (SBI) is a public health intervention that has been shown to be effective in reducing heavy alcohol consumption. The aim of this study is to estimate the cost-effectiveness of implementing universal alcohol SBI in primary care in Canada. We developed a microsimulation model of alcohol consumption and its effects on 18 alcohol-related causes of death. The model simulates a Canadian population. The model simulates individuals and their alcohol consumption on a continuous scale starting from age 17years to death. The reference case assumes no SBI in Canada. The base case assumes screening was conducted using the Alcohol Use Disorders Identification Test (AUDIT) at a threshold score of 8. Additional analyses included evaluating SBI using the AUDIT at threshold scores between 4 and 8 or the Derived Alcohol Use Disorders Identification Test (AUDIT-C) at threshold scores between 3 and 7. The model estimates the direct health-care costs, life years gained and quality-adjusted life years (QALY) gained, which are then used to estimate the incremental cost-effectiveness ratio (ICER) of SBI versus no SBI. SBI with AUDIT (at a threshold score of 8) had an ICER of $8729/QALY. Our results suggest that using AUDIT thresholds between 8 and 4, inclusive, would be cost-effective for the whole population, as well as for men and women individually. Our results suggest that the AUDIT-C would be cost-effective at thresholds of 7 to 3, inclusive, for men, women and the whole population. In Canada, screening and brief intervention via Alcohol Use Disorders Identification Test (AUDIT) and Derived Alcohol Use Disorders Identification Test (AUDIT-C) to reduce heavy alcohol consumption appears to be cost-effective for men and women at Alcohol Use Disorders Identification Test (AUDIT) thresholds of 8 and lower and at Derived Alcohol Use Disorders Identification Test (AUDIT-C) thresholds of 7 and lower.

Using Avoidable Admissions to Measure Quality of Care for Cardiometabolic and Other Physical Comorbidities of Psychiatric Disorders: A Population-Based, Record-Linkage Analysis.

Quality of care for comorbid physical disorders in psychiatric patients can be assessed by the number of avoidable admissions for ambulatory care sensitive (ACS) conditions. These are admissions for physical conditions that, with appropriate primary care, should not require inpatient treatment. Avoidable admissions for ACS conditions feature prominently in Australia's National Health Performance Framework and have been used to assess health care provision for marginalized groups, such as Indigenous patients or those of lower socioeconomic status. They have not been applied to people with mental illness. A population-based, record-linkage analysis was used to measure ACS admissions for physical disorder in psychiatric patients of state-based facilities in Queensland, Australia, during 5 years. There were 77 435 males (48.0%) and 83 783 females (52%) (total n = 161 218). Among these, 13 219 psychiatric patients (8.2%) had at least 1 ACS admission, the most common being for diabetes (n = 6086) and angina (n = 2620). Age-standardized rates were double those of the general population. Within the psychiatric group, and after adjusting for confounders, those who had ever been psychiatric inpatients experienced the highest rates of ACS admissions, especially for diabetes. In common with other marginalized groups, psychiatric patients have increased ACS admissions. Therefore, this measure could be used as an indicator of difficulties in access to appropriate primary care in Canada, given the availability of similar administrative data.

Successful childhood obesity management in primary care in Canada: what are the odds?

Background. The management of a child presenting with obesity in a primary care setting can be viewed as a multi-step behavioral process with many perceived and actual barriers for families and primary care providers. In order to achieve the goal of behavior change and, ultimately, clinically meaningful weight management outcomes in a child who is considered obese, all steps in this process should ideally be completed. We sought to review the evidence for completing each step, and to estimate the population effect of secondary prevention of childhood obesity in Canada.Methods. Data from the 2009/2010 Canadian Community Health Survey and from a review of the literature were used to estimate the probabilities for completion of each step. A flow chart based on these probabilities was used to determine the proportion of children with obesity that would undergo and achieve clinically meaningful weight management outcomes each year in Canada.Results. We estimated that the probability of a child in Canada who presents with obesity achieving clinically meaningful weight management outcomes through secondary prevention in primary care is around 0.6% per year, with a range from 0.01% to 7.2% per year. The lack of accessible and effective weight management programs appeared to be the most important bottleneck in the process.Conclusions. In order to make progress towards supporting effective pediatric obesity management, efforts should focus on population-based primary prevention and a systems approach to change our obesogenic society, alongside the allocation of resources toward weight management approaches that are comprehensively offered, equitably distributed and robustly evaluated.

Is Team-Based Primary Care Associated with Less Access Problems and Self-Reported Unmet Need in Canada?

As in many jurisdictions, the delivery of primary care in Canada is being transformed from solo practice to team-based care. In Canada, team-based primary care involves general practitioners working with nurses or other health care providers, and it is expected to improve equity in access to care. This study examined whether team-based care is associated with fewer access problems and less unmet need and whether socioeconomic gradients in access problems and unmet need are smaller in team-based care than in non-team-based care. Data came from the 2008 Canadian Survey of Experiences with Primary Health Care (sample size: 10,858). We measured primary care type as team-based or non-team-based and socioeconomic status by income and education. We created four access problem variables and four unmet need variables (overall and three specific components). For each, we ran separate logistic regression models to examine their associations with primary care type. We examined socioeconomic gradients in access problems and unmet need stratified by primary care type. Primary care type had no statistically significant, independent associations with access problems or unmet need. Among those with non-team-based care, a statistically significant education gradient for overall access problems existed, whereas among those with team-based care, no statistically significant socioeconomic gradients existed.

Nurse Practitioners as Most Responsible Provider: Impact on Care for Seniors Admitted to an Ontario Hospital

Background and Significance: Evidence for Nurse Practitioners (NP) hospital based roles positively impacting patient care exist. Information on the NP in the Most Responsible Pronder (MRP) role exists in pockets of primary care in Canada and the United States. NP hospital roles have only been evaluated in the context of consultation and shared care. There is limited understanding of the NP role from the MRP lens during care across the hospital trajectory. Aim: To examine patient, family and staff experience with the quality of NP care delivered as the MRP from admission to discharge. Methodology: A mixed methods pilot study examined qualitative NP satisfaction surveys and quantitative data related to the total number of admissions and discharges in a community hospital in Ontario. Data Analysis Results: A total of 602 admissions, 555 discharges, 25 deaths and 45 transfers occurred with NPs practicing as MRPs. The average senior was 78 years old. Survey response rates for patients were 69%, families 41%, and staff 72%. Satisfaction surveys revealed staff worked with NPs for an average of 4 years. Chronbach alpha demonstrated high internal consistency across all groups (a .943). ANOVA analysis showed statistical significance with Question 6 NP approachability (p< .001). Bonferroni post hoc analysis revealed that staff responses statistically differed from family responses (P <.001). Correlation matrix of questions found significance at both 0.05 and 0.01 levels (two tailed). Conclusion: Nurse Practitioners are able to function as most responsible provides delivering hospital care from admission through discharge with high patient, family and staff satisfaction and quality caring. A critical research opportunity exists to fully explore NP role contributions as the MRP for hospitalized populations in both community and academic hospitals. Implications for practice: Enabling, empowering and embracing NP maximal scope of practice contributions as the MRP can be valuable across the continuum of hospital experiences. NP care to meet complex senior care is a timely, safe and an innovative quality caring solution. Full implementation and sustainability for the model of care is a research rich area for exploration.

The value of registered nurses in collaborative family practice: enhancing primary healthcare in Canada.

With the current focus on improving efficiencies and quality of care within the Canadian healthcare system, primary healthcare (PHC) is receiving renewed attention. The time is right for highlighting the value that registered nurses (RNs) can bring to collaborative practice in primary care settings. This paper discusses the untapped utilization of RNs in primary care in Canada, arguing for a strong leadership role for nurses and citing examples of RN services that could enhance care and improve population health and cost-effectiveness. Internationally, other countries with strong PHC strategies in place offer potential lessons regarding features that could be adapted in Canada.

Inter-provincial variation and determinants of access to team-based primary care in Canada

Background: Team-based care involves family physicians working with other health professionals to provide primary care to patients. It has been implemented across Canada; however, its adoption varies, as health care delivery is the responsibility of provincial governments and not the federal government. Objective: To examine variations in the composition of team-based primary care amongst Canadian provinces in 2008 and identify patient characteristics that may have predicted access. Methods: Data are from the 2008 Canadian Survey of Experiences with Primary Health Care, a national survey of patients’ experiences with primary care in Canada. The sample size available for analysis was 11,521 and the response rate was 70.8%. Team-based care was defined as a family physician working with either a nurse or another type of health provider. Logistic regression was used to examine determinants of access to team-based care, adjusting for demographic, health status, and socioeconomic variables. Results: In 2008, 37.1% of Canadians reported having access to team-based care. The composition of team-based care varied amongst provinces and the most common model in all provinces were family physician plus nurse-only teams except in Quebec and Manitoba. Statistically significant predictors of access to team-based care were province of residence and total number of chronic conditions. Conclusion: With continuity of primary care reform in Canada, a new national survey is needed. Future assessments should aim to increase accuracy in the definition of team-based care through improvements in survey question design and patient education.

The Status of Primary Care in Canada after Reforms: Lacking in Performance Incentives for Children

The Status of Primary Care in Canada after Reforms: Lacking in Performance Incentives for Children

Exploring community pharmacists' perceptions of their professional relationships with physicians, in Canada and the Netherlands

Abstract Objective To explore community pharmacists' levels of interaction with, and perceptions of, physicians in primary care in Canada and the Netherlands Method Interviews with community pharmacists Setting Thirty-six community pharmacies in Vancouver, Canada, and 36 in the Nijmegen and Arnhem areas of the Netherlands Key findings Dutch pharmacists were more likely to have “face-to-face contacts with the physician in the pharmacy setting” (P=0.008) and structured professional meetings with physicians (P&amp;lt;0.001). Canadian pharmacists were more likely to agree that “interaction with physicians is mainly limited to phone/fax” (P&amp;lt;0.001) and “the concept of pharmaceutical care is difficult to implement” (P=0.006). Qualitative analysis revealed that in both countries pharmacists had concerns about the attitudes of physicians and issues concerning territoriality. There were also many constructive comments and these enabled consideration of actions to enhance patient care Conclusion The findings of the study suggest four areas which could contribute to improved patient care: (1) Increasing levels of professional interaction; (2) developing a mutual understanding of roles; (3) participating in joint initiatives to benefit patients through the extended role of pharmacists; (4) conducting structured meetings between professionals with an emphasis on the care of individual patients

How are guidelines on allergic respiratory diseases implemented in primary care in Canada?

Asthma is still not optimally controlled in Canada, as in other countries [1,2]. As an effort to determine what could be optimal care of this chronic condition, Clinical Practice Guidelines (CPGs) have been produced and revised regularly in the last two decades, although recent reports suggest that they are not still sufficiently implemented, particularly into primary care [1-4]. Cabana et al. had reported, following a systematic literature review of studies on barriers to adherence to CPGs, that more than half of physicians were not aware of the exact content of current guidelines; common barriers to guidelines implementation included a lack of agreement and/or motivation to change, a lack of self-efficacy, inertia of previous practice, and external factors, such as lack of time and insufficient resources [4]. In regard to asthma, we previously reported data from questionnaires completed by 2,605 Canadian practitioners [5]; we observed that Canadian Asthma Consensus Guidelines (CACG) were considered well known only by a minority of Primary care Physicians (PCP) and that significant discrepancies existed between this Guideline’s recommendations and current care, such as a low use of objective measures of airflow limitation to assist with diagnosis, difficulties with proper assessment of medication needs, a low provision of written action plans for patients and an infrequent referral to other health professionals for asthma education. In keeping with this initial study, following a recent Canadian survey, we proposed that an insufficient use of objective measures for the diagnosis of asthma explained the over-diagnosis of asthma observed [6]. More recently, using a sample of patients treated in primary care in Canada, we confirmed that many patients still do not enjoy adequate guideline-defined asthma control, particularly women, current smokers, older patients and those who lack a written action plan for exacerbation management [1]. However, primary care physicians recognized a lack of control among most asthma patients and were likely to recommend appropriate medication changes and aftercare to patients who fail to achieve guideline targets for asthma control. This, therefore, suggests that although there have been improvements in guideline implementation, some care gaps still persist. In order to better understand how Canadian guidelines are implemented and to develop targeted strategies to improve their translation into current care, we developed a new tool, the Physicians’ Practice Assessment Questionnaire (PPAQ) [7]. As an initial assessment of this tool, implementation of fourteen key-recommendations on asthma management from the most recent CACG was evaluated in a group of 47 general practitioners7. Validation of the questionnaire showed good internal consistency and good test-retest, and revealed that the lowest self-reported rates of implementation were for: 1) referral for patient education; 2) provision of a written action plan; 3) regular assessment of inhaler technique; and 4) referral to a specialist for difficult to control asthma or uncertain diagnosis. This suggests that in order to improve asthma control, these specific behaviors should be addressed and translation of these recommendations facilitated. Finally, in regard to rhinitis, under-diagnosis and under-treatment of rhinitis seems common and although international guidelines are available, we need to better understand how physicians integrate their recommendations into care [8]. Barriers and facilitators of guidelines’ translation into current care should be further addressed.

In the Eyes of the Beholder: Population Perspectives on Performance Priorities for Primary Care in Canada

The purposes of this study were to identify the Canadian population's performance priorities for primary care, to ascertain the stability of these priorities over time and to examine variation across priorities among different subgroups of the population. The authors administered a survey of 10 priorities (determined through earlier work) to over 1,000 Canadians in 2001, and again in 2004. Analysis of variance was used to compare the ratings of each priority across the two years. The authors completed a forward stepwise regression analysis to examine the relationships between performance priorities and population characteristics in each year. The overall order of importance ascribed to the 10 performance priorities is sustained from 2001 to 2004, as is the significance and directionality of several relationships between performance priorities and population subgroups distinguished by sex, age, education, income and province. Respondents generally think that the evaluation of primary care services should be predicated on assessments of physicians' technical skill along with their communication skills, but place less emphasis on practice management aspects of primary care. The findings offer a basis for a meaningful, feasible, national public performance reporting strategy for primary healthcare (reform), where measures reflect the 10 performance priorities highly valued by the Canadian population.