Clare Liddy

Systematic Review and Meta-Analysis of Practice Facilitation Within Primary Care Settings

PURPOSE This study was a systematic review with a quantitative synthesis of the literature examining the overall effect size of practice facilitation and possible moderating factors. The primary outcome was the change in evidence-based practice behavior calculated as a standardized mean difference. METHODS In this systematic review, we searched 4 electronic databases and the reference lists of published literature reviews to find practice facilitation studies that identified evidence-based guideline implementation within primary care practices as the outcome. We included randomized and nonrandomized controlled trials and prospective cohort studies published from 1966 to December 2010 in English language only peer-reviewed journals. Reviews of each study were conducted and assessed for quality; data were abstracted, and standardized mean difference estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. Publication bias, influence, subgroup, and meta-regression analyses were also conducted. RESULTS Twenty-three studies contributed to the analysis for a total of 1,398 participating practices: 697 practice facilitation intervention and 701 control group practices. The degree of variability between studies was consistent with what would be expected to occur by chance alone (I2 = 20%). An overall effect size of 0.56 (95% CI, 0.43–0.68) favored practice facilitation (z = 8.76; P <.001), and publication bias was evident. Primary care practices are 2.76 (95% CI, 2.18–3.43) times more likely to adopt evidence-based guidelines through practice facilitation. Meta-regression analysis indicated that tailoring (P = .05), the intensity of the intervention (P = .03), and the number of intervention practices per facilitator (P = .004) modified evidence-based guideline adoption. CONCLUSION Practice facilitation has a moderately robust effect on evidence-based guideline adoption within primary care. Implementation fidelity factors, such as tailoring, the number of practices per facilitator, and the intensity of the intervention, have important resource implications.

Utilization, Benefits, and Impact of an e-Consultation Service Across Diverse Specialties and Primary Care Providers

BACKGROUND Access to specialist advice remains a barrier for primary care providers (PCPs) and their patients. Virtual consultations have been used to expedite access. There are few studies demonstrating the utilization and impact of such services. We established a regional e-consultation service that was used across a wide range of specialty services and PCPs. MATERIALS AND METHODS We prospectively collected all e-consultations submitted from April 1, 2011 to June 30, 2012. Utilization data collected included number of e-consultations submitted, specialist response, and time required for the specialist to complete the e-consultation. Perceived benefit to the PCPs and their patients and the impact on care delivery were determined from a close-out survey. RESULTS Fifty-nine PCPs submitted 406 e-consultations to 16 specialty services. The specialist provided an answer without requesting further information in 89% of cases, with >90% of cases taking <15 min for the specialist to complete. Seventy-five percent of cases were answered in <3 days. The service was perceived as highly beneficial to providers and patients in>90% of cases. In 43% of submitted cases a traditional referral was originally contemplated but was now avoided. CONCLUSIONS We successfully implemented an e-consultation service across diverse PCPs and specialty services that was highly valued. Almost half of referrals submitted would have required a face-to-face consultation if the service had not been available. Thus e-consultation has tremendous potential for improving access to specialist advice in a much more timely manner than the traditional referral-consultation process.

Barriers and facilitators to recruitment of physicians and practices for primary care health services research at one centre

BackgroundWhile some research has been conducted examining recruitment methods to engage physicians and practices in primary care research, further research is needed on recruitment methodology as it remains a recurrent challenge and plays a crucial role in primary care research. This paper reviews recruitment strategies, common challenges, and innovative practices from five recent primary care health services research studies in Ontario, Canada.MethodsWe used mixed qualitative and quantitative methods to gather data from investigators and/or project staff from five research teams. Team members were interviewed and asked to fill out a brief survey on recruitment methods, results, and challenges encountered during a recent or ongoing project involving primary care practices or physicians. Data analysis included qualitative analysis of interview notes and descriptive statistics generated for each study.ResultsRecruitment rates varied markedly across the projects despite similar initial strategies. Common challenges and creative solutions were reported by many of the research teams, including building a sampling frame, developing front-office rapport, adapting recruitment strategies, promoting buy-in and interest in the research question, and training a staff recruiter.ConclusionsInvestigators must continue to find effective ways of reaching and involving diverse and representative samples of primary care providers and practices by building personal connections with, and buy-in from, potential participants. Flexible recruitment strategies and an understanding of the needs and interests of potential participants may also facilitate recruitment.

Methods to Achieve High Interrater Reliability in Data Collection From Primary Care Medical Records

PURPOSE We assessed interrater reliability (IRR) of chart abstractors within a randomized trial of cardiovascular care in primary care. We report our findings, and outline issues and provide recommendations related to determining sample size, frequency of verification, and minimum thresholds for 2 measures of IRR: the κ statistic and percent agreement. METHODS We designed a data quality monitoring procedure having 4 parts: use of standardized protocols and forms, extensive training, continuous monitoring of IRR, and a quality improvement feedback mechanism. Four abstractors checked a 5% sample of charts at 3 time points for a predefined set of indicators of the quality of care. We set our quality threshold for IRR at a κ of 0.75, a percent agreement of 95%, or both. RESULTS Abstractors reabstracted a sample of charts in 16 of 27 primary care practices, checking a total of 132 charts with 38 indicators per chart. The overall κ across all items was 0.91 (95% confidence interval, 0.90–0.92) and the overall percent agreement was 94.3%, signifying excellent agreement between abstractors. We gave feedback to the abstractors to highlight items that had a κ of less than 0.70 or a percent agreement less than 95%. No practice had to have its charts abstracted again because of poor quality. CONCLUSIONS A 5% sampling of charts for quality control using IRR analysis yielded κ and agreement levels that met or exceeded our quality thresholds. Using 3 time points during the chart audit phase allows for early quality control as well as ongoing quality monitoring. Our results can be used as a guide and benchmark for other medical chart review studies in primary care.

The patient’s voice: an exploratory study of the impact of a group self-management support program

BackgroundGiven the potential value of self-management support programs for people with chronic diseases, it is vital to understand how they influence participants’ health attitudes and behaviours. The Stanford Chronic Disease Self-Management Program (CDSMP), the most well-known and widely studied such program, is funded in many provinces and jurisdictions throughout Canada. However, there is little published evidence on its impact in the Canadian health-care system. We studied participants’ reactions and perceived impacts of attending the Stanford program in one Ontario health region so we could assess its value to the health region. The study asked: What are participants’ reactions and perceived impacts of attending the Stanford CDSMP?MethodsThis mixed methods exploratory study held four focus groups approximately one year after participants attended a Stanford program workshop. At the beginning of each session, participants filled out a survey on the type and frequency of community and health resources used for their self-management. During the sessions, a moderator guided the discussion, asking about such things as long-term impact of the program on their lives and barriers to self-management of their chronic conditions.ResultsParticipants perceived diverse effects of the workshop: from having a profound impact on one area to affecting all aspects of their lives. A change in physical activity patterns was the most prominent behaviour change, noted by over half the participants. Other recurrent effects included an improved sense of social connection and better coping skills. Barriers to self-management were experienced by almost all participants with several dominant themes emerging including problems with the health system and patient-physician interaction. Participants reported a wide variety of resources used in their self-management, and in some cases, an increase in use was noted for some resources.ConclusionsSelf-management support is, at its core, a complex and patient-centred concept, so a diversity of outcomes to match the diversity of participants should be expected. As these interventions move into different target populations and communities, it is essential that we continue to explore through multiple research methods, the effects, and their meaning to participants, ensuring the optimal investment of resources for the very individuals these interventions aim to serve.

Electronic consultation systems: worldwide prevalence and their impact on patient care—a systematic review

BACKGROUND Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care. OBJECTIVE To understand the effectiveness, population impact and costs associated with implementation of eConsult services. METHODS We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework. RESULTS A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability. CONCLUSION Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsults impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.

Ten Steps to Establishing an e-Consultation Service to Improve Access to Specialist Care

There is dissatisfaction among primary care physicians, specialists, and patients with respect to the consultation process. Excessive wait times for receiving specialist services and inefficient communication between practitioners result in decreased access to care and jeopardize patient safety. We created and implemented an electronic consultation (e-consultation) system in Eastern Ontario to address these problems and improve the consultation process. The e-consultation system has passed through the proof-of-concept and pilot study stages and has effectively reduced unnecessary referrals while receiving resoundingly positive feedback from physician-users. Using our experience, we have outlined the 10 steps to developing an e-consultation service. We detail the technical, administrative, and strategic considerations with respect to (1) identifying your partners, (2) choosing your platform, (3) starting as a pilot project, (4) designing your product, (5) ensuring patient privacy, (6) thinking through the process, (7) fostering relationships with your participants, (8) being prepared to provide physician payment, (9) providing feedback, and (10) planning the transition from pilot to permanency. In following these 10 steps, we believe that the e-consultation system and its associated improvements on the consultation process can be effectively implemented in other healthcare settings.

Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study

BackgroundPrimary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models.MethodsThis is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practices adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models.ResultsThe percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management.ConclusionsThis study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.Trial RegistrationClinicalTrials.gov: NCT00574808

Transition of Patients with Type 2 Diabetes from Specialist to Primary Care: A Survey of Primary Care Physicians on the Usefulness of Tools for Transition

Transition from specialty to primary care for patients with type 2 diabetes has not been well studied. Stable patients may be retained in specialty clinics due to concern over the maintenance of diabetes care post-discharge, thus limiting access to specialists for new referrals. Understanding primary care physicians’ perceptions of barriers to diabetes care and the helpfulness of existing tools used in the transition back to primary care is important for facilitating the transition process. Objectives were 1) to determine the perceived helpfulness of preselected tools that could be used in the transition of patients from specialist to primary care; 2) to identify the barriers to implementation of evidence-based diabetes care from the primary care perspective; and 3) to identify the tools used currently by primary care physicians during the transition process.

Quality of cardiovascular disease care in Ontario, Canada: missed opportunities for prevention - a cross sectional study

BackgroundPrimary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients.MethodsWe conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c.ResultsAdherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c.ConclusionsThere remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions.Trial RegistrationNCT00574808