Gayle Halas

Prevalence and Epidemiology of Diabetes in Canadian Primary Care Practices: A Report from the Canadian Primary Care Sentinel Surveillance Network

OBJECTIVE The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is a large, validated national primary care Electronic Medical Records (EMR)-based database. Our objective was to describe the epidemiology of diabetes in this Canadian sample. METHODS We analyzed the records of 272 469 patients10 years of age and older, with at least 1 primary care clinical encounter between January 1, 2011, and December 31, 2012. We calculated the age-gender standardized prevalence of diabetes. We compared health care utilization and comorbidities for 7 selected chronic conditions in patients with and without diabetes. We also examined patterns of medication usage. RESULTS The estimated population prevalence of diabetes was 7.6%. Specifically, we studied 25 425 people with diabetes who had at least 1 primary care encounter in 2 years. On average, patients with diabetes had 1.42 times as many practice encounters as patients without diabetes (95% CI 1.42 to 1.43, p<0.0001). Patients with diabetes had 1.29 times as many other comorbid conditions as those without diabetes (95% CI 1.27 to 1.31, p<0.0001). We found that 85.2% of patients taking hypoglycemic medications were taking metformin, and 51.8% were taking 2 or more classes of medications. CONCLUSIONS This study is the first national Canadian report describing the epidemiology of diabetes using primary care EMR-based data. We found significantly higher rates of primary care use, and greater numbers of comorbidities in patients with diabetes. Most patients were on first-line hypoglycemic medications. Data routinely recorded in EMRs can be used for surveillance of chronic diseases such as diabetes in Canada. These results can enable comparisons with other national EMR-based datasets.

From patient care to research: a validation study examining the factors contributing to data quality in a primary care electronic medical record database

BackgroundElectronic Medical Records (EMRs) are increasingly used in the provision of primary care and have been compiled into databases which can be utilized for surveillance, research and informing practice. The primary purpose of these records is for the provision of individual patient care; validation and examination of underlying limitations is crucial for use for research and data quality improvement. This study examines and describes the validity of chronic disease case definition algorithms and factors affecting data quality in a primary care EMR database.MethodsA retrospective chart audit of an age stratified random sample was used to validate and examine diagnostic algorithms applied to EMR data from the Manitoba Primary Care Research Network (MaPCReN), part of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The presence of diabetes, hypertension, depression, osteoarthritis and chronic obstructive pulmonary disease (COPD) was determined by review of the medical record and compared to algorithm identified cases to identify discrepancies and describe the underlying contributing factors.ResultsThe algorithm for diabetes had high sensitivity, specificity and positive predictive value (PPV) with all scores being over 90%. Specificities of the algorithms were greater than 90% for all conditions except for hypertension at 79.2%. The largest deficits in algorithm performance included poor PPV for COPD at 36.7% and limited sensitivity for COPD, depression and osteoarthritis at 72.0%, 73.3% and 63.2% respectively. Main sources of discrepancy included missing coding, alternative coding, inappropriate diagnosis detection based on medications used for alternate indications, inappropriate exclusion due to comorbidity and loss of data.ConclusionsComparison to medical chart review shows that at MaPCReN the CPCSSN case finding algorithms are valid with a few limitations. This study provides the basis for the validated data to be utilized for research and informs users of its limitations. Analysis of underlying discrepancies provides the ability to improve algorithm performance and facilitate improved data quality.

Mapping interventions that promote mental health in the general population: A scoping review of reviews.

Health policies and programs promoting mental health or preventing mental illness in the general public are under-recognized facets of primary prevention. Increasing awareness and adoption of such strategies could reduce the burden of mental illness in individuals, families, communities, and society as whole. We conducted a scoping review of reviews of interventions to promote mental health or prevent mental illness. We searched PubMed, PsycINFO, Scopus, Cochrane CENTRAL, CINAHL and ERIC from 2004 to 2014. Reviews were included if the authors indicated a systematic approach in their literature searches, and if they comprised interventions in Westernized countries targeting the general population. We identified 39 reviews that met the inclusion criteria. Mental health intervention approaches and outcomes varied across age groups and settings, and included functional, social, and cognitive measures. Most interventions aimed to prevent a specific mental illness or symptoms (depression, anxiety, burnout, or stress). Cognitive-behavioral therapy and educational components were common. School-based programs focused on outcomes involving social and academic development. Interventions for families, especially for young or disadvantaged parents, taught parenting skills to help improve the well-being of children and their care-givers. In the workplace, the focus was on managing stress, while programs for the elderly emphasized quality of life determinants. This review summarizes a wide variety of interventions to promote mental health or prevent mental illness, but the literature is primarily focused on the individual or family unit. More information is required about interventions at the community and societal levels.

Describing the content of primary care: limitations of Canadian billing data.

BackgroundPrimary health care systems are designed to provide comprehensive patient care. However, the ICD 9 coding system used for billing purposes in Canada neither characterizes nor captures the scope of clinical practice or complexity of physician-patient interactions. This study aims to describe the content of primary care clinical encounters and examine the limitations of using administrative data to capture the content of these visits. Although a number of U.S studies have described the content of primary care encounters, this is the first Canadian study to do so.MethodsStudy-specific data collection forms were completed by 16 primary care physicians in community health and family practice clinics in Winnipeg, Manitoba, Canada. The data collection forms were completed immediately following the patient encounter and included patient and visit characteristics, such as primary reason for visit, topics discussed, actions taken, degree of complexity as well as diagnosis and ICD-9 codes.ResultsData was collected for 760 patient encounters. The diagnostic codes often did not reflect the dominant topic of the visit or the topic requiring the most amount of time. Physicians often address multiple problems and provide numerous services thus increasing the complexity of care.ConclusionThis is one of the first Canadian studies to critically analyze the content of primary care clinical encounters. The data allowed a greater understanding of primary care clinical encounters and attests to the deficiencies of singular ICD-9 coding which fails to capture the comprehensiveness and complexity of the primary care encounter. As primary care reform initiatives in the U.S and Canada attempt to transform the way family physicians deliver care, it becomes increasingly important that other tools for structuring primary care data are considered in order to help physicians, researchers and policy makers understand the breadth and complexity of primary care.

Articulating nurse practitioner practice using King's theory of goal attainment.

Purpose:To further understand the interactions between nurse practitioners (NPs) and patients, Kings nursing theory of goal attainment was applied as the conceptual framework to describe the interactions between NPs and patients in the primary care setting. Data sources:Six dyads of NPs and their patients were video‐ and audio‐taped over three consecutive clinic visits. For the purposes of this arm of the study, the audio‐taped interactions were transcribed and then coded using Kings concepts in her theory of goal attainment. Conclusions:Kings theory was applicable to describe NP practice. Kings concepts and processes of nurse–patient interactions, such as disturbances, mutual goal setting, and transactions, were observed in NP–patient interactions. Implications for practice:Disturbances during clinical encounters were essential in the progression toward goal attainment. Elements, such as social exchange, symptom reporting, role explanation, and information around clinical processes facilitated relationship building. NPs as practitioners need to be reflective of their own practice, embrace disturbances in the clinical encounter, and attend to these as opportunities for mutual goal setting.

A Scoping Approach to Systematically Review Published Reviews: Adaptations and Recommendations.

Knowledge translation is a central focus of the health research community, which includes strategies to synthesize published research to support uptake within health care practice and policy arenas. Within the literature concerning review methodologies, a new discussion has emerged concerning methods that review and synthesize published review articles. In this paper, our multidisciplinary team from family medicine, nursing, dental hygiene, kinesiology, occupational therapy, physiology, population health, clinical psychology, and library sciences contributes to this discussion by sharing our experiences in conducting 3 scoping reviews of published review studies. A brief discussion of Cochrane Collaboration overview reviews and Joanna Briggs Institute umbrella reviews foreshadows a discussion of insights from our experiences of conducting the 3 scoping reviews of published reviews. We address 6 adaptations along with our recommendations for each, which may guide other researchers with designing scoping review approaches to synthesize published reviews. The ability of researchers to publish research findings is growing, and our ability to effectively transfer findings into useful evidence for health care practice and policy is imperative to our work.

Implementation and impact of an online tool used in primary care to improve access to financial benefits for patients: a study protocol

Objectives Addressing the social determinants of health has been identified as crucial to reducing health inequities. However, few evidence-based interventions exist. This study emerges from an ongoing collaboration between physicians, researchers and a financial literacy organisation. Our study will answer the following: Is an online tool that improves access to financial benefits feasible and acceptable? Can such a tool be integrated into clinical workflow? What are patient perspectives on the tool and what is the short-term impact on access to benefits? Methods An advisory group made up of patients living on low incomes and representatives from community agencies supports this study. We will recruit three primary care sites in Toronto, Ontario and three in Winnipeg, Manitoba that serve low-income communities. We will introduce clinicians to screening for poverty and how benefits can increase income. Health providers will be encouraged to use the tool with any patient seen. The health provider and patient will complete the online tool together, generating a tailored list of benefits and resources to assist with obtaining these benefits. A brief survey on this experience will be administered to patients after they complete the tool, as well as a request to contact them in 1 month. Those who agree to be contacted will be interviewed on whether the intervention improved access to financial benefits. We will also administer an online survey to providers and conduct focus groups at each site. Ethics and dissemination Key ethical concerns include that patients may feel discomfort when being asked about their financial situation, may feel obliged to complete the tool and may have their expectations falsely raised about receiving benefits. Providers will be trained to address each of these concerns. We will share our findings with providers and policy-makers interested in addressing the social determinants of health within healthcare settings. Trial registration number Clinicaltrials.gov: NCT02959866. Registered 7 November 2016. Retrospectively registered. Pre-results.

Heart health whispering : A randomized, controlled pilot study to promote nursing student perspective-taking on carers’ health risk behaviors

BackgroundLifestyle counseling is described as a “major breakthrough” in the control of chronic diseases. Counseling can be challenging to nurses due their lack of motivation to counsel, hesitancy to appear non-judgmental, lack of empathy, and lack of time. Nurses voice their need for more training in counseling communication skills. Our main objective was to engage in ongoing development and testing of a promising Heart Health Whispering perspective-taking intervention on nursing students’ clinical empathy, perceptual understanding, and client readiness to alter health risk behaviors.MethodsIn this randomized controlled pilot study, the full intervention (perspective-taking instructions, practice, and video-feedback) and partial intervention (video-feedback only) comprised 24 and 18 nursing students, respectively. Quantitative data were collected with a 10-item pre- and post-intervention clinical empathy tool, a one-item ‘readiness to change’ health risk behavior tool plus similarity ratings on students’ empathic accuracy were calculated. Data were analyzed using Independent Samples t Tests and mixed model ANCOVA models. Students’ and actors’ evaluative responses toward the intervention phases were collected by handwritten notes, and analyzed using content analysis and constant comparison techniques.ResultsThe main finding was that students in the full intervention group reported greater clinical empathy in the post versus baseline condition. Students underestimated their clinical empathy in comparison to carers’ reports in the post-condition. In both intervention groups, carers reported more readiness to change in the post-condition. Carers identified favorable and unfavorable perceptions and outcomes of approaches taken by students. Students desired immediate and direct feedback after the video-dialogue and -tagging exercise.ConclusionsHeart Health Whispering is a promising intervention to help educators in basic and continuing education to bolster nurse confidence in empathic conversations on health risk behaviors. This intervention incorporates commonly used strategies to teach empathic communication along with a novel video-analysis application of a perspective-taking task. Student and carer actor comments highlighted the value in opportunities for students to engage in self-evaluation and practicing the empathic process of taking the client’s perspective on health risk behaviors.