Gina Agarwal

The GP perspective: problems experienced in providing diabetes care in UK general practice

Aims To describe the problems and barriers perceived by general practitioners (GPs) whilst providing diabetes care in primary care in England and Wales and to identify those health authorities (HAs) in which primary care reported the most and least difficulty.

Chronically ill Canadians’ experiences of being unattached to a family doctor: a qualitative study of marginalized patients in British Columbia

BackgroundUnattached patients do not have a regular primary care provider. Initiatives are being developed to increase attachment rates across Canada. Most existing attention paid to patient unattachment has focused on quantifying the problem and health system costs. Our purpose is to qualitatively identify the implications of chronically ill patients’ experiences of unattachment for health policy and planning to provide policy-relevant insights for Canadian attachment initiatives.MethodsThree focus groups were conducted with marginalized chronically ill individuals residing in a mid-sized city in British Columbia who are unattached to a family doctor. We use the term marginalized as a descriptor to acknowledge that by virtue of their low socio-economic status and lack of attachment the participants are marginalized in Canada’s health care system Focus groups were structured as an open conversation organized around a series of probing questions. They were digitally recorded and transcribed verbatim. Thematic analysis was employed.ResultsTwenty-six individuals participated in the focus groups. The most common chronic illnesses reported were active drug addiction or recovery (and their associated symptoms), depression, arthritis, and hepatitis C. Participants identified life transitions as being the root cause for not having a family doctor. There was a strong sense that unsuccessful attempts to get a family doctor reflected that they were undesirable patients. Participants wanted to experience having a trusting relationship with a regular family doctor as they believed it would encourage greater honesty and transparency. One of the main health concerns regarding lack of access to a regular family doctor is that participants lacked access to preventative care. Participants were also concerned about having a discontinuous medical record due to unattachment.ConclusionsParticipants perceived that there are many benefits to be had by having attachment to a regular family doctor and that experiencing unattachment challenged their health and access to health care. We encourage more research to be done on the lived experience of unattachment in order to provide on-the-ground insights that policy-makers require in order to develop responsive, patient-centred supports and programs.

Helping primary care teams emerge through a quality improvement program.

BACKGROUND Approaches to improving the quality of health care recognize the need for systems and cultures that facilitate optimal care. Interpersonal relationships and dynamics are a key factor in transforming a system to one that can achieve quality. The Quality in Family Practice (QIFP) program encompasses clinical and practice management using a comprehensive tool of family practice indicators. OBJECTIVE The objective of this study was to explore and describe the views of staff regarding changes in the clinical practice environment at two affiliated academic primary care clinics (comprising one Family Health Team, FHT) who participated in QIFP. METHODS An FHT in Hamilton, Canada, worked through the quality tool in 2008/2009. A qualitative exploratory case study approach was employed to examine staff perceptions of the process of participating. Semi-structured interviews were conducted in early 2010 with 43 FHT staff with representation from physicians, nurses, allied health professionals, support staff and managers. Interviews were audio-taped and transcribed verbatim. A modified template approach was used for coding, with a complexity theory perspective of analysis. RESULTS Themes included importance of leadership, changes to practice environment, changes to communication, an increased understanding of team roles and relationships, strengthened teamwork, flattening of hierarchy through empowerment, changes in clinical care and clinical impacts, challenges and rewards and sustainability. CONCLUSION The program resulted in perceived changes to relationships, teamwork and morale. Addressing issues of leadership, role clarity, empowerment, flattening of hierarchy and teamwork may go a long way in establishing and maintaining a quality culture.

Patient satisfaction with access in two interprofessional academic family medicine clinics

BACKGROUND Satisfaction with access to primary care is one component of overall patient satisfaction. The objectives of this paper were to describe patient satisfaction with access in interprofessional family practices and to examine predictors of being less than satisfied with access. METHODS A survey was mailed to 770 randomly selected patients in two academic interprofessional family practices in Hamilton, Canada. Most items were positively worded statements on a five-point scale from strongly agree to strongly disagree. Outcomes were the proportion of respondents agreeing with statements regarding access. For items where > or =25% of respondents did not agree, we examined socio-demographic predictors of disagreement using multiple variable logistic regression. RESULTS The response rate was 49.9% (384/770). One-quarter or more of respondents did not agree that they received an explanation if the appointment was delayed at the office, obtain urgent appointments, obtain prescription refills without a visit or that wait times at the office were reasonable. Predictors of not agreeing included younger age, being married or single, more educated, employed and of non-white ethnicity. Less than 10 minutes was the most satisfactory wait time for the appointment to begin; however, the most common wait time reported was 11-20 minutes. One-quarter of respondents had visited the weekend/holiday clinic in the past 12 months; however, use was not associated with perceived ability to obtain an appointment in 1-2 days. CONCLUSIONS While satisfaction was generally high, some aspects of access could be improved by changes in practice organization or patient education regarding expectations.

High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme

Background Population-based screening for atrial fibrillation (AF) is a promising public health strategy to prevent stroke. However, none of the published reports have evaluated comprehensive screening for additional stroke risk factors such as hypertension and diabetes in a pharmacy setting. Methods The Program for the Identification of ‘Actionable’ Atrial Fibrillation in the Pharmacy Setting (PIAAF-Pharmacy) screened individuals aged ≥65 years, attending community pharmacies in Canada, who were not receiving oral anticoagulation (OAC). Participants were screened for AF using a hand-held ECG device, had blood pressure (BP) measured, and diabetes risk estimated using the Canadian Diabetes Risk Assessment Questionnaire (CANRISK) questionnaire. ‘Actionable’ AF was defined as unrecognised or undertreated AF. A 6-week follow-up visit with the family physician was suggested for participants with ‘actionable’ AF and a scheduled 3-month visit occurred at an AF clinic. Results During 6 months, 1145 participants were screened at 30 pharmacies. ‘Actionable’ AF was identified in 2.5% (95% CI 1.7 to 3.6; n=29); of these, 96% were newly diagnosed. Participants with ‘actionable AF’ had a mean age of 77.2±6.8 years, 58.6% were male and 93.1% had a CHA2DS2-VASc score ≥2. A BP>140/90 was found in 54.9% (616/1122) of participants and 44.4% (214/492) were found to be at high risk of diabetes. At 3 months, only 17% of participants were started on OAC, 50% had improved BP and 71% had confirmatory diabetes testing. Conclusions Integrated stroke screening identifies a high prevalence of individuals who could benefit from stroke prevention therapies but must be coupled with a defined care pathway.

The CHAP-EMS health promotion program: a qualitative study on participants' views of the role of paramedics

BackgroundExpanded roles for paramedics, commonly termed community paramedicine, are becoming increasingly common. Paramedics working in community paramedicine roles represent a distinct departure away from the traditional emergency paradigm of paramedic services. Despite this, little research has addressed how community paramedics are perceived by their clients.MethodsThis study took an interpretivist qualitative approach to examine participants’ perceptions of paramedics providing a community paramedicine program, named the Community Health Assessment Program through Emergency Medical Services (CHAP-EMS). Both participant observation and semi-structured interviews conducted with program participants were used to gain insight into the on-the-ground experiences of the program. Thematic analysis was employed to analyze all data.ResultsThree themes emerged: i) Caring and trusting relationships; ii) paramedics as health advocates; iii) the added value of EMS skills. Paramedics were perceived by residents as having dual identities: first in a novel role as health advocates and secondly in a traditional role as emergency experts despite lacking contextual features associated with emergency response.ConclusionsFrom this exploratory, qualitative study we present an emerging framework in which to conceptualize paramedic roles in community paramedicine settings. Future research should address the saliency of these roles in different contexts and how these roles relate to paramedic practice.

Rationale and methods of a multicentre randomised controlled trial of the effectiveness of a Community Health Assessment Programme with Emergency Medical Services (CHAP-EMS) implemented on residents aged 55 years and older in subsidised seniors' housing buildings in Ontario, Canada

Introduction Chronic diseases and falls substantially contribute to morbidity/mortality among seniors, causing this population to frequently seek emergency medical care. Research suggests the paramedic role can be successfully expanded to include community-based health promotion and prevention. This study implements a community paramedicine programme targeting seniors in subsidised housing, a high-risk population and frequent users of emergency medical services (EMS). The aims are to reduce EMS calls, improve health outcomes and healthcare utilisation. Methods/analysis This is a pragmatic clustered randomised control trial in four communities across Ontario, Canada. Within each, four to eight seniors’ apartment buildings will be paired and within each pair one building will be randomly assigned to receive the Community Health Assessment Programme through EMS (CHAP-EMS) intervention, while the other building receives no intervention. During the 1-year intervention, paramedics will run weekly sessions in a common area of the building, assessing risk factors for cardiovascular disease, diabetes and falls; providing health education and referrals to community programmes; and communicating results to the participants primary physician. The primary outcomes are rate of emergency calls per 100 residents, change in blood pressure and change in Canadian Diabetes Risk (CANRISK) score, as collected by the local EMS and study databases. The secondary outcomes are change in health behaviours, measured using a preintervention and postintervention survey and healthcare utilisation, available through administrative databases. Analysis will mainly consist of descriptive statistics and generalised estimating equations, including subgroup cluster analysis. Ethics/dissemination This study is approved by the Hamilton Integrated Research Ethics Board and will follow the Tri-Council Policy Statement. Findings will be disseminated through reports to local stakeholders, publication in peer-reviewed journals and conference presentations. Trial registration number NCT02152891.

Community Health Awareness of Diabetes (CHAD): Description of a Community-Wide Diabetes Awareness Demonstration Program and its Feasibility

OBJECTIVE This article describes the Community Health Awareness Diabetes (CHAD) program and its feasibility. Developing and testing the feasibility of strategies to detect diabetes in the community is an important primary care issue. The CHAD program was designed to be a feasible and reproducible, low-cost community program to identify high-risk individuals for subsequent diabetes screening by their family doctors. METHODS Participants from Grimsby, Ontario, older than age 40, were invited to self-risk-assess for diabetes using a validated questionnaire and 2 near-patient blood tests (capillary blood glucose and glycosylated hemoglobin). Some participants were self-selected, having seen advertising for the program, others were invited by a letter from their family doctor. None of the participants had pre-existing diabetes. Numbers and characteristics of participants, numbers found at risk and satisfaction of participants were examined. RESULTS There were 588 participants in CHAD. Of these, the majority had received invitation letters, the majority of participants were seniors and were females, 526 did not have pre-existing diabetes and 16% of participants (n=84 of 526) were identified as being at high risk for diabetes. Participants at high risk of diabetes had significantly more modifiable risk factors, including higher fat, fast food and salt intake, and higher systolic blood pressure. Satisfaction with the program was high. CONCLUSIONS The CHAD program was feasible and participants were satisfied with it. Participants had a large number of modifiable risk factors. This program could be repeated in other communities and modified to suit the infrastructure of the area.

Personal health records—an overview of the changing face of family practice

A personal health record (PHR) is not a new concept but one that has been with us since visits to the doctor started. Primary care physicians may be familiar with their patients who have come into the consulting room carrying reams of paper filled with blood pressure readings, blood sugar logs or diaries of symptoms. These are all personal health records—but paper-based ones. These days, technology has advanced so much that it is possible to access patient-held records that are on electronic platforms such as iPads, laptops, smartphones and on online sites. This technology is rapidly advancing and clinicians will be, or already are, faced with adapting. It is time to ask ourselves, “In what ways will the PHR change the face of family practice as we know it?”

Care for Patients with Type 2 Diabetes in a Random Sample of Community Family Practices in Ontario, Canada

Objective. Diabetes care is an important part of family practice. Previous work indicates that diabetes management is variable. This study aimed to examine diabetes care according to best practices in one part of Ontario. Design and Participants. A retrospective chart audit of 96 charts from 18 physicians was conducted to examine charts regarding diabetes care during a one-year period. Setting. Grimsby, Ontario. Main Outcome Measures. Glycemic screening, control and management strategies, documentation and counselling for lifestyle habits, prevalence of comorbidities, screening for hypertension, hyperlipidemia, and use of appropriate recommended preventive medications in the charts were examined. Results. Mean A1c was within target (less than or equal to 7.00) in 76% of patients (ICC = −0.02), at least 4 readings per annum were taken in 75% of patients (ICC = 0.006). Nearly 2/3 of patients had been counselled about diet, more than 1/2 on exercise, and nearly all (90%) were on medication. Nearly all patients had a documented blood pressure reading and lipid profile. Over half (60%) had a record of their weight and/or BMI. Conclusion. Although room for improvement exists, diabetes targets were mainly reached according to recognized best practices, in keeping with international data on attainment of diabetes targets.