Michelle Greiver

Building a Pan-Canadian Primary Care Sentinel Surveillance Network: Initial Development and Moving Forward

The development of a pan-Canadian network of primary care research networks for studying issues in primary care has been the vision of Canadian primary care researchers for many years. With the opportunity for funding from the Public Health Agency of Canada and the support of the College of Family Physicians of Canada, we have planned and developed a project to assess the feasibility of a network of networks of family medicine practices that exclusively use electronic medical records. The Canadian Primary Care Sentinel Surveillance Network will collect longitudinal data from practices across Canada to assess the primary care epidemiology and management of 5 chronic diseases: hypertension, diabetes, depression, chronic obstructive lung disease, and osteoarthritis. This article reports on the 7-month first phase of the feasibility project of 7 regional networks in Canada to develop a business plan, including governance, mission, and vision; develop memorandum of agreements with the regional networks and their respective universities; develop and obtain approval of research ethics board applications; develop methods for data extraction, a Canadian Primary Care Sentinel Surveillance Network database, and initial assessment of the types of data that can be extracted; and recruitment of 10 practices at each network that use electronic medical records. The project will continue in phase 2 of the feasibility testing until April 2010.

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.

Measuring data reliability for preventive services in electronic medical records

BackgroundImprovements in the quality of health care services are often measured using data present in medical records. Electronic Medical Records (EMRs) contain potentially valuable new sources of health data. However, data quality in EMRs may not be optimal and should be assessed. Data reliability (are the same data elements being measured over time?) is a prerequisite for data validity (are the data accurate?). Our objective was to measure the reliability of data for preventive services in primary care EMRs during the transition to EMR.MethodsOur data sources were randomly selected eligible patients’ medical records and data obtained from provincial administrative datasets. Eighteen community-based family physicians in Toronto, Ontario that implemented EMRs starting in 2006 participated in this study. We measured the proportion of patients eligible for a service (Pap smear, screening mammogram or influenza vaccination) that received the service. We compared the change in rates of selected preventive services calculated from the medical record audits with the change in administrative datasets.ResultsIn the first year of EMR use (2006) services decreased by 8.7% more (95% CI −11.0%– − 6.4%, p < 0.0001) when measured through medical record audits as compared with administrative datasets. Services increased by 2.4% more (95% CI 0%–4.9%, p = 0.05) in the medical record audits during the second year of EMR use (2007).ConclusionThere were differences between the change measured through medical record audits and administrative datasets. Problems could include difficulties with organizing new data entry processes as well as continued use of both paper and EMRs. Data extracted from EMRs had limited reliability during the initial phase of EMR implementation. Unreliable data interferes with the ability to measure and improve health care quality

Finding a BETTER way: A qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice

BackgroundOur randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention.MethodsWe used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding.ResultsA framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings.ConclusionsThe BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.

Where should automated blood pressure measurements be taken? Pilot RCT of BpTRU measurements taken in private or nonprivate areas of a primary care office.

Michelle Greiver, David White, David M. Kaplan, Kevin Katz, Rahim Moineddin and Edita Dolabchian, Departments of Family and Community Medicine, Infection Control, North York General Hospital, North Toronto Primary Care Research Network, Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

Association between neighbourhood walkability and metabolic risk factors influenced by physical activity: a cross-sectional study of adults in Toronto, Canada

Objective To determine whether neighbourhood walkability is associated with clinical measures of obesity, hypertension, diabetes and dyslipidaemia in an urban adult population. Design Observational cross-sectional study. Setting Urban primary care patients. Participants 78 023 Toronto residents, aged 18 years and over, who were formally rostered or had at least 2 visits between 2012 and 2014 with a primary care physician participating in the University of Toronto Practice Based Research Network (UTOPIAN), within the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Main outcome measures Differences in average body mass index (BMI), systolic and diastolic blood pressure, fasting blood glucose, haemoglobin A1c (HbA1C), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein and triglyceride between residents in the highest versus the lowest quartile of neighbourhood walkability, as estimated using multivariable linear regression models and stratified by age. Outcomes were objectively measured and were retrieved from primary care electronic medical records. Models adjusted for age, sex, smoking, medications, medical comorbidities and indices of neighbourhood safety and marginalisation. Results Compared with those in the lowest walkability quartile, individuals in the highest quartile had lower mean BMI (−2.64 kg/m2, 95% CI −2.98 to −2.30; p<0.001), systolic blood pressure (−1.35 mm Hg, 95% CI −2.01 to −0.70; p<0.001), diastolic blood pressure (−0.60 mm Hg, 95% CI 1.06 to −0.14; p=0.010) and HbA1c (−0.063%, 95% CI −0.11 to −0.021; p=0.003) and higher mean HDL (0.052 mmol/L, 95% CI 0.029 to 0.075; p<0.001). In age-stratified analyses, differences in the mean BMI were consistently observed for adults aged 18 to under 40 (−4.44 kg/m2, 95% CI −5.09 to −3.79; p<0.001), adults aged 40–65 (−2.74 kg/m2, 95% CI −3.24 to −2.23; p<0.001) and adults aged over 65 (−0.87 kg/m2, 95% CI −1.48 to −0.26; p=0.005). Conclusions There was a clinically meaningful association between living in the most walkable neighbourhoods and having lower BMI in adults of all ages.

Diabetes screening with hemoglobin A1c prior to a change in guideline recommendations: prevalence and patient characteristics

BackgroundIn January 2010, the American Diabetes Association recommended the use of hemoglobin A1c (Hgb A1c) to screen and diagnose diabetes. This study explored the prevalence and clinical context of Hgb A1c tests done for non-diabetic primary care patients for the three years prior to the release of the new guidelines. We sought to determine the provision of tests in non-diabetic patients age 19 or over, patients age 45 and over (eligible for routine diabetes screening), the annual change in the rate of this screening test, and the patient characteristics associated with the provision of Hgb A1c screening.MethodsWe conducted a retrospective study using data routinely collected in Electronic Medical Records. The participants were thirteen community-based family physicians in Toronto, Ontario. We calculated the proportion of non diabetic patients who had at least one Hbg A1c done in three years. We used logistic generalized estimating equation with year treated as a continuous variable to test for a non-zero slope in yearly Hbg A1c provision. We modelled screening using multivariable logistic regression.ResultsThere were 11,792 non-diabetic adults. Of these, 1,678 (14.2%; 95%CI 13.6%-14.9%) had at least one Hgb A1c test done; this was higher for patients 45 years of age or older (20.2%; 95% CI 19.3% - 21.2%). The proportion of non-diabetic patients with an A1c test increased from 5.2% in 2007 to 8.8% in 2009 (p < 0.0001 for presence of slope). Factors associated with significantly greater adjusted odds ratios of having the test done included increasing diastolic blood pressure, increasing fasting glucose, increasing body mass index, increasing age, as well as male gender and presence of hypertension, but not smoking status or LDL cholesterol. Patients living in the highest income quintile neighbourhoods had significantly lower odds ratios of having this test done than those in the lowest quintile (p < 0.001).ConclusionsA large and increasing proportion of the non-diabetic patients we studied have had an Hgb A1c for screening prior to guidelines recommending the test for this purpose. Several risk factors for cardiovascular disease or diabetes were associated with the provision of the Hgb A1c. Early uptake of the test may represent appropriate utilization.

Are We Asking Patients if They Smoke?: Missing Information on Tobacco Use in Canadian Electronic Medical Records.

INTRODUCTION All adolescent and adult patients should be asked if they smoke. Data entered in electronic medical records offer new opportunities to study tobacco-related clinical activities. The purpose of this study is to examine the recording of tobacco use in Canadian electronic medical records. METHODS Data were collected on September 30, 2013, and analyzed in 2014. Data on 249,223 patients that were aged ≥16 years as of September 30, 2013 and had at least one primary care encounter in the previous 2 years were included. The proportion of patients with information on tobacco use entered in a summative health profile was calculated. Associations between data gaps and patient or physician factors were examined. RESULTS Information on tobacco use was available for 64.4% of patients. Physicians using an electronic medical record for ≥4 years were more likely to have data (AOR=4.57, 95% CI=1.84, 7.29, p<0.0001). Patients aged ≥30 years were more likely to have tobacco information present (AOR=2.92, 95% CI=2.82, 3.02, p<0.0001, for patients aged 30-59 compared to those aged <30 years), as were patients with any comorbidities (AOR=1.41, 95% CI=1.36, 1.45, p<0.0001, for patients with one or two comorbidities compared with none) or more visits. CONCLUSIONS A third of Canadians in this sample lacked data on tobacco in their electronic medical record. Younger, healthier people were less likely to have information about their smoking status. Efforts to improve the recording of tobacco-related information in electronic medical records, especially for younger patients, are needed.

Association between socio-economic status and hemoglobin A1c levels in a Canadian primary care adult population without diabetes

BackgroundHgb A1c levels may be higher in persons without diabetes of lower socio-economic status (SES) but evidence about this association is limited; there is therefore uncertainty about the inclusion of SES in clinical decision support tools informing the provision and frequency of Hgb A1c tests to screen for diabetes. We studied the association between neighborhood-level SES and Hgb A1c in a primary care population without diabetes.MethodsThis is a retrospective study using data routinely collected in the electronic medical records (EMRs) of forty six community-based family physicians in Toronto, Ontario. We analysed records from 4,870 patients without diabetes, age 45 and over, with at least one clinical encounter between January 1st 2009 and December 31st 2011 and one or more Hgb A1c report present in their chart during that time interval. Residential postal codes were used to assign neighborhood deprivation indices and income levels by quintiles. Covariates included elements known to be associated with an increase in the risk of incident diabetes: age, gender, family history of diabetes, body mass index, blood pressure, LDL cholesterol, HDL cholesterol, triglycerides, and fasting blood glucose.ResultsThe difference in mean Hgb A1c between highest and lowest income quintiles was -0.04% (p = 0.005, 95% CI -0.07% to -0.01%), and between least deprived and most deprived was -0.05% (p = 0.003, 95% CI -0.09% to -0.02%) for material deprivation and 0.02% (p = 0.2, 95% CI -0.06% to 0.01%) for social deprivation. After adjustment for covariates, a marginally statistically significant difference in Hgb A1c between highest and lowest SES quintile (p = 0.04) remained in the material deprivation model, but not in the other models.ConclusionsWe found a small inverse relationship between Hgb A1c and the material aspects of SES; this was largely attenuated once we adjusted for diabetes risk factors, indicating that an independent contribution of SES to increasing Hgb A1c may be limited. This study does not support the inclusion of SES in clinical decision support tools that inform the use of Hgb A1c for diabetes screening.

Hypertension screening and follow-up in children and adolescents in a Canadian primary care population sample: a retrospective cohort study

BACKGROUND Uncertainty exists about the need to screen for hypertension in children and adolescents. Information on current screening and follow-up rates in Canadian community practices is not available. There are no Canadian guidelines on the subject. We sought to identify current rates of pediatric hypertension screening and follow-up in Canada. In addition, we examined patient and provider characteristics associated with rates of blood pressure screening. METHODS We used electronic medical record data extracted on Apr. 1, 2013, from 79 family practices in Toronto. We identified children seen at least twice between the ages of 3 and 18 years, with at least 6 months between first and last encounter. We used Multivariate Poisson regression analysis to analyze variation in blood pressure measurement rates and associations with patient and physician factors. RESULTS We identified 5996 children (62% of 9667 in total) who had at least 1 blood pressure measurement recorded. Of these children, 14% had at least 1 abnormal blood pressure measurement, and of those children, only 5% had a follow-up measurement recorded within 6 months. After adjustment, increases in rates of blood pressure measurements were associated with greater number of encounters (rate ratio [RR] = 1.03, 95% confidence interval [CI] 1.02-1.04, p < 0.001), older age at first encounter (RR = 1.06, 95% CI 1.03-1.10, p = 0.002), and female sex (RR = 1.12, 95% CI 1.03-1.20, p = 0.006). Obesity or a recorded family history of hypertension were not associated with more blood pressure measurements. Female physicians recorded more blood pressure measurements than did male physicians (RR = 1.41, 95% CI 1.04-1.89, p = 0.02). INTERPRETATION This screening measure was frequently done and appeared to be incompletely followed up. Clear guidance is needed; guideline developers should consider reviewing this topic.